Interventions for promoting smoking cessation during pregnancy

Stillbirths: the way forward in high-income countries

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Psychosocial characteristics and obstetric health of women attending a specialist substance use antenatal clinic in a large metropolitan hospital

Objective. This paper reports the findings comparing the obstetrical health, antenatal care, and psychosocial characteristics of pregnant women with a known history of substance dependence (n = 41) and a comparison group of pregnant women attending a general antenatal clinic (n = 47). Method. Face-to-face interviews were used to assess obstetrical health, antenatal care, physical and mental functioning, substance use, and exposure to violence. Results. The substance-dependent group had more difficulty accessing antenatal care and reported more obstetrical health complications during pregnancy. Women in the substance-dependent group were more likely to report not wanting to become pregnant and were less likely to report using birth control at the time of conception. Conclusions. The profile of pregnant women (in specialised antenatal care for substance dependence) is one of severe disadvantage and poor health. The challenge is to develop and resource innovative and effective multisectoral systems to educate women and provide effective care for both women and infants.

The Pittsburgh STOP program: disseminating an evidence-informed intervention for low-income pregnant smokers

PURPOSE

Prenatal smoking is a preventable risk factor for poor perinatal outcomes and is more prevalent in pregnant smokers of low socioeconomic status (SES). We describe the intervention model and factors associated with quitting from the Pittsburgh STOP Program, an evidence-informed dissemination intervention for low-SES pregnant smokers.

SETTING

STOP is delivered in community health care clinics serving economically disadvantaged women.

PARTICIPANTS

Participants were 856 pregnant women who were current smokers (93%) and recent quitters (7%). Most were white (59%) or black (35%), single (74%), young (mean age = 25), and experiencing an unplanned pregnancy (84%); 90% were insured by Medicaid/uninsured.

METHODS

An evidence-informed intervention for community pregnant women was delivered individually in a single-group pre-post evaluation design. Measures were demographics, participation and retention, smoking status, satisfaction, and cost. Analyses included descriptive statistics and logistic regression.

RESULTS

Participants attended an average of 4.7 sessions. Dropout rate after the first session was 5%. Over 11% of smokers quit; 48% of preenrollment spontaneous quitters remained abstinent. Factors significantly associated with quitting included race, mother's age, nicotine dependence, and number of sessions attended.

LIMITATIONS

STOP is a community program with self-selected participants and no control group.

CONCLUSION

Low-income pregnant smokers will engage in an evidence-informed cessation program tailored for this group, with quit rates that compare to controlled research results.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis

BACKGROUND

Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries.

METHODS

Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated.

FINDINGS

Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries.

INTERPRETATION

The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries.

FUNDING

The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

Competitions and incentives for smoking cessation

BACKGROUND

Background Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Public health initiatives in the UK are currently planning to deploy incentive schemes to change unhealthy behaviours. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author (KC) and checked by the second (RP). We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Nineteen studies met our inclusion criteria, covering >4500 participants. Only one study, the largest in our review and covering 878 smokers, demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. This trial referred its participants to local smoking cessation services, and offered substantial cash payments (up to US$750) for prolonged abstinence. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. There is some evidence that recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis was not appropriate to this review, since the efficacy of most of the interventions was not demonstrated.

AUTHORS' CONCLUSIONS

With the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered. Rewarding participation and compliance in contests and cessation programmes may have potential to deliver higher absolute numbers of quitters. The one trial that achieved sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available. Future research might explore the scale and longevity of possible cash reward schedules, within a variety of smoking populations.

Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care

BACKGROUND

Investment in strategies to promote 'a healthy start to life' has been identified as having the greatest potential to reduce health inequalities across the life course. The aim of this study was to examine social determinants of low birthweight in an Australian population-based birth cohort and consider implications for health policy and health care systems.

METHODS

Population-based survey distributed by hospitals and home birth practitioners to >8000 women six months after childbirth in two states of Australia. Participants were women who gave birth to a liveborn infant in Victoria and South Australia in September/October 2007. Main outcome measures included stressful life events and social health issues, perceived discrimination in health care settings, infant birthweight.

RESULTS

4,366/8468 (52%) of eligible women returned completed surveys. Two-thirds (2912/4352) reported one or more stressful life events or social health issues during pregnancy. Women reporting three or more social health issues (18%, 768/4352) were significantly more likely to have a low birthweight infant (< 2500 grams) after controlling for smoking and other socio-demographic covariates (Adj OR = 1.77, 95% CI 1.1-2.8). Mothers born overseas in non-English speaking countries also had a higher risk of having a low birthweight infant (Adj OR = 1.85, 95% CI 1.2-2.9). Women reporting three or more stressful life events/social health issues were more likely to attend antenatal care later in pregnancy (OR = 2.06, 95% CI 1.3-3.1), to have fewer antenatal visits (OR = 2.17, 95% CI 1.4-3.4) and to experience discrimination in health care settings (OR = 2.69, 95% CI 2.2-3.3).

CONCLUSIONS

There is a window of opportunity in antenatal care to implement targeted preventive interventions addressing potentially modifiable risk factors for poor maternal and infant outcomes. Developing the evidence base and infrastructure necessary in order for antenatal services to respond effectively to the social circumstances of women's lives is long overdue.

