STARSS

1. STARSS Start Thinking About Reducing Secondhand Smoke: A harm reduction support strategy for low-income mothers who smoke Developed by AWARE: Action on Women’s Addictions – Research and Education info@aware.on.cawww.aware.on.ca

2. Objectives for Webinar #2 • Understand and support women who smoke, in particular those with young children • Enhance capacity to incorporate STARSS into existing programs • Offer STARSS implementation strategies for varying levels of service capacity • Illustrate sample STARSS scenarios

3. Recap – Women & Smoking • Why do women smoke? • Understanding tobacco addiction & dependence • Red flags • The STARSS message • Who STARSS is for

4. Why Women Smoke • Acts as an appetite suppressant • Gives a sense of control over a life that may feel is out of control • A chance to take a break and breathe • A reward – the one thing they do for themselves • A way to cope with difficult emotions/stress • A friend • To feel part of a social group • Partners, friends, family who smoke

5. Women & Smoking • Women often smoke to help them deal with life issues • Smoking rates are higher for single moms, low-income, Aboriginal & Francophone women • Women make more attempts to quit before they are successful • Children living in poverty have higher smoking rates and lower quit rates (by 50%)

6. Why It’s Hard to Quit • Addicted • Very difficult life circumstances • Poverty • Abuse (current or history of trauma) • Partners, friends, family who smoke • Surveillance (from ex-partners, child protection services, community)

7. Red Flags Smoking (& especially difficulty quitting) is a red flag for: • Mental health issues • Associated substance use/abuse with other drugs/alcohol • Less healthy pregnancy outcomes • Potential developmental, physical & cognitive problems in children exposed to SHS

8. Who Benefits from STARSS STARSS was designed to meet the needs of women who: • Live on a low-income • Are single parents (which may mean they have a part time partner) and have children under age 6 • Receive support from service providers who don’t necessarily have experience with tobacco strategies • Are not ready to quit smoking (i.e., precontemplators and contemplators)

9. Precontemplation /Contemplation Our role with pre/contemplators is to: • Develop rapport • Raise consciousness of risks but avoid scare tactics • Show interest and curiosity • Avoid action statements—focus on listening • Avoid commands (even action statements can seem like accusations)

10. Finding Your Voice Things to consider: • Be sensitive to the stresses in her life and the role tobacco plays • Think of motivational ways to begin the discussion • You don’t have to “fix” the problem • Plant a seed • I believe in you • Small steps are steps forward

11. How To Talk Like a STAR! Avoid saying: Do you have any idea how much you put your children at risk by smoking around them? Try saying: You do so many things to protect your children (such as holding their hands when you cross the street). Would you like to learn some ideas about how to protect your children from second hand smoke without having to quit smoking?

12. How To Talk Like a STAR! Avoid saying: Smoking in your room with the door closed doesn’t make a difference. Try saying: It’s great you’re trying to protect your children from second hand smoke. It is best to go outside when you can. But when you can’t, a first step is to smoke in your room with the door closed, the window open, and a fan behind you to blow the smoke out the window. Can I talk with you about more steps you can take?

13. How To Talk Like a STAR! Avoid saying: If you quit smoking, you would have more money for yourself and your children. Try saying: It can be hard to make changes in your smoking. And changes take time. Do you want to talk about some small steps you can start to take now? In the long run, there are lots of benefits when you quit or cut down on your smoking.

14. How To Talk Like a STAR! Avoid saying: Don’t you realize you’re being a bad role model for your children when you smoke around them? Try saying: You don’t have to be perfect to be a good role model. Your children will appreciate your efforts when you try to take steps to smoke outside and away from them.

15. How To Talk Like a STAR! Avoid saying: Why don’t you just quit? Why don’t you try the Patch? Try saying: When you’re ready to think about quitting smoking, I can try to help you find supports. And there might be a way to get you involved with a program that provides NRTs and other smoking cessation aids for people who are trying to quit smoking.

16. How to Act Like a STAR! • In your community kitchen program, you are standing beside a young mom and can smell smoke on her clothes. Smoking has never been addressed as a topic in your community kitchen program. • Put up STARSS posters. Make handouts available. (You can provide Handouts “What Works” and “Effects of SHS on Children”.)The next time you have an opportunity, say “I’ve just learned more about STARSS. Would you be interested in talking about it?” (If yes, show Worksheet #1 “Short Term Goal Examples” to attempt to demonstrate how simple the first steps can be. Then move to Worksheet #4 “Positives and Negatives” to show you’re aware of positive aspects of smoking.)

17. How to Talk Like a STAR! • During your program, you notice that mothers watch each other’s children so they can take turns going out for a smoke. • I notice that you have a great plan to cover each other off so you don’t have to take your kids outside with you to smoke, which protects them from SHS. Sometimes it can be more of a challenge to do that at home. I have some information about reducing SHS further. May I share it with you? (If yes, provide Worksheet #1 and #3.)

