Psychosocial interventions for supporting women to stop smoking in pregnancy

Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status: A Randomized Clinical Trial

Importance

Participation in cardiac rehabilitation is associated with significant decreases in morbidity and mortality. Despite the proven benefits, cardiac rehabilitation is severely underutilized in certain populations, specifically those with lower socioeconomic status (SES).

Objective

To assess the efficacy of early case management and/or financial incentives for increasing cardiac rehabilitation adherence among patients with lower SES.

Design, Setting, and Participants

This randomized clinical trial enrolled patients from December 2018 to December 2022. Participants were followed up for 1 year with assessors and cardiac rehabilitation staff blinded to study condition. Patients with lower SES with a cardiac rehabilitation-qualifying diagnosis (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, heart valve replacement/repair, or stable systolic heart failure) were recruited. Then patients attended one of 3 cardiac rehabilitation programs at 1 university or 2 community-based hospitals. A consecutively recruited sample was randomized and stratified by age (<57 vs ≥57 years) and smoking status (current smoker vs nonsmoker or former smoker).

Intervention

Participants were randomized 2:3:3:3 to either a usual care control, case management starting in-hospital, financial incentives for completing cardiac rehabilitation sessions, or both interventions (case management plus financial incentives). Interventions were in place for 4 months following informed consent.

Main Outcomes and Measures

The main outcome was cardiac rehabilitation adherence (proportion of patients completing ≥30 sessions). The a priori hypothesis was that interventions would improve adherence, with the combined intervention performing best.

Results

Of 314 individuals approached, 11 were ineligible, and 94 declined participation. Of the 209 individuals who were randomized, 17 were withdrawn. A total of 192 individuals (67 [35%] female; mean [SD] age, 58 [11] years) were included in the analysis. Interventions significantly improved cardiac rehabilitation adherence with 4 of 36 (11%), 13 of 51 (25%), 22 of 53 (42%), and 32 of 52 (62%) participants completing at least 30 sessions in the usual care, case management, financial incentives, and case management plus financial incentives conditions, respectively. The financial incentives and case management plus financial incentives conditions significantly improved cardiac rehabilitation adherence vs usual care (adjusted odds ratio [AOR], 5.1 [95% CI, 1.5-16.7]; P = .01; AOR, 13.2 [95% CI, 4.0-43.5]; P < .001, respectively), and the case management plus financial incentives condition was superior to both case management or financial incentives alone (AOR, 5.0 [95% CI, 2.1-11.9]; P < .001; AOR, 2.6 [95% CI, 1.2-5.9]; P = .02, respectively). Interventions were received well by participants: 86 of 105 (82%) in the financial incentives conditions earned at least some incentives, and 96 of 103 participants (93%) assigned to a case manager completed the initial needs assessment.

Conclusion and Relevance

In this randomized clinical trial, financial incentives improved cardiac rehabilitation adherence in a population with higher risk and lower SES with additional benefit from adding case management.

Trial Registration

ClinicalTrials.gov Identifier: NCT03759873.

Cervical elastography using E-Cervix™ for prediction of preterm birth in twin pregnancies with threatened preterm labor

OBJECTIVE

To evaluate the prediction performance of E-Cervix™ for preterm birth in twin pregnancies with threatened preterm labor.

METHODS

This was a single-center retrospective cohort study of twin pregnancies presenting to obstetrics triage for threatened preterm labor (PTL) between 23 0/7 - 33 6/7 weeks who received screening for PTL with transvaginal ultrasound cervical length (TVU CL) and cervical elastography with E-Cervix™ at the time of triage. Cervical elastography parameters were examined and compared between women who delivered preterm and those who did not. The quantification of cervical strain was calculated by a data analysis system that directly analyzes raw data from the region of interest (ROI) and described as hardness ratio (HR), mean strain level within 1 cm from internal (IOS) and external (EOS) os.

RESULTS

63 twin gestations without prior preterm birth and with threatened PTL between 23 0/7 - 33 6/7 weeks of gestation were included in the study. 27 (42.9 %) had cervical length < 25 mm, and were admitted for true PLT. Out of the 36 women with cervical length ≥ 25 mm, 6 (16.7 %) were admitted. Women with threatened PTL had significantly higher HR compared to those with true PTL (p < 0.01), and significantly lower IOS and EOS. Women who delivered preterm had significantly higher HR compared to those who did not delivery preterm and significantly lower IOS and EOS, in overall cohort, and in the subset of women with true PTL. Incidences of HR < 50 % and < 35 % were statistically significantly higher in women who delivered preterm compared to those who did not (p < 0.01).

CONCLUSION

Cervical elastography with E-Cervix™ may be useful for assessment of twin gestations presenting to obstetrics triage for threatened PTL.

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

Factors associated with the implementation of the 5As model of smoking cessation support during pregnancy: A scoping review

INTRODUCTION

The prevalence of smoking among pregnant women is the highest in the European region, making smoking cessation a public health priority. In order to address this, pregnant smokers need to be better supported by their healthcare professionals in their attempts to quit smoking. The 5As model, which is a psychosocial intervention, seems to be effective in this specific population. The objective of this review is to identify the factors that act as barriers or facilitators to the implementation of the 5As model within prenatal practices.

METHODS

We conducted a scoping review of the literature on PubMed and Scopus databases, using the terms: 'smoking cessation', 'pregnan*', and ('5A' or '5As'). The identified factors were categorized using a theoretical framework of The European Observatory on Health Systems and Policies.

RESULTS

Among the 43 articles identified in the databases, 13 articles were included in this review. In total, we identified 48 factors. When necessary, we grouped them together, resulting in 12 sub-categories, which in turn were grouped into 9 categories. Those 9 categories were then classified into the 3 levels of the theoretical framework: the clinical level (motivation), the organizational level (healthcare pathway), and the health system level (political environment).

CONCLUSIONS

The factors identified are varied and numerous and are involved in each level of the theoretical framework.

Helping pregnant smokers quit: a multi-centre randomised controlled trial of electronic cigarettes versus nicotine replacement therapy

Background

Some pregnant smokers try e-cigarettes, but effectiveness and safety of such use are unknown.

Objectives

To compare effectiveness and safety of nicotine patches and e-cigarettes in pregnancy.

Design

A pragmatic multi-centre randomised controlled trial.

Setting

Twenty-three hospitals across England, and a Stop Smoking Service in Scotland.

Participants

One thousand one hundred and forty pregnant daily smokers (12-24 weeks' gestation) motivated to stop smoking, with no strong preference for using nicotine patches or e-cigarettes.

Interventions

Participants in the e-cigarette arm were posted a refillable e-cigarette device with two 10 ml bottles of tobacco-flavoured e-liquid (18 mg nicotine). Participants in the nicotine patches arm were posted a 2-week supply of 15 mg/16-hour nicotine patches. Supplies were provided for up to 8 weeks. Participants sourced further supplies themselves as needed. Participants in both arms received support calls prior to their target quit date, on the quit date, and weekly for the next 4 weeks.

Outcome measures

The primary outcome was validated prolonged abstinence at the end of pregnancy. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. Secondary outcomes included self-reported abstinence at different time points, treatment adherence and safety outcomes.

Results

Only 55% of self-reported abstainers mailed back useable saliva samples. Due to this, validated sustained abstinence rates were low (6.8% vs. 4.4% in the e-cigarettes and nicotine patches arms, respectively, risk ratio = 1.55, 95% confidence interval 0.95 to 2.53; Bayes factor = 2.7). In a pre-specified sensitivity analysis that excluded abstainers using non-allocated products, the difference became significant (6.8% vs. 3.6%, risk ratio = 1.93, 95% confidence interval 1.14 to 3.26; Bayes factor = 10). Almost a third of the sample did not set a target quit date and the uptake of support calls was low, as was the initial product use. At end of pregnancy, 33.8% versus 5.6% of participants were using their allocated product in the e-cigarettes versus nicotine patches arm (risk ratio = 6.01, 95% confidence interval 4.21 to 8.58). Regular use of e-cigarettes in the nicotine patches arm was more common than use of nicotine replacement products in the e-cigarette arm (17.8% vs. 2.8%). Rates of adverse events and adverse birth outcomes were similar in the two study arms, apart from participants in the e-cigarette arm having fewer infants with low birthweight (<2500 g) (9.6% vs. 14.8%, risk ratio = 0.65, 95% confidence interval 0.47 to 0.90; Bayes factor = 10.3).

Limitations

Low rates of validation reduced the study power. A substantial proportion of participants did not use the support on offer sufficiently to test its benefits. Sample size may have been too small to detect differences in less frequent adverse effects.