Examining maternal weight gain during contingency-management treatment for smoking cessation among pregnant women

Excessive maternal weight gain during pregnancy can result in serious adverse maternal and neonatal health consequences making it an important outcome to monitor in developing smoking-cessation interventions for pregnant women. Maternal weight gain was investigated in the present study with 154 pregnant participants in controlled trials investigating the efficacy of contingency management (CM) for smoking cessation. Women were assigned to either an abstinence-contingent condition wherein they earned vouchers exchangeable for retail items by abstaining from smoking or to a control condition where they received comparable vouchers independent of smoking status. Mean percent of negative smoking-status tests throughout antepartum was greater in the incentive than control condition (45.2±4.6 vs. 15.5±2.4, p<.001) as was late-pregnancy point-prevalence abstinence (36% vs. 8%, p<.001) but maternal weight gain did not differ significantly between treatment conditions (15.0±0.8kg vs. 15.0±0.9 kg, p=.97). In a comparison of women classified by smoking status rather than treatment condition, a greater percent of negative smoking-status tests predicted significantly more weight gain (0.34 kg per 10% increase in negative tests), an effect that appeared to be attributable to women with greater abstinence having larger infants. This study shows no evidence of excessive maternal weight gain among pregnant women receiving a CM intervention for smoking cessation.

Pregnant women's responses to a tailored smoking cessation intervention: turning hopelessness into competence

BACKGROUND

Cognitive behavioral interventions consisting of brief counseling and the provision of self-help material designed for pregnancy have been documented as effective smoking cessation interventions for pregnant women. However, there is a need to understand how such interventions are perceived by the targeted group.

AIM

To understand the cognitive, emotional, and behavioral responses of pregnant women to a clinic-based smoking cessation intervention.

METHODS

In-depth interviews with women attending four antenatal clinics in Cape Town, South Africa, who were exposed to a smoking intervention delivered by midwives and peer counselors. Women were purposively selected to represent a variation in smoking behavior. Thirteen women were interviewed at their first antenatal visit and 10 were followed up and reinterviewed later in their pregnancies. A content analysis approach was used, which resulted in categories and themes describing women's experiences, thoughts, and feelings about the intervention.

RESULTS

Five women quit, five had cut down, and three could not be traced for follow-up. All informants perceived the intervention positively. Four main themes captured the intervention's role in influencing women's smoking behavior. The process started with 'understanding their reality,' which led to 'embracing change' and 'deciding to hold nothing back,' which created a basis for 'turning hopelessness into a feeling of competence.'

CONCLUSION

The intervention succeeded in shifting women from feeling pessimistic about ever quitting to feeling encouraged to try and quit. Informants rated the social support they received very highly and expressed the need for the intervention to become a routine component of clinic services.

Perinatal interventions and survival in resource-poor settings: which work, which don't, which have the jury out?

Perinatal conditions make the largest contribution to the burden of disease in low-income countries. Although postneonatal mortality rates have declined, stillbirth and early neonatal mortality rates remain high in many countries in Africa and Asia, and there is a concentration of mortality around the time of birth. Our article begins by considering differences in the interpretation of 'intervention' to improve perinatal survival. We identify three types of

INTERVENTION

a single action, a collection of actions delivered in a package and a broader social or system approach. We use this classification to summarise the findings of recent systematic reviews and meta-analyses. After describing the growing evidence base for the effectiveness of community-based perinatal care, we discuss current concerns about integration: of women's and children's health programmes, of community-based and institutional care, and of formal and informal sector human resources. We end with some thoughts on the complexity of choices confronting women and their families in low-income countries, particularly in view of the growth in non-government and private sector healthcare.

Linkages among reproductive health, maternal health, and perinatal outcomes

Some interventions in women before and during pregnancy may reduce perinatal and neonatal deaths, and recent research has established linkages of reproductive health with maternal, perinatal, and early neonatal health outcomes. In this review, we attempted to analyze the impact of biological, clinical, and epidemiologic aspects of reproductive and maternal health interventions on perinatal and neonatal outcomes through an elucidation of a biological framework for linking reproductive, maternal and newborn health (RHMNH); care strategies and interventions for improved perinatal and neonatal health outcomes; public health implications of these linkages and implementation strategies; and evidence gaps for scaling up such strategies. Approximately 1000 studies (up to June 15, 2010) were reviewed that have addressed an impact of reproductive and maternal health interventions on perinatal and neonatal outcomes. These include systematic reviews, meta-analyses, and stand-alone experimental and observational studies. Evidences were also drawn from recent work undertaken by the Child Health Epidemiology Reference Group (CHERG), the interconnections between maternal and newborn health reviews identified by the Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS), as well as relevant work by the Partnership for Maternal, Newborn and Child Health. Our review amply demonstrates that opportunities for assessing outcomes for both mothers and newborns have been poorly realized and documented. Most of the interventions reviewed will require more greater-quality evidence before solid programmatic recommendations can be made. However, on the basis of our review, birth spacing, prevention of indoor air pollution, prevention of intimate partner violence before and during pregnancy, antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy, insecticide-treated mosquito nets, birth and newborn care preparedness via community-based intervention packages, emergency obstetrical care, elective induction for postterm delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth and newborn care preparedness through community-based intervention packages reduce neonatal mortality. This review demonstrates that RHMNH are inextricably linked, and that, therefore, health policies and programs should link them together. Such potential integration of strategies would not only help improve outcomes for millions of mothers and newborns but would also save scant resources. This would also allow for greater efficiency in training, monitoring, and supervision of health care workers and would also help families and communities to access and use services easily.

Effects of smoking cessation with voucher-based contingency management on birth outcomes

AIMS

This study examined whether smoking cessation using voucher-based contingency management (CM) improves birth outcomes.

DESIGN

Data were combined from three controlled trials.

SETTING

Each of the trials was conducted in the same research clinic devoted to smoking and pregnancy.

PARTICIPANTS

Participants (n=166) were pregnant women who participated in trials examining the efficacy of voucher-based CM for smoking cessation. Women were assigned to either a contingent condition, wherein they earned vouchers exchangeable for retail items by abstaining from smoking, or to a non-contingent condition where they received vouchers independent of smoking status.