18. How To Use STARSS Step 1: Posters and Handouts • Put up posters • Leave out the following handouts: • What works! • Effects of Second-hand Smoke on Children • What Smoking Costs • How to Be a Star! Second-hand Smoke Protection • Rotate posters and handouts • Make sure there aren’t other posters/handouts contradicting the STARSS message • Have snacks in the shape of stars • Hang/decorate your organization with stars (go to http://aware.on.ca/starss/starss-showcase for ideas from across Canada) • Have kids do a star activity • Good way to first introduce topic of smoking into your organization • Generates interest among participants • Increases staff confidence to discuss smoking issues

19. More About Step 1 • Ensure the message is clear: STARSS doesn’t require a commitment to quit smoking • Create an environment supportive of STARSS – take a critical look at other smoking cessation/second hand smoke posters and pamphlets • Get co-workers onside with the STARSS philosophy and language • Create interest by visiting with moms at playgroups or other programs within your site • Incorporate discussions about protecting children from second hand smoke into existing programs • Use the “What Works!” Handout to gently dispel myths about common but ineffective strategies

20. How To Use STARSS Step 2: Handouts and Worksheets in Existing Groups • Put out What Works! Handout before a group to start discussion or promote questions • Introduce the topic starting with the positives that moms already do to protect their kids • Distribute and discuss worksheets or handouts as time permits: • Worksheet 1: Short term Goal Examples • Worksheet 2: DEEDS • Worksheet 3: How to choose a Smoking Place • Worksheet 4: Positives and Negatives of Smoking • What Works! Handout • Have a discussion/activity about the facts and myths of second hand smoke (see http://aware.on.ca/sites/default/files/Whitehorse_Myth_Fact.pdf) • Keep the discussion away from quitting

21. More About Step 2 • Start small, see what the interest is, and move on • Have a STARSS discussion over lunch using Worksheet #3 (How to Choose a Smoking Place) and Worksheet #4 (Positives and Negatives of Smoking) • Build the STARSS information into existing programs • Hold a STARSS workshop using “The Role of Smoking in Women’s Lives” from the Welcome Section of the Guide to STARSS Strategies and Worksheets #1, #2, #3, and #4

22. How To Use STARSS Step 3: STARSS Workshop or Series • Once moms in your program are familiar with the STARSS materials, you can offer to hold a specific discussion group • Could be one session or 2 – 3 sessions • Talk about and validate the reasons women smoke and why it’s hard to quit • Discuss all the ways women protect their children and introduce STARSS as one other way she can protect her child from second-hand smoke • Distribute and discuss Worksheets 1 – 4 or provide participants with the I’m a STAR! Journal

23. More About Step 3 Sample script • Introduce the topic and provide positive feedback • Generate discussion about steps participants already take • Distribute and discuss STARSS strategies • Move on as time allows

24. More About Step 3 To consider for groups of smokers … • Demonstrate empathy—start with Worksheet #4 (“Positives and Negatives of Smoking”) To consider for groups with men and women … • Talk more generically about caregivers or parents • Don’t focus on gender differences or situations specific to moms • Focus on manageable small steps any caregiver can take to protect children from SHS To consider for groups with non-smokers, former smokers, and smokers …  • Congratulate those who have quit smoking … but don’t focus on quitting • Move the conversation away from quitting—focus on small steps to second hand smoke protection (“If you’re not ready to quit, there are small steps you can take to protect your children from SHS.”)

25. How To Use STARSS Step 4: Individual or One-to-One Sessions • Each session can be delivered as part of regular contacts you already have with women • There are 7 sessions outlined in the Guide: • First 2 take a little longer but the remainder take no more than 20 min each • Sessions do not need to be every week • Participant led – depends on the woman’s readiness to move on (use I’m a STAR! Journal)

26. Scenario 1 • Mother’s day is coming up and your program is planning a celebration. Using the STARSS workbook and resources, plan a STARSS activity that fits with the Mother’s Day theme

27. Scenario 1 For moms: • Put stars everywhere • Have a STARSS myths/facts discussion or offer a spa experience (using Worksheet #8) For children: • Think of stars for snacks • Photocopy stars for kids to colour (see website)

28. Scenario 2 • You overhear one mother say to two of her friends “well I finally quit smoking, but it’s so hard!” Her friend says “I’ve cut down but can’t seem to give up those last few.”

29. Scenario 2 For mom who has quit: • Handouts “Quitting Smoking”, “Why It’s So Hard to Quit”, “What Happens When You Quit” For mom who is struggling: • Ask for permission to share ideas • Acknowledge her steps to date • Try to determine what role those remaining cigarettes fulfill – select Worksheets to complement that response (e.g. addiction vs stress)

30. Scenario 3 • Your centre has put up STARSS posters and resources. It’s working because you hear women talking about reducing second hand smoke. One woman tells you she doesn’t smoke but her father-in-law who lives with her does.

