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 Wendy Reynolds (613) 545-0117 wendy@aware.on.cawww.aware.on.ca

2. A Smoker’s Story

3. Women’s Voices • “I’m afraid of the stress of quitting - it’s hard enough to be cheerful to begin with.” • “I think I would go up the wall if I quit smoking.” • “Boredom is a big reason I smoke. Night after night staying in with the kids all day and all night, I need relief.”

4. Women’s Voices •  “I know in the long run over a month I would spend less on the patch than I do on cigarettes, but I never have that kind of money all at once to buy the patch. And then I think what happens if I do spend the money on the patch and I start smoking again anyway, I’ve wasted all that money.” • “If I could relieve some of my guilt about smoking, it might make it easier to quit. I don’t have any physical outlets. My option is don’t smoke and possibly be physical with my child. So it’s a lose-lose situation. My choice is smoke or slap my child. I can’t quit smoking. I want my daughter to live to see 4.”

5. Women’s Voices • “Before I got involved with Better Beginnings, I smoked four packs a day, 24 hours a day, just to stay calm. The cigarettes were my only friend. I couldn’t get away from my two little boys (aged 2 & 4), so I just smoked.” • “I feel so guilty smoking around my daughter. In the winter, I try not to smoke around her but it’s impossible. You just bite the guilt.”

6. Women’s Voices • “If my three year old daughter would just quit following me to the bathroom, I could really try to limit my smoking to just one room.” • “In the summer it’s easier not to smoke around my kids because I can go outside and the windows are open so I can monitor what my daughter is doing. In the winter with all the windows and doors closed, it’s too far away from her room for me to keep an eye on her.”

7. Women’s Voices • “I can’t leave my kids alone to go outside to smoke. The logistics are just too difficult. Either the kids tear the house apart. Or if they’re asleep and wake up, they scream because they’re scared.” • “I smoke but I try as hard as I can not to smoke around my kids. But then their grandparents come over and they smoke. I can’t ask them not to smoke because I do. So then we’re all smoking. We try to vent the smoke to the outside.”

8. 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

9. 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)

10. Obstacles for CAPC Staff • Fear of turning women away from basic services • No time to provide interventions • Lack of skills and knowledge about smoking • Competing priorities

11. Obstacles for CAPC Staff • Many CAPC staff may be smokers themselves • Often, staff have had negative experiences providing smoking cessation programs • Dislike of traditional non-smoking messages

12. Existing Messages What are some of the negative messages in campaigns/programs on smoking cessation ? • Advice based • All or nothing • Focus on quitting • Punitive • Guilt based • Judgemental • Non-supportive

13. Existing messages Think about the women we work with. How do these traditional messages impact them? • Tune out • Feel like failure • Feel guilty – leads to more smoking • Feel defeated before even beginning • Feels unattainable • Feel like a bad parent • Avoid/ignore the message/resources • Doesn’t work

14. 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) • have children under age 6 living with them • receive support from a service provider • are not ready to quit smoking

15. Not Ready to Quit • Abstinence is healthiest for everyone – no known safe level of smoking • BUT: abstinence not always possible • Focus on positives of reducing smoking: • Smaller, more manageable steps • Accomplishments can increase confidence • Can eventually move to quitting • Keeps participant engaged

16. Project Background • Pilot project in Ontario with CAPC and similar sites (2000-2004), followed by a national rollout in 5 CAPC/CPNP sites (2006-2007), and Phase 2 of national rollout in 7 CAPC/CPNP sites (2009-2010) • Low-income moms who smoke integral to development of strategies and messaging

17. Philosophy • Harm Reduction • notsmoking cessation • “success” is measured by small steps • Strengths based • acknowledges the love moms have for their children • positives are emphasized and self-efficacy is nurtured • Cognitive approach • encourages moms to think through their behaviours in order to make changes • gives moms skills to help them make a quit attempt when they’re ready • Goal setting strategy • builds on every change a mom makes (no matter how small) to the larger goal of smoking outside (not quitting)

18. Philosophy • Empowerment • gives moms a sense of control over their smoking and their lives • setbacks are not failures but an opportunity to try a different approach • Participant focused • moms guide the entire process • we meet them where they are in their process • Flexible • can be used in existing programs or be a program on its own • can be used one-on-one or in a group setting • can be introduced formally or informally

19. STARSS Message • Women wanted an approach that supports the role of moms (especially if they are sole parents), acknowledges the love they have for their children, and affirmsmeasures moms already take to protect their children in a variety of ways

20. STARSS Message • The posters emphasize the many things moms do to protect children and includes smoking outside as one of those things • “Just because I smoke doesn’t mean I don’t love my children.”