MEASUREMENT

Birth outcomes were determined by review of hospital delivery records.

FINDINGS

Antepartum abstinence was greater in the contingent than non-contingent condition, with late-pregnancy abstinence being 34.1% versus 7.4% (P<0.001). Mean birth weight of infants born to mothers treated in the contingent condition was greater than infants born to mothers treated in the non-contingent condition (3295.6 ± 63.8 g versus 3093.6 ± 67.0 g, P = 0.03) and the percentage of low birth weight (<2500 g) deliveries was less (5.9% versus 18.5%, P = 0.02). No significant treatment effects were observed across three other outcomes investigated, although each was in the direction of improved outcomes in the contingent versus the non-contingent condition: mean gestational age (39.1 ± 0.2 weeks versus 38.5 ± 0.3 weeks, P = 0.06), percentage of preterm deliveries (5.9 versus 13.6, P = 0.09), and percentage of admissions to the neonatal intensive care unit (4.7% versus 13.8%, P = 0.06).

CONCLUSIONS

These results provide evidence that smoking-cessation treatment with voucher-based CM may improve important birth outcomes.

Preventing Relapse Following Smoking Cessation

Cigarette smoking is the leading cause of preventable deaths worldwide. Long-term smoking cessation can drastically reduce people's risk for developing smoking-related disease. The research literature points to a need for clearer operationalization and differentiation between smoking cessation and relapse prevention interventions and outcomes. That said, extensive meta-analyses and research studies have indicated that there are various efficacious smoking interventions that can both support smoking cessation and relapse prevention efforts. Specifically, behavioral treatments, relapse prevention psychotherapy, pharmacologic interventions, motivational enhancement, smoking reduction to quit, brief advice, alternative intervention modes (telephone, Internet, computer), self-help, and tailored treatments can help prepare smokers for longer-term abstinence. Although these methods vary on reach, they are relatively efficacious, particularly in combined formats.

The 'quit' smoker and stillbirth risk: a review of contemporary literature in the light of findings from a case-control study

OBJECTIVE

to identify existing literature which addresses the topic of detecting, assessing and intervening when a pregnant woman who has quit smoking relapses. This literature review was conducted in the light of findings of a case-control study which suggest that a quit smoking status is associated with increased risk of late stillbirth (odds ratio 3.03, 95% confidence interval 1.27-7.24, p = 0.01).

METHOD

a structured review was conducted to identify literature related to quitting smoking in early pregnancy, prevalence and likelihood of relapse, possible methods for detecting smoking resumption, potential intervention strategies for the relapsed smoker and the societal burden of continuing to smoke in pregnancy.

FINDINGS

there is a wide variety of evidence for the effectiveness of intervention strategies aimed at assisting women to quit smoking during pregnancy. However, few studies have specifically aimed to identify strategies to assist those women who report quitting in early pregnancy to maintain that status throughout pregnancy.

CONCLUSIONS

in light of the results of the case-control study and this literature review, it is important that changes are made to prenatal care in order to enable midwives to better identify women who are struggling with abstinence or who resume smoking during pregnancy.

IMPLICATIONS FOR PRACTICE

midwives should discuss and monitor smoking status with women at every prenatal visit. If a midwife finds that a woman has relapsed into smoking, they can be offered a range of quit smoking intervention strategies, including referral to a dedicated cessation service, counselling support, alternative therapies and, perhaps, nicotine replacement therapy. Further research aimed at identifying the extent of relapse among these women and the impact this may have on pregnancy outcome is warranted. Research to ascertain the most appropriate interventions to prevent relapse is also needed.

Smoking and Aboriginal and Torres Strait Islander and Māori children

Smoking and the deaths and suffering it causes are more common among Aboriginal and Torres Strait Islander peoples and Māori than other Australians and New Zealanders. While, many tobacco control activities that are not specifically targeted at children will have a positive impact on child health, this review concentrates on recent tobacco control research on pregnant women and children. The important tasks are to reduce smoking by pregnant Māori and Aboriginal and Torres Strait Islander women to reduce infant and child exposure to second-hand smoke and to reduce smoking initiation of children and adolescents. Health professionals who want to reduce the suffering caused by smoking among Māori and Aboriginal and Torres Strait Islander children can be guided by much new relevant research evidence and clear frameworks about how to approach tobacco control in these communities.

Smoking cessation in pregnancy

Managing smoking cessation during pregnancy is vital to the wellbeing of the fetus and the mother. Women who continue to smoke during pregnancy expose the fetus to thousands of chemicals which have been shown to cause deleterious short- and long-term effects. Although a large majority of women cease smoking early in the pregnancy, many of them relapse following delivery. Following a review of current research, an overview of the safety and efficacy of smoking cessation treatments for pregnant women will be considered. Limited research has been performed in this field; however, it can be concluded that low-dose intermittent nicotine replacement therapy is a safe treatment modality for women who smoke during pregnancy. At present there has been no research on other current smoking cessation treatments; however, we will suggest techniques to improve cessation rates and strategies to reduce relapse.

Care for women with prior preterm birth

Women who have delivered an infant between 16 and 36 weeks' gestation have an increased risk of preterm birth in subsequent pregnancies. The risk increases with more than 1 preterm birth and is inversely proportional to the gestational age of the previous preterm birth. African American women have rates of recurrent preterm birth that are nearly twice that of women of other backgrounds. An approximate risk of recurrent preterm birth can be estimated by a comprehensive reproductive history, with emphasis on maternal race, the number and gestational age of prior births, and the sequence of events preceding the index preterm birth. Interventions including smoking cessation, eradication of asymptomatic bacteriuria, progestational agents, and cervical cerclage can reduce the risk of recurrent preterm birth when employed appropriately.

Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis to investigate the efficacy of interventions incorporating motivational interviewing for smoking cessation and identify correlates of treatment effects.

DATA SOURCES

Medline/PubMed, PsycInfo and other sources including grey literature.

STUDY SELECTION

Title/abstract search terms were motivational interview* OR motivational enhancement AND smok*, cigarette*, tobacco, OR nicotine. Randomised trials reporting number of smokers abstinent at follow up were eligible.

DATA EXTRACTION

Data were independently coded by the first and third authors. We coded for a variety of study, participant, and intervention related variables.

DATA SYNTHESIS

A random effects logistic regression with both a random intercept and a random slope for the treatment effect.

RESULTS

31 smoking cessation research trials were selected for the study: eight comprised adolescent samples, eight comprised adults with chronic physical or mental illness, five comprised pregnant/postpartum women and 10 comprised other adult samples. Analysis of the trials (9485 individual participants) showed an overall OR comparing likelihood of abstinence in the motivational interviewing (MI) versus control condition of OR 1.45 (95% CI 1.14 to 1.83). Additional potential correlates of treatment effects such as study, sample, and intervention characteristics were examined.

CONCLUSIONS

This is the most comprehensive review of MI for smoking cessation conducted to date. These findings suggest that current MI smoking cessation approaches can be effective for adolescents and adults. However, comparative efficacy trials could be useful.

Cigarette smoking knowledge, attitudes, and practices of patients and staff at a perinatal substance abuse treatment center

This study compares cigarette smoking knowledge, attitudes, and practices (S-KAP) of opioid- and other substance-dependent patients and their multidisciplinary staff at an outpatient perinatal substance abuse treatment center. Consenting patients (n = 95) and staff (n = 41) concurrently completed a modified form of the S-KAP survey instrument. Ninety-five percent of patients reported currently smoking, and half endorsed wanting "to quit smoking now." This patient desire to quit smoking was significantly underrated by staff compared to the patients themselves (p = .028). Both patients and staff demonstrated suboptimal knowledge of smoking health risks, but 73% of patients reported trying to quit with past pregnancies to avoid harm to the fetus/baby. Although results show that patients could benefit from smoking cessation strategies centered on smoking's fetal/neonatal health risks, organizational interventions that focus on changing staff attitudes about patient desire to quit smoking may first need to be implemented.

What has public health got to do with midwifery? Midwives' role in securing better health outcomes for mothers and babies

BACKGROUND

The maternity services hold a unique position in influencing current and future maternal and infant health and midwives play a pivotal role. However, midwifery's role in public health is rarely acknowledged by the "system" or by midwives themselves. In fact most midwives may find it difficult reconciling public health with the care they provide.

AIM AND METHODS

This paper aims to raise midwives' public health consciousness and explores the ways in which they can, regardless of the maternity service context in which they work, explicitly acknowledge their own public health practice and the role of midwifery more generally in securing maternal and infant health.

DISCUSSION

Salient examples in antenatal, intrapartum and postnatal care have highlighted how midwives can engage in public health issues relevant to their everyday clinical practice and in so doing re-define and extend their boundaries of care. Public health has much to do with midwifery and midwifery has much to do with public health.

IMPLICATIONS FOR PRACTICE

Midwifery practice can have a profound impact on maternal and infant health both short and long-term, so it is critical that all midwives take up the public health challenge for the benefit of the population they serve.

Support during pregnancy for women at increased risk of low birthweight babies

BACKGROUND

Studies consistently show a relationship between social disadvantage and low birthweight. Many countries have programs offering special assistance to women thought to be at risk for giving birth to a low birthweight infant. These programs may include advice and counseling (about nutrition, rest, stress management, alcohol, and recreational drug use), tangible assistance (e.g., transportation to clinic appointments, household help), and emotional support. The programs may be delivered by multidisciplinary teams of health professionals, specially trained lay workers, or combination of lay and professional workers.

OBJECTIVES

The primary objective was to assess effects of programs offering additional social support compared with routine care, for pregnant women believed at high risk for giving birth to babies that are either preterm or weigh less than 2500 gm, or both, at birth. Secondary objectives were to determine whether effectiveness of support was mediated by timing of onset (early versus later in pregnancy) or type of provider (healthcare professional or lay woman).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010).

SELECTION CRITERIA

Randomized trials of additional support during at-risk pregnancy by either a professional (social worker, midwife, or nurse) or specially trained lay person, compared to routine care. We defined additional support as some form of emotional support (e.g., counseling, reassurance, sympathetic listening) and information or advice or both, either in home visits or during clinic appointments, and could include tangible assistance (e.g., transportation to clinic appointments, assistance with care of other children at home).

DATA COLLECTION AND ANALYSIS

Two review authors evaluated methodological quality. We performed double data entry.

MAIN RESULTS

We included 17 trials (12,264 women). Programs offering additional social support for at-risk pregnant women were not associated with improvements in any perinatal outcomes, but there was a reduction in the likelihood of antenatal hospital admission (three trials; n = 737; RR 0.79, 95% CI 0.68 to 0.92) and caesarean birth (nine trials; n = 4522; RR 0.87, 95% CI 0.78 to 0.97).

AUTHORS' CONCLUSIONS

Pregnant women need the support of caring family members, friends, and health professionals. While programs which offer additional support during pregnancy are unlikely to prevent the pregnancy from resulting in a low birthweight or preterm baby, they may be helpful in reducing the likelihood of antenatal hospital admission and caesarean birth.