Conclusions

E-cigarettes were not significantly more effective than nicotine patches in the primary analysis, but when e-cigarettes use in the nicotine patches arm was accounted for, e-cigarettes were almost twice as effective as patches in all abstinence outcomes. In pregnant smokers seeking help, compared to nicotine patches, e-cigarettes are probably more effective, do not pose more risks to birth outcomes assessed in this study and may reduce the incidence of low birthweight.

Future work

Routine monitoring of smoking cessation and birth outcomes in pregnant women using nicotine patches and e-cigarettes and further studies are needed to confirm these results.

Trial registration

This trial is registered as ISRCTN62025374 and Eudract 2017-001237-65.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 13. See the NIHR Journals Library website for further project information.

Financial incentives and case management to improve cardiac rehabilitation participation among patients with lower socio-economic status: Rationale and protocol for a randomized controlled trial

BACKGROUND

Participation in phase 2 cardiac rehabilitation (CR) is associated with significant decreases in morbidity and mortality. Unfortunately, attendance at CR is not optimal and certain populations, such as those with lower-socioeconomic status (SES), are less likely to participate. In order to remedy this disparity we have designed a trial to examine the efficacy of early case management and/or financial incentives for increasing CR participation among lower-SES patients.

METHODS

We will employ a randomized controlled trial with a sample goal of 209 patients who will be randomized 2:3:3:3 to either a usual care control, to receive a case manager starting in-hospital, to receive financial incentives for completing CR sessions, or to receive both interventions.

RESULTS

Treatment conditions will be compared on attendance at CR and end-of-intervention (four months) improvements in cardiorespiratory fitness, executive function, and health-related quality of life. The primary outcome measures for this project will be number of CR sessions completed and the percentage who complete ≥30 sessions. Secondary outcomes will include improvements in health outcomes by condition, as well as the cost-effectiveness of the intervention with a focus on potential reductions in emergency department visits and hospitalizations. We hypothesize that either intervention will perform better than the control and that the combination of interventions will perform better than either alone.

CONCLUSIONS

This systematic examination of interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to increase CR participation substantially and significantly improve health outcomes among patients with lower-SES.

Active or passive maternal smoking increases the risk of low birth weight or preterm delivery: Benefits of cessation and tobacco control policies

In France, maternal smoking, active or passive, remains one of the highest in Europe. At the same time, there is an increase in the number of low birth weight (<2500 g) and premature (<37 weeks of amenorrhea) newborns. The objective of this narrative review is to examine the impact of active or passive maternal smoking on birth weight or prematurity rates, and to consider the benefits of policies to stop or control smoking. This is a narrative review that analyzes and discusses the major articles published over the past 20 years regarding the role of active or passive maternal smoking on the risk of low birth weight or preterm delivery. Articles were selected using the following keywords: maternal smoking, low birth weight, preterm birth, smoking cessation, passive smoking, exhaled carbon monoxide, tobacco control policies. Active smoking is associated, in a dose-response relationship, with increased risks of low birth weight and preterm delivery. Passive smoking, mainly related to the presence of a smoking spouse, increases the risk of low birth weight and preterm birth. Our review confirmed also the benefits of smoking cessation, even in the third trimester, in reducing the risk of small for gestation age or fetal growth restriction and preterm birth. Several studies of tobacco control policies have been shown to be effective in significantly reducing maternal smoking. There is sufficient evidence to infer a causal link between active or passive maternal smoking and low birth weight or preterm delivery. This causal link is compelling and sufficient to justify intensifying efforts to promote rapid progress in tobacco control policies, with the vision of a tobacco-free generation, and smoking cessation with best practices during preconception or pregnancy.

Interventions for the prevention of spontaneous preterm birth: a scoping review of systematic reviews

BACKGROUND

Globally, 11% of babies are born preterm each year. Preterm birth (PTB) is a leading cause of neonatal death and under-five mortality and morbidity, with lifelong sequelae in those who survive. PTB disproportionately impacts low/middle-income countries (LMICs) where the burden is highest.

OBJECTIVES

This scoping review sought to the evidence for interventions that reduce the risk of PTB, focusing on the evidence from LMICs and describing how context is considered in evidence synthesis.

DESIGN

We conducted a scoping review, to describe this wide topic area. We searched five electronic databases (2009-2020) and contacted experts to identify relevant systematic reviews of interventions to reduce the risk of PTB. We included published systematic reviews that examined the effectiveness of interventions and their effect on reducing the risk of PTB. Data were extracted and is described narratively.

RESULTS

139 published systematic reviews were included in the review. Interventions were categorised as primary or secondary. The interventions where the results showed a greater effect size and consistency across review findings included treatment of syphilis and vaginal candidiasis, vitamin D supplementation and cervical cerclage. Included in the 139 reviews were 1372 unique primary source studies. 28% primary studies were undertaken in LMIC contexts and only 4.5% undertaken in a low-income country (LIC) Only 10.8% of the reviews sought to explore the impact of context on findings, and 19.4% reviews did not report the settings or the primary studies.

CONCLUSION

This scoping review highlights the lack of research evidence derived from contexts where the burden of PTB globally is greatest. The lack of rigour in addressing contextual applicability within systematic review methods is also highlighted. This presents a risk of inappropriate and unsafe recommendations for practice within these contexts. It also highlights a need for primary research, developing and testing interventions in LIC settings.

Maternal Smoking, Alcohol and Recreational Drug Use and the Risk of SIDS Among a US Urban Black Population

BACKGROUND

Rates of sudden infant death syndrome (SIDS) are twice as high among Black infants compared to white infants in the US. While the contribution of sleep environment factors to this disparity is known, little is known about the risk of SIDS among Black infants in relation to maternal prenatal smoking, alcohol and drug use as well as infant smoke exposure.

OBJECTIVE

To assess the contribution of maternal substance use during pregnancy and the potential interactions with infant bedsharing in a high-risk, urban Black population.

METHODS

The Chicago Infant Mortality Study (CIMS) collected data on 195 Black infants who died of SIDS and 195 controls matched on race, age and birthweight. Risk of SIDS was calculated for maternal smoking, alcohol and drug use, adjusting for potential confounding variables and other risk factors for SIDS. Interactions between these substance use variables and bedsharing were also calculated.

RESULTS

Infants were more likely to die from SIDS if the mother smoked during pregnancy (aOR 3.90, 95% CI 1.37-3.30) and post-pregnancy (aOR 2.49, 95% CI 1.49-4.19). There was a dose response seen between amount smoked during pregnancy and risk of SIDS. Use of alcohol (aOR 2.89, 95% CI 1.29-6.99), cocaine (aOR 4.78, 95% CI 2.45-9.82) and marijuana (aOR 2.76, 95% CI 1.28-5.93) were associated with increased risk of SIDS. In the final, multivariable model controlling for sociodemographic factors and covariates, maternal smoking (aOR 3.03, 95% CI 1.03-8.88) and cocaine use (aOR 4.65, 95% CI 1.02-21.3) during pregnancy remained significant. There were significant, positive interactions between bedsharing and maternal smoking during pregnancy and post-pregnancy, alcohol use and cocaine use.

CONCLUSION

Maternal use of tobacco, alcohol and cocaine during pregnancy is associated with significantly increased risk of SIDS in a Black, urban population. Reducing substance use and eliminating disparities in SIDS, sudden unexpected infant death (SUID) (also known as sudden unexpected death in infancy or SUDI) and infant mortality need to involve more than individual level education, but instead will require a comprehensive examination of the role of social determinants of health as well as a multi-pronged approach to address both maternal and infant health and wellbeing.

Willingness to Oppose Smoking among Pregnant Women

Even though smoking causes numerous threats to the developing foetus, it is the most common addiction in Polish women of reproductive age. Most studies undertake to examine the subject of opposing second-hand smoking or creating tools to reprimand pregnant women more effectively using a qualitative methodology. The study aimed to determine the profile of a pregnant woman who is willing to oppose the smoking of another pregnant woman. The research was conducted using an original multiple-choice questionnaire. The survey was shared on websites for expecting parents. Completed questionnaires were collected from 11,448 pregnant women. The Wald test for logistic regression was used for statistical analysis. Predictors of whether someone would draw another pregnant women's attention to the fact that smoking is harmful were: intellectual work (OR 1.136; p-value 0.020) and currently being a student (OR 1.363; p-value 0.004), involvement of the child's father (OR 1.377; p-value < 0.001), contact with social campaigns (OR 1.150; p-value 0.005) and knowledge about the consequences of smoking, as well as talking to the midwife about the harmfulness of cigarettes during pregnancy (OR 1.655; p-value < 0.001). Interpersonal relationships leave scope for public health interventions. It is worth enhancing criticism against smoking by specialists through information and education campaigns.