21. Contents • The Guide to STARSS Strategies (a training manual for service providers) • The I’m A STAR! Journal (a workbook for moms) • Series of 5 posters • Goal of this component to assist CAPC staff to use the STARSS strategies to encourage discussion with moms regarding SHS either individually or in an informal group setting

22. Contents The Guide to STARSS Strategies includes 6 sections that include: • Welcome (issues) • How to use STARSS • STARSS sessions (the 7 individual sessions to use with moms one-on-one) • Worksheets • Handouts • Appendix

23. How To Use STARSS 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 that contradict the STARSS message • Have snacks in the shape of stars • Hang/decorate your organization with stars • 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

24. How To Use STARSS • Handouts and Worksheets in Existing Groups • Put out What works! Handout before a group • This may 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. The following are good ones to use (may only have time for one): • Worksheet 1: Short term Goal Examples • Worksheet 3: How to choose a Smoking Place • Worksheet 2: DEEDS • Worksheet 4: Positives and Negatives of Smoking • What Works! Handout • Have a discussion/activity that talks about the facts and myths of second hand smoke • Keep the discussion away from quitting

25. How To Use STARSS • STARSS Workshop or Series • Once the 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 is 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

26. How To Use STARSS • 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: • 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

27. One-to-One Sessions • Goals of each session • Step-by-step instruction for each session • Which forms you will need • Worksheets and other forms moms will need • What moms need to do before next session

28. Worksheets • Worksheet #1Short Term Goal Examples • Worksheet #2 Cigarette Fading and DEEDS • Worksheet #3 How to Choose a Smoking Place • Worksheet #4 Positives & Negatives of Smoking • Worksheet #5 How to Identify Your Triggers • Worksheet #6 Ideas to Keep Your Hands Busy • Worksheet #7 Coping With Cravings • Worksheet #8 Deep Breathing/Muscle Relaxation • Worksheet #9 Coping With Stress • Worksheet #10 Some Ideas to Help You Quit

29. Session 1 Goals of Session 1 • to help the mom see her smoking patterns • to start brainstorming possible long and short term goals What you need • Fagerstrom Test for Nicotine Dependence • Short and Long Term Goal Contracts What moms need • Current Smoking Patterns • Worksheet #1 • Cigarette Monitoring Form for Moms

30. Session 2 Goals of Session • to set realistic long and short term goals • to discuss any barriers to success she might encounter What you need • Short and Long Term Goal Contracts • Cigarette Monitoring Form for Moms What moms need • Current Smoking Patterns • Worksheet #1 • Cigarette Monitoring Form for Moms • Goal Setting Record

31. Session 3 Goals of Session • to review short term goals • to discuss any barriers and strategies for success • to practice DEEDS strategies and choose a smoking place • to renegotiate goals and help her move forward What you need • Progress Report What moms need • Worksheets #2 and #3 • Cigarette Monitoring Form for Moms • Goal Setting Record

32. Session 4 Goals of Session • to review short term goals • to discuss barriers and strategies for success • to reflect on the positives and negatives of smoking and how to identify triggers • to renegotiate goals and help her move forward What you need • Progress Report • Cigarette Monitoring Form for Moms What moms need • Worksheets #4 and #5 • Cigarette Monitoring Form for Moms • Goal Setting Record

33. Session 5 Goals of Session • to review short term goals • to discuss any barriers and strategies for success • to discuss cravings and strategies to cope with cravings • to renegotiate goals and help her move forward What you need • Progress Report What moms need • Worksheets #6 and #7 • Goal Setting Record