Maternal age, education level and migration: socioeconomic determinants for smoking during pregnancy in a field study from Turkey

BACKGROUND

Smoking during pregnancy has been associated with socioeconomic determinants and it is recognized as the most important preventable risk factor for an unsuccessful pregnancy outcome. Turkey has national data on the prevalance of smoking during pregnancy; however there is no data on the characteristics of the high-risk population. This is a field study that aims to identify socioeconomic determinants for smoking during pregnancy as well as differentiating the daily and occasional smokers.

METHOD

Cross sectional study was conducted among women with 0-5 year old children living in the area served by Primary Health Care Center (PHCC) in Burhaniye, Turkey. Face-to-face interviews were conducted by the researchers during January-March 2008 at the home of the participants with 83.7% response rate (n = 256). The relation of "smoking during pregnacy" and "daily smoking during pregnancy" with the independent variables was determined with chi2 tests. Women's age, educational level, number of previous births, place of origin, migration, partner's educational level, poverty, perceived income, social class were evaluated. Statistical significance was achieved when the p value was less than 0.05. The variables in relation with the dependent variables in the chi2 tests were included in the forward-stepwise logistic analysis.

RESULTS

Prevalance of smoking during pregnancy was 22.7%. The majority (74.1%) were daily smokers. Young mothers (< 20), low educated women and migrants were at increased risk for smoking during pregnancy. Low education and being a migrant were risk factors for daily consumption (p < 0.05).

CONCLUSIONS

Systematic attention should be paid to socioeconomic determinants in smoking for pregnant women, especially in countries like Turkey with high rates of infant and mother mortality and substantial health inequalities. Young mothers (< 20), low educated women and migrants are important groups to focus on.

Smoking and smoking cessation during early pregnancy and its effect on adverse pregnancy outcomes and fetal growth

Maternal smoking during pregnancy is a significant threat to the fetus. We examined the association between active maternal smoking and smoking cessation during early pregnancy with newborn somatometrics and adverse pregnancy outcomes including preterm delivery, low birth weight, and fetal growth restriction. One thousand four hundred mother-child pairs with extensive questionnaire data were followed up until delivery, within the context of a population-based mother-child cohort study (Rhea study), in Crete, Greece, 2007-2008. Comparing smokers to nonsmokers, the adjusted odds ratio (OR) was 2.8 [95% confidence interval (CI), 1.7, 4.6] for low birth weight and 2.6 (95%CI: 1.6, 4.2) for fetal growth restriction. This corresponded to a 119-g reduction in birth weight, a 0.53-cm reduction in length, and a 0.35-cm reduction in head circumference. Smoking cessation early during pregnancy modified significantly these pregnancy outcomes indicating the necessity for primary smoking prevention.

The effectiveness of adapted, best practice guidelines for smoking cessation counseling with disadvantaged, pregnant smokers attending public sector antenatal clinics in Cape Town, South Africa

AIM AND OBJECTIVES

To evaluate the effect of a smoking cessation intervention, based on best practice guidelines on the quit rates of disadvantaged, pregnant women in Cape Town, South Africa.

DESIGN

Quasi-experimental using a natural history cohort as a control group, consisting of women attending antenatal care in 2006 and an intervention cohort, attending the same clinics a year later.

SETTING

Four, public sector antenatal clinics in Cape Town staffed and managed by midwives.

POPULATION

Pregnant women of low socio-economic status.

METHODS

The natural history cohort received usual care, whilst the intervention cohort was offered self-help quit materials in the context of brief counseling by midwives and peer counselors. Smoking behavior was measured in early, mid and late pregnancy. The equivalence of the groups in terms of smoking profile, self-reported smoking and demographic variables was assessed at baseline.

MAIN OUTCOME MEASURES

Quit rates measured by urinary cotinine towards the end of pregnancy (36-39 weeks gestation).

RESULTS

The two cohorts were comparable at baseline. The difference in quit rates between the two cohorts in late pregnancy was 5.3% (95% CI: 3.2-7.4%, p < 0.0001) in an intention to treat analysis. There was also a significant difference in reduction of smoking of 11.8% (95% CI: 5.0-18.4%, p = 0.0006).

CONCLUSION

A smoking cessation intervention based on best practice guidelines was effective among high risk, pregnant smokers in South Africa.

Preconception lifestyle advice for people with subfertility

BACKGROUND

Infertility is a prevalent problem and has significant consequences for individuals, families and the wider community. People's chance of having a healthy, live birth may be impacted upon by factors such as weight, diet, smoking, other substance abuse, environmental pollutants, infections, medical conditions, medications and family medical history. However, there is no current guideline about what preconception advice should be offered to people presenting for infertility treatment. It is important to determine what preconception advice should be given about these types of factors to such people in order to help them to make positive changes and hopefully improve their chances of conception and delivering a healthy, live baby.

OBJECTIVES

To assess the effects of preconception advice on the chances of a live birth for people who perceive that they may be infertile and are investigating the possibility of medical treatment to address subfertility.

SEARCH STRATEGY

All published and unpublished randomised controlled trials addressing preconception advice to influence lifestyle factors in people who perceived that they may be infertile and investigated the possibility of medical treatment to address subfertility were sought from the Cochrane Menstrual Disorders and Subfertility Review Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, MEDLINE, PubMed, EMBASE, PsycINFO, AMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), LILACS, trial registers for ongoing and registered trials, citation indexes, ISI Web of Knowledge, Clinical Study Results database, OpenSIGLE database, China National Knowledge Infrastructure (CNKI) Periodical Index and Google (inception to 5 October 2009).