Bridging the postpartum gap: best practices for training of obstetrical patient navigators

The postpartum period represents a critical window of opportunity to improve maternal short- and long-term health, including optimizing postpartum recovery, providing effective contraception, caring for mood disorders, managing weight, supporting lactation, initiating preventive care, and promoting cardiometabolic health. However, inadequate postpartum care, especially for individuals facing social and structural barriers, is common in the United States and contributes to suboptimal health outcomes with lasting consequences. Patient navigation is a patient-centered intervention that uses trained personnel to identify financial, cultural, logistical, and educational obstacles to effective healthcare and to mitigate these barriers to facilitate comprehensive and timely access to needed health services. Given the emerging evidence suggesting that patient navigation may be a promising method to improve health among postpartum individuals, our team developed a postpartum patient navigator training guide to be used in the Navigating New Motherhood 2 and other obstetrical navigation programs. Navigating New Motherhood 2 is a randomized trial exploring whether patient navigation by a trained, lay postpartum navigator for individuals with a low income can improve health and patient-reported outcomes during and after the postpartum period. Hiring and training patient navigators without health professional degrees are integral components of initiating a navigation program. However, patient navigator training is highly variable, and no guideline regarding key elements in such a training program exists for obstetrics specifically. Thus, this paper aimed to describe the core principles, content, and rationale for each element in a comprehensive postpartum patient navigator training program. Training should be centered around the following 6 core elements: (1) principles of patient navigation; (2) knowledge of pregnancy and postpartum care; (3) health education and health promotion principles; (4) cultural sensitivity and health equity; (5) care coordination and community resources; and (6) electronic medical record systems. These core elements can serve as a basis for the development of adaptable curricula for several institutions and contexts. In addition, we offer recommendations for the implementation of a navigator training program. A curriculum with built-in flexibility to meet community and institutional needs may promote the effective and sustainable use of patient navigation in the postpartum context.

Childhood Origins of Adult Lung Disease as Opportunities for Prevention

Prenatal and childhood exposures have been shown to impact lung development, lung function trajectory, and incidence and prevalence of respiratory disease. Early life may serve as a window of susceptibility to such exposures, with the potential to influence lifelong respiratory health. Risk factors encountered in early life with potentially durable impact on lung health include prematurity, respiratory viral illness, allergen sensitization and exposure, tobacco use and exposure, indoor and outdoor pollution, diet, and obesity. These exposures vary in the extent to which they are modifiable, and interventions aimed at reducing harmful exposures range from individual-level behavior modification to policy initiatives implemented to promote population health. For many exposures, including tobacco-related exposures, multilevel interventions are needed. Future research is needed to provide insight as to early-life interventions to promote optimal lung growth and prevent development of chronic respiratory disease. Clinicians should play an active role, assisting individual patients in avoiding known detrimental exposures including maternal smoking during pregnancy and initiation of active smoking. Clinicians can be empowered by evidence to support policies promoting reduction of population-level risk factors, such as restriction on electronic cigarette sales and legislation to uphold air quality standards, to encourage attainment of maximal lung function and reduce risk of chronic lung disease.

Protocol for a randomised trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada)

INTRODUCTION

The 'Developmental Origins of Health and Disease' hypothesis suggests that a healthy trajectory of growth and development in pregnancy and early childhood is necessary for optimal health, development and lifetime well-being. The purpose of this paper is to present the protocol for a randomised controlled trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada). The primary objective of HeLTI Canada is to determine whether a 4-phase 'preconception to early childhood' lifecourse intervention can reduce the rate of child overweight and obesity. Secondary objectives include improved child: (1) growth trajectories; (2) cardiometabolic risk factors; (3) health behaviours, including nutrition, physical activity, sedentary behaviour and sleep; and (4) development and school readiness at age 5 years.

METHOD AND ANALYSIS

A randomised controlled multicentre trial will be conducted in two of Canada's highly populous provinces-Alberta and Ontario-with 786 nulliparous (15%) and 4444 primiparous (85%) women, their partners and, when possible, the first 'sibling child.' The intervention is telephone-based collaborative care delivered by experienced public health nurses trained in healthy conversation skills that includes detailed risk assessments, individualised structured management plans, scheduled follow-up calls, and access to a web-based app with individualised, evidence-based resources. An 'index child' conceived after randomisation will be followed until age 5 years and assessed for the primary and secondary outcomes. Pregnancy, infancy (age 2 years) and parental outcomes across time will also be assessed.

ETHICS AND DISSEMINATION

The study has received approval from Clinical Trials Ontario (CTO 1776). The findings will be published in peer-reviewed journals and disseminated to policymakers at local, national and international agencies. Findings will also be shared with study participants and their communities.

TRIAL REGISTRATION NUMBER

ISRCTN13308752; Pre-results.

A Qualitative Study of Factors Influencing Adherence among Pregnant Women Taking Part in a Trial of E-Cigarettes for Smoking Cessation

Use of e-cigarettes (vaping) has potential to help pregnant women stop smoking. This study explored factors influencing adherence among participants in the vaping arm of the first trial of vaping for smoking cessation in pregnancy. We conducted semi-structured telephone interviews (n = 28) with women at three-months postpartum. Interviews were analysed using thematic analysis, informed by the Theoretical-Domains Framework, Necessity-Concerns Framework and Perceptions and Practicalities Approach. Interviewees generally reported high levels of vaping. We found that: (1) intervention adherence was driven by four necessity beliefs-stopping smoking for the baby, and vaping for harm reduction, smoking cessation or as a last resort; (2) necessity beliefs outweighed vaping concerns, such as dependence and safety; (3) adherence was linked to four practicalities themes, acting as barriers and facilitators to vaping-device and e-liquid perceptions, resources and support, whether vaping became habitual, and social and environmental factors; and (4) intentional non-adherence was rare; unintentional non-adherence was due to device failures, forgetting to vape, and personal circumstances and stress. Pregnant smokers provided with e-cigarettes, and with generally high levels of vaping, had positive beliefs about the necessity of vaping for smoking cessation which outweighed concerns about vaping. Non-adherence was mainly due to unintentional factors.

Stillbirth in Australia 2: Working together to reduce stillbirth in Australia: The Safer Baby Bundle initiative

The rate of late gestation stillbirth in Australia is unacceptably high. Up to one third of stillbirths are preventable, particularly beyond 28 weeks' gestation. The aim of this second paper in the Stillbirth in Australia series is to highlight one key national initiative, the Safer Baby Bundle (SBB), which has been led by the Centre of Research Excellence in Stillbirth in partnership with state health departments. Addressing commonly identified evidence practice gaps, the SBB contains five elements that, when implemented together, should result in better outcomes than if performed individually. This paper describes the development of the SBB, what the initiative aims to achieve, and progress to date. By collaborating with Departments of Health and other partners to amplify uptake of the SBB, we anticipate a reduction of at least 20% in Australia's stillbirth rate after 28 weeks' gestation is achievable.

Decreasing smoking during pregnancy: Potential economic benefit of reducing sudden unexpected infant death

Sudden Unexpected Infant Death (SUID) remains the leading cause of death among U.S. infants age 1-12 months. Extensive epidemiological evidence documents maternal prenatal cigarette smoking as a major risk factor for SUID, but leaves unclear whether quitting reduces risk. This Commentary draws attention to a report by Anderson et al. (Pediatrics. 2019, 143[4]) that represents a breakthrough on this question and uses their data on SUID risk reduction to delineate potential economic benefits. Using a five-year (2007-11) U.S. CDC Birth Cohort Linked Birth/Infant Death dataset, Anderson et al. demonstrated that compared to those who continued smoking, women who quit or reduced smoking by third trimester decreased the adjusted odds of SUID risk by 23% (95% CI, 13%-33%) and 12% (95% CI, 2%-21%), respectively. We applied these reductions to the U.S. Department of Health and Human Services' recommended value of a statistical life in 2020 ($10.1 million). Compared to continued smoking during pregnancy, the economic benefits per woman of quitting or reducing smoking are $4700 (95% CI $2700-$6800) and $2500 (95% CI, $400-$4300), respectively. While the U.S. obtained aggregate annual economic benefits of $0.58 (95% CI, 0.35-0.82) billion from pregnant women who quit or reduced smoking, it missed an additional $1.16 (95%CI 0.71-1.60) billion from the women who continued smoking. Delineating the health and economic impacts of decreasing smoking during pregnancy using large epidemiological studies like Anderson et al. is critically important for conducting meaningful economic analyses of the benefits-costs of developing more effective interventions for decreasing smoking during pregnancy.