31. Scenario 3 • Ask how father-in-law might respond if she were to provide him with STARSS Handouts • If safe, say “this is what research is now saying” (i.e., deflect from the personal) • Provide STARSS Handouts (“Effects of SHS on Children” and “How to Be a STAR! SHS Protection”) • If not, discuss ways to reduce child’s exposure

32. Scenario 4 • Getting back to pre-pregnancy weight is a hot topic in the group you are running. One member has told you that she wants to quit smoking but last time she quit she gained a lot of weight. You suspect there may be others in the group with similar concerns.

33. Scenario 4 • Provide positive feedback regarding desire to quit smoking • Acknowledge that quitting smoking can lead to weight gain, but weight gain is less likely when you are prepared ahead of time • Provide STARSS Handout (“What Happens When You Quit Smoking”) • If eating is related to stress, provide Worksheet #9 (“Coping With Stress”)

34. Difficult Life Situations Moms might have difficulty engaging in STARSS due to: • Lack of support from family and friends • Difficult life situations • Shame, guilt, embarrassment • Strategies feel overwhelming

35. Difficult Life Situations For the service provider: • Convey hope and optimism • Start all over again or think of smaller steps • Use the time to discuss other pressing issues; begin the STARSS discussion later when she’s ready • Focuson her strengths and successes with STARSS so far • Remind her (and yourself) change is a gradual process and setbacks happen

36. Lack of Support #1 Sue and Ann have been smoking buddies for fifteen years. Their children were even born about the same time six years ago. Then Sue had a second child, and she decided it was time to start thinking about reducing second hand smoke around her children. Sue told Ann that she was smoking either outside or (when she couldn’t leave her children alone) in her smoking place with the window open and a fan blowing the smoke outside. Ann laughed at her and said “Good luck! I’ll see you at my house where I can smoke where ever I want.” Sue did not want to lose the friendship and support of her only friend but she didn’t want to lose sight of her goal with STARSS either. • What could Sue do to help her remain involved with STARSS and yet not lose her long standing friendship with Ann? • Can Sue identify any patterns in her smoking that may help her delay smoking until she can go outside to smoke? • What ways can Sue gain support other than with her friend Ann?

37. Lack of Support #2 Alice is a single mom with two young children. She has recently cut back on smoking by going in another room away from her children, where she smokes in front of an open window with a fan blowing the smoke outside. Sometimes she is so tempted just to say “forget it” but she delays the timing as long as she can. Alice’s mother visits a lot, helps out with child care, and gives Alice money when she can to cover bills and food. Her mother also smokes and loves to sit at the kitchen table, coffee in one hand and cigarette in the other, with no concern about the children or her affect on Alice’s goal. Alice is scared to say anything to her mother for fear of losing her support. Alice hasn’t told anyone about her goals regarding protecting her children from second hand smoke because of her own fear of failure.   • What strategy can Alice practice to protect her children from SHS when her mother visits? • How can she communicate to her mother her goal of reducing cigarettes? • How can Alice solicit more support from her mother in decreasing her cigarette smoking even though her mother continues to smoke the same amount?

38. Abusive Home Situation Hannah has smoked since she was 13 and has 3 children under age 5. Her partner Jake works, but the hours are few and the money is even worse. Jake is unhappy with his job and he sometimes comes home angry, aggressive, and smelling of alcohol. Most of the time Hannah just rolls with his mood, but now that she has begun to reduce the amount that she smokes around the children, she is also feeling irritable. When he goes to light up, she asks him to take it to the spare room and turn on the fan in front of the open window. Jake gets angry, stating that he makes the money to pay for the rent, food and heat in this house and that he can do whatever he likes. Hannah is worried that if she tries to make her point again, Jake might lash out at her. • What safety measures can she employ for herself and her children? • Are there ways Hannah can reach her goal to protect her children from second hand smoke while still living with Jake?

39. Coping With Guilt Frances’ daughter, Jane, has just finished her first day in grade 2. Frances was cleaning up around the house when Jane got off of the bus. While Frances was emptying the ashtrays, Jane said to her “Mommy, you shouldn’t smoke. It’s bad for me and you’re going to die.” Frances feels terrible but isn’t ready to quit smoking. • What can Francis say to her daughter to reassure her that she cares? • What small steps can Frances take to protect her daughter from second hand smoke?

40. Strategies Feel Overwhelming Barb was confident about her STARSS goals, especially when all three children are home. But between fixing meals, homework and bedtime routines, she struggles not to smoke until the kids are in bed at 7:30. Now, her bills are piling up and phone calls start at 5:00 from people wanting money. Barb feels her anxiety go up with each threatening phone call about hydro or phone being cut off. By 6:00, Barb feels like screaming at everyone and definitely wants to smoke. • How can Barb use the DEEDS strategy to her advantage? • What forms of substitution for smoking could Barb consider to help her cope with her anxiety and stress?