SELECTION CRITERIA

Only randomised controlled trials (RCTs), including cluster-randomised (group-randomised) trials, that considered preconception advice given to individuals who perceived that they may be infertile and were investigating the possibility of medical treatment from subfertility specialist services were eligible for inclusion. The primary outcome was live birth, defined as delivery of a live fetus after 20 completed weeks of gestation.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied eligibility criteria to, extracted data from and assessed the risk of bias in the single included trial.

MAIN RESULTS

One trial assessing smoking cessation advice for 94 infertile women smokers fulfilled the criteria for this review, but the trial did not report on the review's primary outcome of live birth or any other fertility-related outcomes. This trial of women attending a fertility clinic showed that smoking cessation advice tailored to a woman's "stage-of-change" (readiness to stop smoking) did not show significant evidence of a difference in stage (including smoking cessation rates) compared with standard clinical advice.

AUTHORS' CONCLUSIONS

No RCTs were located that assessed the effects of preconception advice on the chance of a live birth or other fertility outcomes in people who perceived that they may be infertile and were investigating the possibility of medical treatment to address subfertility. Given the lack of RCTs evaluating the effectiveness of preconception lifestyle advice for people in the afore-mentioned population, this review cannot provide guidance for clinical practice in this area. However, it does highlight the need for further research into this important subject.

Long-term consequences of fetal and neonatal nicotine exposure: a critical review

Cigarette smoking during pregnancy is associated with numerous obstetrical, fetal, and developmental complications, as well as an increased risk of adverse health consequences in the adult offspring. Nicotine replacement therapy (NRT) has been developed as a pharmacotherapy for smoking cessation and is considered to be a safer alternative for women to smoking during pregnancy. The safety of NRT use during pregnancy has been evaluated in a limited number of short-term human trials, but there is currently no information on the long-term effects of developmental nicotine exposure in humans. However, animal studies suggest that nicotine alone may be a key chemical responsible for many of the long-term effects associated with maternal cigarette smoking on the offspring, such as impaired fertility, type 2 diabetes, obesity, hypertension, neurobehavioral defects, and respiratory dysfunction. This review will examine the long-term effects of fetal and neonatal nicotine exposure on postnatal health.

Smoking prevalence and smoking cessation services for pregnant women in Scotland

Background

Over 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later.

Methods

This was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services.

Results

13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006.

Conclusions

In Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision - identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help smokers to a make a successful attempt to quit.

OBJECTIVES

To determine the effects of motivational interviewing in promoting smoking cessation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies with terms (motivational OR motivation OR motivating OR motivate OR behavi* OR motivat*) and (interview* OR session* OR counsel* OR practi*) in the title or abstract, or as keywords. Date of the most recent search: April 2009.

SELECTION CRITERIA

Randomized controlled trials in which motivational interviewing or its variants were offered to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were treated as continuing smokers. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.

MAIN RESULTS

We identified 14 studies published between 1997 and 2008, involving over 10,000 smokers. Trials were conducted in one to four sessions, with the duration of each session ranging from 15 to 45 minutes. All but two of the trials used supportive telephone contacts, and supplemented the counselling with self-help materials. MI was generally compared with brief advice or usual care in the trials. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (RR 1.27; 95% CI 1.14 to 1.42). Subgroup analyses suggested that MI was effective when delivered by primary care physicians (RR 3.49; 95% CI 1.53 to 7.94) and by counsellors (RR 1.27; 95% CI 1.12 to 1.43), and when it was conducted in longer sessions (more than 20 minutes per session) (RR 1.31; 95% CI 1.16 to 1.49). Multiple session treatments may be slightly more effective than single sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing.Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.

AUTHORS' CONCLUSIONS

Motivational interviewing may assist smokers to quit. However, the results should be interpreted with caution due to variations in study quality, treatment fidelity and the possibility of publication or selective reporting bias.

North-South Gradients in Adverse Birth Outcomes for First Nations and Others in Manitoba, Canada

Objective

to determine the relationship of north-south place of residence to adverse birth outcomes among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance.

Study Design

Live birth records (n=151,472) for the province of Manitoba, Canada 1991–2000 were analyzed, including 25,743 First Nations and 125,729 non-First Nations infants. North-south and rural-urban residence was determined for each birth through geocoding.

Results

Comparing First Nations to non-First Nations, crude rates in North (and South) were: 7.0% versus 8.4% (9.3% versus 7.5%) for preterm birth; 6.1% versus 8.4% (8.7% versus 10.0%) for small-for-gestational-age birth, 4.2% versus 6.5% (6.2% versus 5.7%) for low birth weight, and 20.6% versus 13.7% (17.0% versus 11.0%) for large-for-gestational-age birth; and mortality per 1000 - neonatal 3.2 versus 6.2 (3.8 versus 3.3), post-neonatal 6.4 versus 6.4 (5.8 versus 1.5), and infant 9.5 versus 12.6 (9.6 versus 4.8). Adjusting for observed maternal and infant characteristics and rural versus urban residence, the North was high risk for large-for-gestational-age birth for both First Nations and non-First Nations. First Nations’ risk of preterm, small-for-gestational-age and low birth weight was lowest in the North, but for non-First Nations, the North was lower only for small-for-gestational-age. First Nations mortality indicators were similar North to South, but for non-First Nations, the North was high risk.

Conclusion

North-South place of residence does matter for adverse birth outcomes, but the effects may differ by ethnicity and could require different intervention strategies.