Reducing tobacco use among women of childbearing age: Contributions of tobacco regulatory science and tobacco control

Tobacco use has unique, adverse health consequences for reproductive-aged women, particularly should these women become pregnant. Thus, successful efforts to reduce tobacco use among this population have strong potential to improve public health and reduce health disparities. The present review examines contributions to reducing tobacco use among women of childbearing age spanning the domains of tobacco regulatory science and tobacco control from the passage of the Family Smoking Prevention and Tobacco Control Act in 2009 through September 2019. In the domain of tobacco regulatory science, such efforts include research conducted by various National Institutes of Health/Food and Drug Administration (FDA)-supported Tobacco Centers of Regulatory Science, epidemiological surveillance studies, as well as studies examining the potential impact of tobacco regulatory policies currently under consideration by the FDA (e.g., reduced nicotine content cigarettes, health warning labels). Tobacco control efforts within this same 10-year timeframe include developments in pharmacological and psychosocial approaches to promoting tobacco cessation, mHealth interventions, and tobacco control policy. Emerging issues pertinent to ongoing efforts to reduce tobacco use within the domains of both tobacco regulatory science and tobacco control are also reviewed, including e-cigarettes, comorbid health conditions, course of tobacco and other drugs of abuse, and obstacles to the dissemination and implementation of evidence-based treatment and policy. Although the past decade has seen numerous important contributions to reducing tobacco use among reproductive-aged women within both domains, existing obstacles must be surmounted to continue reducing tobacco use and protecting health among this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evaluation of a Text Messaging Intervention to Support Self-Management of Diabetes During Pregnancy Among Low-Income, Minority Women: Qualitative Study

Background

Given the growing burden of diabetes in underserved communities and the complexity of diabetes self-management during pregnancy, the development of interventions to support low-income pregnant women with diabetes is urgently needed.

Objective

This study aims to develop and pilot test a theory-driven curriculum of SMS text messaging for diabetes support and education during pregnancy.

Methods

This was a prospective pilot investigation of a novel SMS text messaging intervention offered to pregnant women with pregestational or gestational diabetes mellitus and publicly funded prenatal care. Prior work yielded a conceptual model of diabetes self-management barriers and support factors in this population, which was used to guide curriculum development along with health behavior theories. Participants received three supportive or educational one-way text messages per week during pregnancy. In-depth semistructured interviews were performed at study exit to solicit feedback on the program. Narrative data were analyzed using the constant comparative technique to identify themes and subthemes.

Results

Participants (N=31 enrolled and n=26 completed both interviews) consistently reported that SMS text messaging provided enhanced motivation for diabetes self-care, reduced diabetes-related social isolation, increased perceived diabetes-associated knowledge, enhanced comfort with the health care team, and reduced logistical burdens of diabetes during pregnancy. Participants requested enhanced interactive and customizable features in future intervention iterations.

Conclusions

Pregnant women with diabetes who were enrolled in this pilot study of an SMS text messaging curriculum for diabetes support described enhanced motivation, knowledge, and comfort with diabetes self-care activities as a result of the health education intervention. The next steps include enriching the interactive features of the intervention and investigating the effect of the intervention on perinatal outcomes.

The effectiveness of smoking cessation, alcohol reduction, diet and physical activity interventions in changing behaviours during pregnancy: A systematic review of systematic reviews

BACKGROUND

Pregnancy is a teachable moment for behaviour change. Multiple guidelines target pregnant women for behavioural intervention. This systematic review of systematic reviews reports the effectiveness of interventions delivered during pregnancy on changing women's behaviour across multiple behavioural domains.

METHODS

Fourteen databases were searched for systematic reviews published from 2008, reporting interventions delivered during pregnancy targeting smoking, alcohol, diet or physical activity as outcomes. Data on behaviour change related to these behaviours are reported here. Quality was assessed using the JBI critical appraisal tool for umbrella reviews. Consistency in intervention effectiveness and gaps in the evidence-base are described.

RESULTS

Searches identified 24,388 results; 109 were systematic reviews of behaviour change interventions delivered in pregnancy, and 36 reported behavioural outcomes. All smoking and alcohol reviews identified reported maternal behaviours as outcomes (n = 16 and 4 respectively), whereas only 16 out of 89 diet and/or physical activity reviews reported these behaviours. Most reviews were high quality (67%) and interventions were predominantly set in high-income countries. Overall, there was consistent evidence for improving healthy diet behaviours related to increasing fruit and vegetable consumption and decreasing carbohydrate intake, and fairly consistent evidence for increase in some measures of physical activity (METs and VO2 max) and for reductions in fat intake and smoking during pregnancy. There was a lack of consistent evidence across reviews reporting energy, protein, fibre, or micronutrient intakes; smoking cessation, abstinence or relapse; any alcohol behaviours.

CONCLUSIONS

The most consistent review evidence is for interventions improving dietary behaviours during pregnancy compared with other behaviours, although the majority of diet reviews prioritised reporting health-related outcomes over behavioural outcomes. Heterogeneity between reported behaviour outcomes limits ability to pool data in meta-analysis and more consistent reporting is needed. Limited data are available for alcohol interventions in pregnancy or interventions in low- or middle-income-countries, which are priority areas for future research.

Are personality traits associated with smoking and alcohol use prior to and during pregnancy?

Cigarette smoking and alcohol consumption during pregnancy can have detrimental effects on the developing fetus, including fetal alcohol syndrome and low birth weight. Surprisingly little is known about the association of personality traits with smoking and alcohol consumption in the specific subpopulation of pregnant women. This study analyzed data from a geographically diverse sample of 603 pregnant women, aged 18 years and older, who provided information regarding their smoking and drinking habits before and during pregnancy. We compared women who consumed alcohol or smoked cigarettes before pregnancy with women who quit or continued smoking or drinking during pregnancy. Associations between personality and maladaptive behaviors prior to and during pregnancy were modeled using logistic regression. The study revealed that women who scored high on openness to experience were significantly more likely to continue alcohol consumption during pregnancy (OR = 1.07, 95% CI 1.01, 1.14, p = .02). This association was maintained after adjusting for potential confounds. This study demonstrated a significant relationship between personality traits and women's likelihood of continued alcohol consumption prior to and during pregnancy. Understanding personality-based determinants of health-detrimental behavior is important in order to design interventions that aim at decreasing rates of maladaptive health behaviors among pregnant women.

Midwives' engagement in smoking- and alcohol-prevention in prenatal care before and after the introduction of practice guidelines in Switzerland: comparison of survey findings from 2008 and 2018

Background

Evidence suggests that cigarette smoking and alcohol consumption during pregnancy negatively impacts fetal health. Health agencies across countries have developed specific guidelines for health professionals in perinatal care to strengthen their role in smoking and alcohol use prevention. One such example is the “Guideline on Screening and Counselling for prevention of cigarette smoking and alcohol consumption before, during, and after pregnancy” introduced by the Swiss Midwives Association in 2011. The current study assesses the changes in midwives’ engagement in smoking and alcohol use prevention before (2008) and after the introduction of the Guideline (2018). Further, the current study examines differences across regions (German vs. French speaking regions), graduation years (before and after the introduction of the Guideline) and different work settings (hospital vs. self-employed).

Methods

Survey data were collected in 2008 (n = 366) and in 2018 (n = 459). Differences in how midwives engaged in smoking and alcohol use prevention between 2008 and 2018 were assessed with chi-square tests, as were differences across German and French speaking regions, graduation years (before and after the introduction of the Guideline) and across different work settings (working in hospitals or as self-employed).

Results

An increase in midwives’ awareness of the risks of consuming even small quantities of cigarettes and alcohol for the unborn child between 2008 and 2018 is evident. Explaining the risks to pregnant women who smoke or use alcohol remained the most frequently reported prevention strategy. However, engagement with more extensive smoking and alcohol use preventive strategies across the whole course of pregnancy, such as assisting women in the elaboration of a plan to stop smoking/alcohol use, remained limited.

Conclusions

Seven years after its introduction, the effectiveness of the Guideline in increasing midwives’ engagement in smoking and alcohol use prevention appears limited despite midwives’ increased awareness.

Effects of Financial Incentives for Smoking Cessation on Mood and Anxiety Symptoms Among Pregnant and Newly Postpartum Women

Introduction

Financial incentives for smoking cessation increase smoking abstinence and decrease Beck Depression Inventory (BDI) scores among depression-prone pregnant and postpartum women. The present study is a secondary analysis using the Brief Symptom Inventory (BSI) to examine whether this treatment impacts a broader array of mood and anxiety symptoms.

Methods

Participants (N = 253) were pregnant cigarette smokers who participated in four controlled clinical trials examining the efficacy of financial incentives for smoking cessation. Women were assigned to an intervention wherein they earned vouchers exchangeable for retail items contingent on smoking abstinence (Contingent, n = 143) or a control condition wherein they received comparable vouchers independent of smoking status (Noncontingent, n = 110). Participants were categorized as depression-prone (n = 105) or depression-negative (n = 148) based on self-reported history of depression and BDI scores at intake. A prior study demonstrated that financial incentives decreased depressive symptoms among depression-prone women in this sample. The present study examined whether those effects extended to a broader array of mood and anxiety symptoms using the BSI. Effects of treatment, time, and depression status were examined using repeated measures analyses of covariance.