34. Session 6 Goals of Session • to review short term goals • to discuss barriers and strategies for success • to discuss stress management strategies • to renegotiate goals and help her move forward What you need • Progress Report What moms need • Worksheets #8 and #9 • Cigarette Monitoring Form for Moms • Goal Setting Record

35. Session 7 Goals of Session • to evaluate and celebrate improvements the woman was able to make • to outline future directions • to receive feedback from the mom What you need • Progress Report • Cigarette Monitoring Form for Moms • STARSS Completion Certificate What moms need • Cigarette Monitoring Form for Moms

36. Handouts • What works • Effects of SHS on children • Information for STARSS moms • How to help your mom be a STAR! • Help my mom be a STAR! • Ideas to help protect your children from SHS

37. Handouts • Ideas to help you quit smoking when you’re ready • Why it’s so hard to quit smoking • What smoking cost in November 2009 • What happens when you quit smoking • Smoking cessation aids fact sheet

38. Appendix • Research background to STARSS • Overview of motivational counselling • Evaluation highlights • Women’s STARSS stories

39. Service Provider Role • Identify realistic, manageable goals that work for each mom to reduce her children’s exposure to second-hand smoke • Create a contract with each mom • Praise every small step a mom takes • Brainstorm ways to problem solve when setbacks occur • Help each mom record her progress

40. Role of the Mom • Decide what her short and long term goals are • Brainstorm small steps to take towards her goals • Attempt to make changes • Record progress and setbacks • Discuss progress with you and strategize ways to improve or re-negotiate goals • Make a contract for her goals

41. Value of Incentives Use incentives to welcome moms and thank them for participating A STARSS Welcome Bag could include: • Star shaped squeezie, star fridge magnet, window cling • Microwave popcorn • Straws and licorice cut the length of cigarettes • Toothbrush and small tube of toothpaste • Gum • Hard candies • Deck of cards to shuffle

42. Women’s Voices • I don’t like any of the stuff the kids say or bring home from school about how we’re going to die if we smoke. It adds to the guilt and turns kids into cops. • I want stress relievers, like exercise or yoga classes. I don’t want ideas about doing exercises at home. I want to be able to get out to do things. We need to do things with our kids in a smoke free environment. But it’s all part of having access to free childcare. • Anything that helps with reducing the stress in my life is a benefit. If you help reduce my stress, you will help reduce my smoking.

43. Learnings from Phase 1 of the National Rollout • STARSS is easy to use and integrate • Implementing STARSS does not add a burden to work loads • Make it FUN! • Good buy-in from staff & participants • Self efficacy of staff greatly improved • Participants respond well • There have been adaptations and ripple effects locally and regionally

44. Learnings from Phase 1 of the National Rollout • Handouts and posters only (minimal) • Handouts and worksheets as the basis of group discussion in existing groups (informal strategies) • STARSS sessions as the basis for a STARSS group (formal group strategy) • STARSS sessions one-on-one (formal individual strategy)

45. Learnings from Phase 1 of the National Rollout • Integration of STARSS strategies depended upon site capacity • Two tried to offer all of the different methods of delivery • One was to offer minimal strategies only and one was to offer informal strategies only • These two sites were able to do far more than they originally thought • Minimal and informal strategies were the easiest to integrate

46. Moms’ Stories • “I was attracted to STARSS because they weren’t trying to pressure me to quit smoking or trying to make me feel guilty. I wouldn’t have gotten involved in the first place if they were trying to get me to quit.” • “I’m not ready to quit smoking again. But being involved with STARSS has made a number of big changes in my life.”

47. Counsellors’ Stories • “I learned how to stay hopeful and involved, even if the women didn’t quit smoking.” • “Before STARSS, I was reluctant to talk about smoking with moms. It felt like such a huge issue and I really didn’t know what to say or do. I was reassured you didn’t have to get moms to quit smoking; it’s just as important to develop a rapport about secondhand smoke and protecting children.”

48. Points to Ponder • Even minimal interventions are effective • More intensive interventions are manageable and even more effective • It’s all in the approach we take! • “It was easy to piggyback STARSS onto our existing programs. We were able to fully integrate it into everything we do. So, instead of it being one in a long list of programs that we offer, STARSS became part of everything that we offered.”