Prenatal tobacco prevention and cessation interventions for women in low- and middle-income countries

Although the prevalence of tobacco use is decreasing in many high-income countries, it is increasing in many low- and middle-income countries. The health and economic burden of increasing tobacco use and dependence is predictable and will have devastating effects in countries with limited resources, particularly for vulnerable populations such as pregnant women. We sought to review effective tobacco prevention and intervention strategies for decreasing tobacco use and secondhand smoke exposure before and during pregnancy in high-, middle-, and low-income countries. We reviewed several types of interventions, including population-level efforts (increasing tobacco prices, implementing tobacco control policies), community interventions, clinical interventions, and pharmacological treatments. A second purpose of this report is to present findings of an international expert working group that was convened to review the evidence and to establish research priorities in the following areas: (a) preventing the uptake and reducing tobacco use among girls and women of reproductive age; and (b) reducing tobacco use and secondhand smoke exposure among pregnant women. The working group considered the evidence on existing interventions in terms of burden of disease, intervention impact, intervention costs, feasibility of integration into existing services, uniqueness of the contribution, and overall feasibility. Finally, we present the working group's recommendations for intervention research priorities.

Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial

OBJECTIVE

This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy.

DESIGN

A randomized clinical trial was conducted from 2006 to 2008.

SETTING

Five community prenatal clinics in the San Francisco Bay Area of the United States.

PARTICIPANTS

A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking.

METHODS

Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers.

MAIN OUTCOME MEASURES

Receipt of advice from the provider and 30-day smoking abstinence, both by self-report.

RESULTS

Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12).

CONCLUSIONS

The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.

Clustering of socioeconomic, behavioural, and neonatal risk factors for infant health in pregnant smokers

Background

Tobacco smoking is a major cause of morbidity and mortality, including during pregnancy. Although effective ways of promoting smoking cessation during pregnancy exist, the impact of these interventions has not been studied at a national level. We estimated the prevalence of smoking throughout pregnancy in the Netherlands and quantified associations of maternal smoking throughout pregnancy with socioeconomic, behavioural, and neonatal risk factors for infant health and development.

Methodology/Principal Findings

Data of five national surveys, containing records of 14,553 Dutch mothers and their offspring were analyzed. From 2001 to 2007, the overall rate of smoking throughout pregnancy fell by 42% (from 13.2% to 7.6%) mainly as a result of a decrease among highly educated women. In the lowest-educated group, the overall rate of smoking throughout pregnancy was six times as high as in the highest-educated group (18.7% versus 3.2%). Prenatal tobacco smoke exposure was associated with increased risk of extremely preterm (≤28 completed weeks) (OR 7.25; 95% CI 3.40 to 15.38) and small-for-gestational age (SGA) infants (OR 3.08; 95% CI 2.66 to 3.57). Smoking-attributable risk percents in the population (based on adjusted risk ratios) were estimated at 29% for extremely preterm births and at 17% for SGA outcomes. Infants of smokers were more likely to experience significant alcohol exposure in utero (OR 2.08; 95%CI 1.25 to 3.45) and formula feeding in early life (OR 1.91; 95% CI 1.69 to 2.16).

Conclusions

The rates of maternal smoking throughout pregnancy decreased significantly in the Netherlands from 2001 to 2007. If pregnant women were to cease tobacco use completely, an estimated 29% of extremely preterm births and 17% of SGA infants may be avoided annually.

Baby BEEP: A randomized controlled trial of nurses' individualized social support for poor rural pregnant smokers

OBJECTIVES

We tested the effect of nurse-delivered telephone individualized social support ("Baby BEEP") and eight mailed prenatal smoking cessation booklets singly and in combination (2 x 2 factorial design) on smoking cessation in low-income rural pregnant women (N = 695; 75% participation).

METHODS

Participants randomized to Baby BEEP groups (n = 345) received weekly calls throughout pregnancy plus 24-7 beeper access. Saliva cotinine samples were collected monthly from all groups by other nurses at home visits up to 6 weeks post-delivery. Primary outcomes were point prevalence abstinence (cotinine < 30 ng/ml) in late pregnancy and post-delivery.

RESULTS

Only 47 women were lost to follow-up. Intent-to-treat analyses showed no difference across intervention groups (17-22%, late pregnancy; 11-13.5%, postpartum), and no difference from the controls (17%, late pregnancy; 13%, postpartum). Post hoc analyses of study completers suggested a four percentage-point advantage for the intervention groups over controls in producing early and mid-pregnancy continuous abstainers. Partner smoking had no effect on late pregnancy abstinence (OR = 1.7, 95% CI = 0.95, 3.2), but post-delivery, the effect was pronounced (OR = 3.2, 95% CI = 1.8, 5.9).

CONCLUSIONS

High abstinence rates in the controls indicate the power of biologic monitoring and home visits to assess stress, support, depression, and intimate partner violence; these elements plus booklets were as effective as more intensive interventions. Targeting partners who smoke is needed.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH STRATEGY

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in March 2007.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included. Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality. One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among nine campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the seven studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign, while another (California) showed positive results only during the period of adequate funding and implementation. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Nicotine replacement and behavioral therapy for smoking cessation in pregnancy

BACKGROUND

This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation.

METHODS

An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum.

RESULTS

Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth.

CONCLUSIONS

The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy.

Protocol for the smoking, nicotine and pregnancy (SNAP) trial: double-blind, placebo-randomised, controlled trial of nicotine replacement therapy in pregnancy

BACKGROUND

Smoking in pregnancy remains a public health challenge. Nicotine replacement therapy (NRT) is effective for smoking cessation in non-pregnant people, but because women metabolise nicotine and cotinine much faster in pregnancy, it is unclear whether this will be effective for smoking cessation in pregnancy. The NHS Health Technology Assessment Programme (HTA)-funded smoking, nicotine and pregnancy (SNAP) trial will investigate whether or not nicotine replacement therapy (NRT) is effective, cost-effective and safe when used for smoking cessation by pregnant women.