Results

In addition to depressive symptoms, financial incentives reduced a multitude of BSI scores among depression-prone women, including the BSI global measure of distress and seven symptom subscales. Treatment effects were discernible by late pregnancy, peaked at 8 weeks postpartum, and dissipated by 24 weeks postpartum.

Discussion

In addition to reducing smoking, this financial incentives treatment appears to reduce a range of mood and anxiety symptoms among depression-prone pregnant and postpartum women.

Implications

This study adds evidence that providing financial incentives contingent on smoking cessation lowers a broad array of psychiatric symptoms, as measured by the BSI, among depression-prone pregnant and newly postpartum women during a time of heightened risk for peripartum mood disorders.

Factors associated with post-partum smoking relapse in Taiwan: A trial of Smoker's helpline

OBJECTIVE

Many women quit smoking during pregnancy resume in postpartum period and difficult to prevent. No studies had focused on their psychosocial response in Taiwan. We analyzed data from a trial of Taiwan Smoker's Helpline (TSH) to determine factors associated with smoking relapse after delivery.

MATERIALS AND METHODS

A prospective cohort was conducted at Taipei City Hospital during Sep. 2014 and Nov. 2015 period. We collected data by self-developed questionnaire combining theory of planned behavior (TPB), Fagerstrom test for nicotine dependence (FTND) and Edinburgh Postnatal Depression Scale (EPDS) from 68 women immediately after delivery, 2 months later and followed up until 6 months. Multivariable logistic models for relapse of smoking at the end of 3rd month and 6th month were created.

RESULTS

At 6th month, 42.6% participants relapsed with odds lower among first parity (OR = 0.04, 95% CI = <0.01-0.54, p = 0.015), having quitting experience in past (OR = 0.09, 95% CI = 0.01-0.84, p = 0.019) and higher perceived behavior control (PBC) (OR = 0.99, 95% CI = 0.98-1.00, p = 0.035), but greater for those with longer smoking duration in past (OR = 1.29, 95% CI = 1.04-1.58, p = 0.018).

CONCLUSION

Protective and precipitating factors to post-partum's smoking relapse were identified in our study.

Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions

The United States lags far behind other industrialized countries on major markers of population health. Population health experts identify unhealthy behavior patterns (e.g., cigarette smoking, other substance use disorders, physical inactivity and poor food choices, nonadherence with recommended medical regimens) as the largest contributor to the status quo. Because these risk behaviors are overrepresented in socioeconomically disadvantaged and other vulnerable populations, they also increase health disparities. Hence, identifying evidence-based strategies to promote and sustain health-related behavior change is critical to improving U.S. population health. In this report, we review research demonstrating the efficacy of voucher-based contingency management delivered alone or in combination with other interventions for treating substance use disorders and other health-related behavior problems. The efficacy supporting these interventions is robust and discernible at the level of controlled randomized clinical trials and meta-analyses. Unfortunately, these evidence-based interventions are being underutilized in routine clinical care for substance use disorders, although they are used broadly in private-sector wellness programs and international programs to reduce chronic poverty. This report reviews the evidence supporting the efficacy of voucher-based contingency management using projects developed at the University of Vermont as exemplars and discusses dissemination of the model to public and private sector efforts to improve individual and population health.

Identifying Effective Behavior Change Techniques for Alcohol and Illicit Substance Use During Pregnancy: A Systematic Review

BACKGROUND

During pregnancy, consuming alcohol and using illicit drugs can have serious health implications for both mother and child. Behavioral change interventions, especially those underpinned by theoretical constructs, can be effective in reducing harmful substance use among pregnant women.

PURPOSE

To understand what type of behavior change mechanisms could be useful in reducing alcohol consumption or achieving abstinence from illicit drug use during pregnancy, this review aimed to identify behavior change techniques (BCTs), the smallest, active components of interventions that may be effective. It also aimed to establish the extent that psychosocial-based theories were used to inform intervention design.

METHODS

To identify eligible randomized controlled trials (RCTs), five databases were searched electronically from the end search dates of the most recent Cochrane systematic reviews on behavioral interventions for each behavior, until March 2018. Within the RCTs, intervention descriptions were analyzed for BCT content and extent of theory use in the intervention design process and outcome measurements, in each trial, was established. "Effectiveness percentages," the number of times a BCT had been a component of an effective intervention divided by the total number of interventions it had been used in, were calculated for BCTs used in two or more trials.

RESULTS

Including all RCTs from the Cochrane reviews, and those published subsequently, nine alcohol and six illicit drug trials were identified. Interventions tested in four alcohol RCTs and no illicit drugs RCTs showed positive results. Subsequent data were extracted for alcohol consumption trials only. Thirteen BCTs showed "potential effectiveness" for alcohol consumption. Six of nine included alcohol trials reported using theory but not extensively.

CONCLUSIONS

Action planning, behavioral contract, prompts/cues, self-talk, offer/direct toward written material, problem solving, feedback on behavior, social support (unspecified), information about health consequences, behavior substitution, assess current readiness and ability to reduce excess alcohol consumption, goal setting (behavior), and tailor interactions appropriately are BCTs that could be useful in helping reduce alcohol consumption among pregnant women.

Is the apparently protective effect of maternal nicotine replacement therapy (NRT) used in pregnancy on infant development explained by smoking cessation?: secondary analyses of a randomised controlled trial

OBJECTIVE

To investigate relationships between maternal smoking status in pregnancy and infant development. The largest randomised controlled trial of nicotine replacement therapy (NRT) for smoking cessation in pregnancy, the smoking, nicotine and pregnancy (SNAP) trial, found that at 1 month after randomisation, smoking cessation rates were doubled in the NRT group compared with the placebo group. At delivery, there was no significant difference in cessation rates between groups. Surprisingly, infants born to women randomised to NRT were more likely to have unimpaired development at 2 years. We hypothesised that this apparently protective effect was due to smoking cessation caused by NRT and so, investigate this relationship using the same cohort.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

Seven antenatal hospitals in the Midlands and North-West England.

PARTICIPANTS

Eight hundred and eighty-four pregnant smokers randomised to receive either NRT patches or visually-identical placebo in the SNAP trial. Participants' smoking behaviour were recorded at randomisation, 1 month after their target quit date and at delivery.

METHODS

Using logistic regression models, we investigated associations between participants' smoking measures and infant development (assessed using the Ages and Stages questionnaire) at 2 years.

MAIN OUTCOME MEASURES

2 year infant development.

RESULTS

Developmental impairment was reported for 12.7% of study 2 year olds. Maternal heaviness of smoking at randomisation (OR: 1.26, 95% CI: 0.82 to 1.96, p=0.091), validated smoking abstinence recorded at 1 month after a quit date (OR: 1.02, 95% CI: 0.60 to 1.74, p=0.914) and validated smoking abstinence recorded at both 1 month after a quit date and at the end of pregnancy (OR: 1.52, 95% CI: 0.81 to 2.85, p=0.795) were not independently associated with infant developmental impairment at 2 years.

CONCLUSION

We found no evidence that NRT treatment improved infants' developmental outcomes through smoking cessation.

TRIAL REGISTRATION NUMBER

CTA03057/0002/001-0001; Post-results.

Survey of Australian maternity hospitals to inform development and implementation of a stillbirth prevention 'bundle of care'

BACKGROUND

'Bundles of care' are being implemented to improve key practice gaps in perinatal care. As part of our development of a stillbirth prevention bundle, we consulted with Australian maternity care providers.

OBJECTIVE

To gain the insights of Australian maternity care providers to inform the development and implementation of a bundle of care for stillbirth prevention.

METHODS

A 2018 on-line survey of hospitals providing maternity services included 55 questions incorporating multiple choice, Likert items and open text. A senior clinician at each site completed the survey. The survey asked questions about practices related to fetal growth restriction, decreased fetal movements, smoking cessation, intrapartum fetal monitoring, maternal sleep position and perinatal mortality audit. The objectives were to assess which elements of care were most valued; best practice frequency; and, barriers and enablers to implementation.

RESULTS

227 hospitals were invited with 83 (37%) responding. All proposed elements were perceived as important. Hospitals were least likely to follow best practice recommendations "all the time" for smoking cessation support (<50%), risk assessment for fetal growth restriction (<40%) and advice on sleep position (<20%). Time constraints, absence of clear guidelines and lack of continuity of carer were recognised as barriers to implementation across care practices.

CONCLUSIONS

Areas for practice improvement were evident. All elements of care were valued, with increasing awareness of safe sleeping position perceived as less important. There is strong support from maternity care providers across Australia for a bundle of care to reduce stillbirth.

Effectiveness and cost-effectiveness of a tailored text-message programme (MiQuit) for smoking cessation in pregnancy: study protocol for a randomised controlled trial (RCT) and meta-analysis

BACKGROUND

Smoking in pregnancy is a major international public health problem. Self-help support (SHS) increases the likelihood of women stopping smoking in pregnancy and delivering this kind of support by text message could be a cost-effective way to deliver SHS to pregnant women who smoke. SHS delivered by text message helps non-pregnant smokers to stop but the currently available message programmes are not appropriate for use in pregnancy. A randomised controlled trial (RCT) has demonstrated the feasibility and acceptability of using a programme called 'MiQuit' to text SHS support to pregnant women who smoke. Another pilot RCT has shown that it would be feasible to run a larger, multi-centre trial within the UK National Health Service (NHS). The aim of this third RCT is to complete MiQuit's evaluation, demonstrating whether or not this is efficacious for smoking cessation in pregnancy.

METHODS/DESIGN

This is a multi-centre, parallel-group RCT. Pregnant women aged over 16 years, of less than 25 weeks' gestation who smoke one or more daily cigarettes but smoked at least five daily cigarettes before pregnancy and who understand written English and are being identified in 24 English antenatal care hospitals. Participants are randomised to control or intervention groups in a 1:1 ratio stratified by gestation (< 16 weeks versus ≥ 16 weeks). All participants receive a leaflet on stopping smoking during pregnancy; they are also able to access standard NHS smoking cessation support. Intervention group women also receive the 12-week MiQuit programme of tailored, interactive text message, and self-help cessation support. Women are followed up by telephone at 4 weeks after randomisation and 36 weeks' gestation. The RCT will recruit 692 women (346 per group), enabling a 95% confidence interval for the difference in quit rates to be estimated within ± 3%. To determine whether or not MiQuit helps pregnant smokers to stop, intervention group quit rates from this trial will be combined with those from the two earlier trials in a Trial Sequential Analysis (TSA) meta-analysis to derive a pooled efficacy estimate.

DISCUSSION

If effective, MiQuit will be a cheap, cost-effective method to help pregnant women to stop smoking.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03231553 . Registered on 20 July 2017.

What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory

BACKGROUND

Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention.

METHODS

Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices.

RESULTS

Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability.

CONCLUSIONS

NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Trends in Smoking and Smoking Cessation During Pregnancy from 1985 to 2014, Racial and Ethnic Disparity Observed from Multiple National Surveys

Objective Current report assessed the trends in smoking prevalence and the percentage of smoking cessation during pregnancy among women from three major races/ethnicities. Methods Data were collected between 1999 and 2014 from the continuous National Health and Nutrition Examination Survey (NHANES). Smoking habits of women while pregnant with the child sampled by NHANES were assessed retrospectively. A total of 28,090 women who gave live birth between 1985 and 2014 were included. The prevalence ratios (PRs) of smoking and quitting smoking during pregnancy were calculated. The adjusted annual prevalence ratio (aaPR: the ratio associated with a 1-year increase in time) was estimated using logistic regression with the year of birth as a predictor. Results With child's race/ethnicity, gender, and mother's age controlled, the aaPR of smoking was 0.95 (95% confidence interval 0.92-0.97) for Hispanics, 0.96 (0.94-0.98) for whites, and 0.98 (0.94-1.00) for blacks. The aaPR of quitting smoking was 1.09 (1.02-1.16) for Hispanics, 1.01 (0.97-1.06) for whites, and 1.03 (0.95-1.12) for blacks. Compared with the counterparts aged 35 years or older, pregnant women younger than 20 years were more likely to smoke among whites [PR 1.56 (1.07-2.29)] but less likely among blacks [PR 0.37 (0.26-0.52)]. Conclusions for Practice Smoking prevalence has been declining continuously for all but at different rates among three major races/ethnicities. The risk profiles of smoking during pregnancy were race/ethnicity specific. Culturally appropriate programs should be developed to further reduce the maternal smoking during pregnancy.

Exploring Efficacy of a Serious Game (Tobbstop) for Smoking Cessation During Pregnancy: Randomized Controlled Trial

Background

Tobacco use during pregnancy entails a serious risk to the mother and harmful effects on the development of the child. Europe has the highest tobacco smoking prevalence (19.3%) compared with the 6.8% global mean. Between 20% to 30% of pregnant women used tobacco during pregnancy worldwide. These data emphasize the urgent need for community education and implementation of prevention strategies focused on the risks associated with tobacco use during pregnancy.

Objective

The aim of this study was to investigate the efficacy of an intervention that incorporates a serious game (Tobbstop) to help pregnant smokers quit smoking.

Methods

A two-arm randomized controlled trial enrolled 42 women who visited 2 primary care centers in Catalonia, Spain, between March 2015 and November 2016. All participants were pregnant smokers, above 18 years old, attending consultation with a midwife during the first trimester of pregnancy, and had expressed their desire to stop smoking. Participants were randomized to the intervention (n=21) or control group (n=21). The intervention group was instructed to install the game on their mobile phone or tablet and use it for 3 months. Until delivery, all the participants were assessed on their stage of smoking cessation during their follow-up midwife consultations. The primary outcome was continuous tobacco abstinence until delivery confirmed by the amount of carbon monoxide at each visit, measured with a carboxymeter.

Results

Continuous abstinence until delivery outcome was 57% (12/21) in the intervention group versus 14% (3/21) in the control group (hazard ratio=4.31; 95% CI 1.87-9.97; P=.001). The mean of total days without smoking until delivery was higher in the intervention group (mean 139.75, SD 21.76) compared with the control group (mean 33.28, SD 13.27; P<.001). In addition, a Kapplan-Meier survival analysis showed that intervention group has a higher abstinence rate compared with the control group (log-rank test, χ²₁=13.91; P<.001).

Conclusions

Serious game use is associated with an increased likelihood to maintain abstinence during the intervention period if compared with those not using the game. Pregnancy is an ideal opportunity to intervene and control tobacco use among future mothers. On the other hand, serious games are an emerging technology, growing in importance, which are shown to be a good tool to help quitting smoking during pregnancy and also to maintain this abstinent behavior. However, because of the study design limitations, these outcomes should be interpreted with caution. More research, using larger samples and longer follow-up periods, is needed to replicate the findings of this study.

Trial Registration

ClinicalTrials.gov NCT01734421; https://clinicaltrials.gov/ct2/show/NCT01734421 (Archived by WebCite at http://www.webcitation.org/75ISc59pB)

Comparison of nicotine exposure during pregnancy when smoking and abstinent with nicotine replacement therapy: systematic review and meta-analysis

BACKGROUND AND AIMS

Smoking during pregnancy is strongly associated with negative pregnancy and perinatal outcomes. Some guidelines recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy, but adherence with NRT is generally poor and could be partially explained by nicotine-related safety concerns. We compared pregnant women's cotinine and nicotine exposures from smoking with those when they were abstinent from smoking and using NRT.

DESIGN

Systematic review with meta-analysis and narrative reporting. Twelve studies were included: in most, only one type of NRT was used. Seven were quality-assessed and judge of variable quality.

SETTING

Studies from any setting that reported nicotine or cotinine levels when smoking and later when abstinent and using NRT.

PARTICIPANTS

Pregnant women who smoked and became abstinent but used NRT either in a cessation study or in a study investigating other impacts of NRT.

MEASUREMENTS

We quality-assessed longitudinal cohort studies using a modified version of the Newcastle-Ottawa scale. For meta-analysis, we used mean within-person differences in cotinine or nicotine levels when smoking and at later follow-up when abstinent and using NRT. Where such data were not available, we calculated differences in group mean levels and reported these narratively, indicating where data were not completely longitudinal.

FINDINGS

Of the 12 included studies, four cotinine-measuring studies (n = 83) were combined in a random effects meta-analysis; the pooled estimate for the mean difference (95% confidence intervals) in cotinine levels between when women were smoking and abstinent but using NRT was 75.3 (57.1 to 93.4) ng/ml (I2  = 42.1%, P = 0.11). Of eight narratively-described studies, six reported lower cotinine and/or nicotine levels when abstinent and using NRT; two had mixed findings, with higher levels when abstinent but using NRT reported from at least one assay time-point.

CONCLUSIONS

Pregnant women who use nicotine replacement therapy instead of smoking reduce their nicotine exposure.

Competitions for smoking cessation

BACKGROUND

Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle.

OBJECTIVES

To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions.

SEARCH METHODS

This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes.

DATA COLLECTION AND ANALYSIS

For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively.

MAIN RESULTS

Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated.

AUTHORS' CONCLUSIONS

At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.

Incentives and Patches for Medicaid Smokers: An RCT

INTRODUCTION

Most successful trials of financial incentives for smoking cessation have offered large rewards contingent on outcomes. This study examines whether more modest incentives to encourage engagement, non-contingent on outcomes, also increase cessation; whether sending medications directly to participants boosts quitting; and whether these strategies are effective in Medicaid.