METHODS/DESIGN

Over two years, in 5 trial centres, 1050 pregnant women who are between 12 and 24 weeks pregnant will be randomised as they attend hospital for ante-natal ultrasound scans. Women will receive either nicotine or placebo transdermal patches with behavioural support. The primary outcome measure is biochemically-validated, self-reported, prolonged and total abstinence from smoking between a quit date (defined before randomisation and set within two weeks of this) and delivery. At six months after childbirth self-reported maternal smoking status will be ascertained and two years after childbirth, self-reported maternal smoking status and the behaviour, cognitive development and respiratory symptoms of children born in the trial will be compared in both groups.

DISCUSSION

This trial is designed to ascertain whether or not standard doses of NRT (as transdermal patches) are effective and safe when used for smoking cessation during pregnancy.

Tobacco cessation interventions for young people

BACKGROUND

Teenage smoking prevalence is around 15% in developing countries (with wide variation from country to country), and around 26% in the UK and USA. Although most tobacco control programmes for adolescents are based around prevention of uptake, there are also a number of initiatives to help those who want to quit. Since those who do not smoke before the age of 20 are significantly less likely to start as adults, there is a strong case for programmes for young people that address both prevention and treatment.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, and the bibliographies of identified trials. We also searched the 'grey' literature (unpublished materials), and contacted authors and experts in the field where necessary.

SELECTION CRITERIA

Types of studies: Randomized controlled trials, cluster-randomized controlled trials and controlled trials.

TYPES OF PARTICIPANTS

Young people, aged less than 20, who are regular tobacco smokers. Types of interventions: The interventions ranged from simple ones such as pharmacotherapy, targeting individual young people, through complex programmes targeting people or organizations associated with young people (for example, their families or schools), or the community in which young people live. We included cessation programmes but excluded programmes primarily aimed at prevention of uptake. Types of outcome measures: The primary outcome was smoking status at six months follow up, among those who smoked at baseline. We report the definition of cessation used in each trial (e.g seven- or thirty-day point prevalence abstinence, or sustained or prolonged abstinence), and we preferred biochemically verified cessation when that measure was available.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the eligibility of candidate trials identified by the searches, and extracted data from them. We categorized included trials as being at low, medium or high risk of bias, based on concealment of allocation, blinding (where applicable) and the handling of attrition and losses to follow up. We conducted limited meta-analyses of some of the trials, provided that it was appropriate to group them and provided that there was minimal heterogeneity between them. We estimated pooled odds ratios using the Mantel-Haenszel method, based on the quit rates at longest follow up for trials with at least six months follow up from the start of the intervention.

MAIN RESULTS

We found 15 trials, covering 3605 young people, which met our inclusion criteria (seven cluster-randomized controlled trials, six randomized controlled trials and two controlled trials). Three trials used or tested the transtheoretical model (stages of change) approach, two tested pharmacological aids to quitting (nicotine replacement and bupropion), and the remaining trials used various psycho-social interventions, such as motivational enhancement or behavioural management. The trials evaluating TTM interventions achieved moderate long-term success, with a pooled odds ratio (OR) at one year of 1.70 ( 95% confidence interval (CI) 1.25 to 2.33) persisting at two-year follow up with an OR of 1.38 (95% CI 0.99 to 1.92). Neither of the pharmacological intervention trials achieved statistically significant results (data not pooled), but both were small-scale, with low power to detect an effect. The three interventions (5 trials) which used cognitive behavioural therapy interventions did not individually achieve statistically significant results, although when the three Not on Tobacco trials were pooled the OR 1.87; (95% CI 1.00 to 3.50) suggested some measure of effectiveness. Although the three trials that incorporated motivational interviewing as a component of the intervention achieved a pooled OR of 2.05 (95% CI 1.10 to 3.80), the impossibility of isolating the effect of the motivational interviewing in these trials meant that we could not draw meaningful inferences from that analysis.

AUTHORS' CONCLUSIONS

Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence at six months), especially those incorporating elements sensitive to stage of change. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. Psycho-social interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking. There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.

Socio-demographic factors associated with smoking and smoking cessation among 426,344 pregnant women in New South Wales, Australia

Background

This study explores the socio-demographic characteristics of pregnant women who continue to smoke during the pregnancy, and identifies the characteristics of the smokers who were likely to quit smoking during the pregnancy period.

Methods

This was secondary analysis of the New South Wales (NSW) Midwives Data Collection (MDC) 1999–2003, a surveillance system covering all births in NSW public and private hospitals, as well as home births. Bivariate and multiple logistic regression analyses were performed to explore the associations between socio-demographic characteristics and smoking behaviour during pregnancy.

Results

Data from 426,344 pregnant women in NSW showed that 17.0% continued to smoke during pregnancy. The smoking rate was higher among teenage mothers, those with an Aboriginal (indigenous) background, and lower among more affluent and overseas-born mothers. This study also found that unbooked confinements, and lack of antenatal care in the first trimester were strongly associated with increased risk of smoking during pregnancy. About 4.0% of the smoking women reported they may quit smoking during their pregnancy. Findings showed that mothers born overseas, of higher socio-economic status, first time mothers and those who attended antenatal care early showed an increased likelihood of smoking cessation during pregnancy. Those who were heavy smokers were less likely to quit during pregnancy.

Conclusion

Although the prevalence of smoking during pregnancy has been declining, it remains a significant public health concern. Smoking cessation programs should target the population subgroups of women at highest risk of smoking and who are least likely to quit. Effective antismoking interventions could reduce the obstetric and perinatal complications of smoking in pregnancy.