STUDY DESIGN

Three-group RCT of usual care (UC); nicotine patch (NP); and NP and financial incentive (NP+FI).

SETTING/PARTICIPANTS

Medicaid beneficiaries calling the California Smokers' Helpline, 2012-2013 (N=3,816). Data were analyzed in 2017.

INTERVENTION

All participants enrolled in evidence-based, multisession telephone counseling. All received proof of enrollment with which they could obtain free quitting aids at their pharmacy. NP and NP+FI also received nicotine patches sent to their homes. NP+FI received up to $60 for completing counseling calls.

MAIN OUTCOME MEASURES

Quit attempt rate, 7-day and 30-day abstinence at 2 and 7 months, and 6-month prolonged abstinence (primary outcome).

RESULTS

In both complete-case and intention-to-treat analyses, outcomes trended upward from UC to NP to NP+FI. Differences between NP and UC were generally nonsignificant. By contrast, the NP+FI group significantly outperformed the other groups on all measures. In intention-to-treat analysis, compared with UC, NP+FI was more likely to make a quit attempt (68.4% vs 54.3%, p<0.001); be abstinent for 7 days at 2 months (36.1% vs 25.5%, p<0.001) and 7 months (21.2% vs 16.1%, p=0.002); be abstinent for 30 days at 2 months (30.0% vs 18.9%, p<0.001) and 7 months (21.5% vs 16.7%, p=0.004); and achieve 6-month prolonged abstinence (13.2% vs 9.0%, p=0.001).

CONCLUSIONS

Financial incentives increased treatment engagement and short- and long-term smoking cessation, despite being modest and non-contingent on outcomes. The study found that incentives can be effective in a Medicaid population, and can feasibly be integrated into existing quitline services.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrials.gov NCT01502306.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

A pilot study of the Tobacco Treatment Guidelines for High-Risk Groups (TOB-G) for pregnant and postpartum women

INTRODUCTION

Maternal smoking constitutes a significant risk to the fetus and is associated with multiple adverse pregnancy outcomes. Despite this, an estimated 6-19% of women in Europe smoke during pregnancy. We conducted a pilot study to examine the feasibility and effectiveness of the clinical practice recommendations of the 2017 Tobacco Cessation Guidelines for High-Risk Groups (TOB-G) for pregnant and postpartum women in an outpatient obstetrics setting.

METHODS

The guideline recommendations were tested on a sample of 67 pregnant women recruited from obstetrics outpatient visits. Pregnant women who smoked received three behavioural counselling sessions through a combination of face-toface and telephone consultations by a midwife trained in the TOBG tobacco treatment recommendations. Smoking status was assessed at 1 month and at 6 months follow-up via self-report.

RESULTS

Seventy-one per cent of pregnant smokers screened agreed to participate in the counselling intervention. Pregnant women participants (mean age, M=31.73 years, SD±6.09) smoked for an average of 12.2 (SD±6.55) years. Women reported smoking an average of 4.82 (SD±4.14) cigarettes per day with 51% reporting smoking within 30 minutes of waking, an indicator of higher levels of nicotine addiction. Rates of smoking abstinence among pregnant women undergoing the counselling intervention were 43.9% and 45.6% at the 1 month and at 6 months follow-up, respectively. Replacing those participants with missing data as smokers, the quit rates were 26.9% and 38.8% at the 1 month and 6 months follow-up, respectively.

CONCLUSIONS

The counselling intervention delivered to pregnant women who smoke was feasible to implement in a manner that was consistent with the TOB-G guideline recommendations in an outpatient obstetrics setting. Future work should focus on increasing uptake of evidence-based tobacco treatment recommendations in outpatient obstetrics settings.

Prenatal Point-of-Care Tobacco Screening and Clinical Relationships

PURPOSE

Up to one-third of female smokers with Medicaid deny tobacco use during pregnancy. Point-of-care urine tests for cotinine, a tobacco metabolite, can help to identify women who may benefit from cessation counseling. We sought to evaluate patient and clinician perspectives about using such tests during prenatal care to identify smokers, with particular focus on the impact of testing on clinical relationships and the potential for tobacco cessation.

METHODS

We conducted 19 individual interviews and 4 focus groups with 40 pregnant or postpartum women covered by Medicaid who smoked before or during pregnancy. Patients also took the urine cotinine test and received sample results. Interviews were conducted with 20 health care practitioners. We analyzed the transcripts using an inductive approach and developed a model of how prenatal testing for cotinine could affect the patient-clinician relationship.

RESULTS

Patients were more likely than clinicians to believe that testing could encourage discussions on tobacco cessation but emphasized that the clinician's approach to testing was critical. Clinicians feared that testing would negatively affect relationships.

CONCLUSIONS

Despite having reservations, low-income patients had a surprisingly favorable view of using point-of-care urine testing to promote smoking cessation during pregnancy, which could increase the availability of cessation resources to women who do not disclose their tobacco use to clinicians.

Striving to Meet Healthy People 2020 Objectives: Trend Analysis of Maternal Smoking

OBJECTIVES

We examined trends in prevalence rates of smoking and smoking cessation during pregnancy among women in the United States to assess achievement of Healthy People 2020 prevention targets.

METHODS

We assessed the smoking habits of 30 667 mothers whose children were born between 1985 and 2014 and who were sampled by the National Health and Nutrition Examination Survey, 1999-2014. Sampled participants were children aged 0-15 at the time of interview; however, an adult proxy-usually the biological mother-responded on the child's behalf and reported information about maternal tobacco use during pregnancy. We calculated prevalence rates, adjusted odds ratios (aORs), and predicted annual increase or decrease of smoking and quitting smoking during pregnancy, adjusting for mother's age at delivery and income level and child's race/ethnicity and sex.

RESULTS

The average annual prevalence of smoking at any time during pregnancy decreased from 25.7% (95% confidence interval [CI], 15.3%-36.0%) in 1985 to 10.1% (95% CI, 7.1%-13.0%) in 2014 ( P < .001), and quitting smoking at any time during the index pregnancy increased from 36.6% (95% CI, 20.3%-52.9%) in 1985 to 54.9% (95% CI, 44.4%-65.4%) in 2008 ( P = .002). The adjusted annual risk of smoking during pregnancy decreased significantly by 3% (aOR = 0.97; 95% CI, 0.95-0.98; P < .001). The prevalence rate of smoking in the year 2020 extrapolated from the current trend would be 6.1%.

CONCLUSIONS

Smoking during pregnancy in the United States is declining. However, renewed public health measures are needed to achieve the Healthy People 2020 objectives of preventing smoking among pregnant women in the United States.

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

OBJECTIVE

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

DESIGN

Systematic review and Delphi study.

METHODS

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

RESULTS

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

CONCLUSIONS

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO REGISTRATION NUMBER

CRD42015027351.

Tobacco Use Prevalence and Outcomes Among Perinatal Patients Assessed Through an "Opt-out" Cessation and Follow-Up Clinical Program

Purpose Cigarette smoking in the perinatal period is associated with costly morbidity and mortality for mother and infant, yet many women continue to smoke throughout their pregnancy and following delivery. This report describes tobacco use prevalence among perinatal smokers identified through an "opt-out" inpatient smoking cessation clinical service. Description Adult women admitted to the peripartum, delivery, and postpartum units at a large academic hospital were screened for tobacco use. Smokers were identified through their medical record and referred to a bedside consult and follow-up using an interactive voice response (IVR) system to assess smoking up to 30 days post-discharge. Assessment Between February 2014 and March 2016, 533 (10%) current and 898 (16%) former smokers were identified out of 5649 women admitted to the perinatal units. Current smokers reported an average of 11 cigarettes per day for approximately 12 years. Only 10% reported having made a quit attempt in the past year. The majority of smokers (56%) were visited by a bedside tobacco cessation counselor during their stay and 27% were contacted through the IVR system. Those counselled in the hospital were twice as likely (RR 1.98, CI 1.04-3.78) to be abstinent from smoking using intent-to-treat analysis at any time during the 30 days post-discharge. Conclusions This opt-out service reached a highly nicotine-dependent perinatal population, many of whom were receptive to the service, and it appeared to improve abstinence rates post-discharge. Opt-out tobacco cessation services may have a significant impact on the health outcomes of this population and their children.

Positive parenting behaviors in women who spontaneously quit smoking during pregnancy: Clues to putative targets for preventive interventions

BACKGROUND

While the majority of pregnant smokers do not respond to intervention, little is known about how a subset of pregnant smokers known as spontaneous quitters achieve sustained biologically-confirmed abstinence through delivery in the absence of intervention. We explore a developmental framework to address this question by viewing spontaneous quitting as an adaptive parenting behavior, facilitated by abilities necessary for sensitive parenting, or responsiveness. Utilizing existing data, we examined responsiveness from parenting assessments in women who exhibited a variety of smoking patterns during pregnancy, including spontaneous quitting.

METHODS

Participants were N = 305 pregnant women assessed for smoking prospectively and biochemically at 16 weeks, 28 weeks, delivery, and 4 weeks postpartum, then reassessed with their children 5 years later with directly-observed home- and lab-based measures of parenting. We used linear regression analysis to compare spontaneous quitters with women who exhibited other prenatal smoking patterns on parenting responsiveness, controlling for potential confounders.

RESULTS

In home-based observations, spontaneous quitters (n = 22) exhibited greater responsiveness with their children relative to intermittent pregnancy smokers [n = 70; β = 0.258, p = .022]; persistent pregnancy smokers [n = 66; β = 0.228, p = .040]; former smokers (quit before pregnancy) [n = 78; β = 266, p = .028]; and never smokers [n = 69; β = 0.312, p = .009]. Hypothesized differences were not observed in lab-based and self-report measures.

CONCLUSIONS

Putative protective characteristics in spontaneous quitters were captured in mother-child interactions at home, but not in lab-based and maternal report measures of responsiveness. Specification of these characteristics using prospective designs that oversample for spontaneous quitters is recommended to enable translation to preventive interventions.

Intergenerational pathways linking maternal early life adversity to offspring birthweight

Adverse birth outcomes can lead to problematic long-term outcomes for children, and are also known to transmit socioeconomic disadvantage across generations, thereby amplifying the importance of identifying their social determinants. However, the full set of factors causing adverse birth outcomes remains unknown. Drawing together theory describing intragenerational (life course) processes linking early life adversity to adult health, and intergenerational transmissions of inequality via birthweight, this study tests a chain of risk that originates within early adolescence, impacts young women's risky health behaviors in late adolescence/early adulthood and risky health behaviors during pregnancy, and ultimately decreases offspring's birthweight. We do so using structural equation models and prospective, population-level data on a racially and socioeconomically diverse cohort of young adults (National Longitudinal Study of Adolescent to Adult Health). Results (a) reveal four pathways that fully mediate the association between a young woman's family-of-origin socioeconomic status in adolescence and her offspring's birthweight, and (b) identify a trigger effect-a place in the chain of risk where prevention efforts could be targeted, thereby breaking the chain of risk leading to poor offspring health at birth for vulnerable individuals.

Exercise to Support Indigenous Pregnant Women to Stop Smoking: Acceptability to Māori

Objectives Smoking during pregnancy is harmful for the woman and the unborn child, and the harms raise risks for the child going forward. Indigenous women often have higher rates of smoking prevalence than non-indigenous. Exercise has been proposed as a strategy to help pregnant smokers to quit. Māori (New Zealand Indigenous) women have high rates of physical activity suggesting that an exercise programme to aid quitting could be an attractive initiative. This study explored attitudes towards an exercise programme to aid smoking cessation for Māori pregnant women. Methods Focus groups with Māori pregnant women, and key stakeholder interviews were conducted. Results Overall, participants were supportive of the idea of a physical activity programme for pregnant Māori smokers to aid smoking cessation. The principal, over-arching finding, consistent across all participants, was the critical need for a Kaupapa Māori approach (designed and run by Māori, for Māori people) for successful programme delivery, whereby Māori cultural values are respected and infused throughout all aspects of the programme. A number of practical and environmental barriers to attendance were raised including: cost, the timing of the programme, accessibility, transport, and childcare considerations. Conclusions A feasibility study is needed to design an intervention following the suggestions presented in this paper with effort given to minimising the negative impact of barriers to attendance.

Uptake of Tailored Text Message Smoking Cessation Support in Pregnancy When Advertised on the Internet (MiQuit): Observational Study

Background

Smoking in pregnancy is a major public health concern. Pregnant smokers are particularly difficult to reach, with low uptake of support options and few effective interventions. Text message–based self-help is a promising, low-cost intervention for this population, but its real-world uptake is largely unknown.

Objective

The objective of this study was to explore the uptake and cost-effectiveness of a tailored, theory-guided, text message intervention for pregnant smokers (“MiQuit”) when advertised on the internet.

Methods

Links to a website providing MiQuit initiation information (texting a short code) were advertised on a cost-per-click basis on 2 websites (Google Search and Facebook; £1000 budget each) and free of charge within smoking-in-pregnancy webpages on 2 noncommercial websites (National Childbirth Trust and NHS Choices). Daily budgets were capped to allow the Google and Facebook adverts to run for 1 and 3 months, respectively. We recorded the number of times adverts were shown and clicked on, the number of MiQuit initiations, the characteristics of those initiating MiQuit, and whether support was discontinued prematurely. For the commercial adverts, we calculated the cost per initiation and, using quit rates obtained from an earlier clinical trial, estimated the cost per additional quitter.

Results

With equal capped budgets, there were 812 and 1889 advert clicks to the MiQuit website from Google (search-based) and Facebook (banner) adverts, respectively. MiQuit was initiated by 5.2% (42/812) of those clicking via Google (95% CI 3.9%-6.9%) and 2.22% (42/1889) of those clicking via Facebook (95% CI 1.65%-2.99%). Adverts on noncommercial webpages generated 53 clicks over 6 months, with 9 initiations (9/53, 17%; 95% CI 9%-30%). For the commercial websites combined, mean cost per initiation was £24.73; estimated cost per additional quitter, including text delivery costs, was £735.86 (95% CI £227.66-£5223.93). Those initiating MiQuit via Google were typically very early in pregnancy (median gestation 5 weeks, interquartile range 10 weeks); those initiating via Facebook were distributed more evenly across pregnancy (median gestation 16 weeks, interquartile range 14 weeks).

Conclusions

Commercial online adverts are a feasible, likely cost-effective method for engaging pregnant smokers in digital cessation support and may generate uptake at a faster rate than noncommercial websites. As a strategy for implementing MiQuit, online advertising has large reach potential and can offer support to a hard-to-reach population of smokers.

Predictors of smoking cessation during pregnancy: a systematic review and meta-analysis

AIM

To identify factors found in the research literature to be associated with smoking cessation in pregnancy.

METHODS

Electronic searches of the bibliographic databases of PubMed, EMBASE, PsycINFO, Elsevier, Scopus and ISI Web of Science were conducted to April 2017. All studies reporting factors associated with smoking cessation or continuing smoking during pregnancy were included and reviewed systematically, irrespective of study design. The Newcastle-Ottawa Quality Assessment Scale was used to assess the study quality. The DerSimonian & Laird random-effects model was used to conduct meta-analyses, and where effect estimates were reported for factors included in at least three studies.

RESULTS

Fifty-four studies, including 505 584 women globally who smoked before pregnancy, 15 clinical trials and 40 observational studies, were included in the review and 36 (65.5%) were considered to be of high quality. This review identified 11 socio-demographic, seven socially related, 19 smoking behaviour-related, five pregnancy-related, six health-related and six psychological factors that were associated significantly with smoking cessation during pregnancy. The most frequently observed significant factors associated with cessation were: higher level of education, pooled odds ratio (OR), 95% confidence interval (CI) = 2.16 (1.80-2.84), higher socio-economic status: 1.97 (1.20-3.24), overseas maternal birth: 2.00 (1.40-2.84), Medicaid coverage or private insurance: 1.54 (1.29-1.85), living with partner or married: 1.49 (1.38-1.61), partner/other members of the household do not smoke: 0.42 (0.35-0.50), lower heaviness of smoking index score: 0.45 (0.27-0.77, lower baseline cotinine level: 0.78 (0.64-0.94), low exposure to second-hand smoking: 0.45 (0.20-1.02), not consuming alcohol before and/or during pregnancy: 2.03 (1.47-2.80), primiparity: 1.85 (1.68-2.05), planned breastfeeding:1.99 (1.94-2.05), perceived adequate pre-natal care: 1.74 (1.38-2.19), no depression: 2.65 (1.62-4.30) and low stress during pregnancy: 0.58 (0.44-0.77).

CONCLUSION

A wide range of socio-demographics, relationship, social, smoking-related, pregnancy-related, health and psychological factors have been found to predict smoking cessation in pregnancy.

Screening and Management of Substance Use in Pregnancy: A Review

Substance use during pregnancy has important implications for health care providers, policy makers, and can negatively impact a woman's health and the health of her children. Understanding trends, patterns of use and outcomes are critical to prevention campaigns, building awareness, and providing effective care. This review will discuss the current therapeutic approaches and recommendations for screening and patient management for substance use in pregnancy and during the postpartum period, and it is geared towards any care providers who care for patients or those who may care for patients who may be at risk for substance use during pregnancy.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

OBJECTIVES

To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

SELECTION CRITERIA

We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

MAIN RESULTS

Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

AUTHORS' CONCLUSIONS

A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.