Randomized trial of a secondhand smoke exposure reduction intervention among hospital-based pregnant women

Designing, implementing and evaluating an educational program regarding the effects of second-hand smoke in pregnancy on the knowledge, attitude and performance of male smokers

INTRODUCTION

Contact with second-hand cigarette smoke includes inhalation of cigarette smoke caused by the burning of the cigarette itself and inhalation of smoke exhaled by the smoker. Wife's pregnancy can be a motivating factor to change the behavior of men who smoke. Therefore, this study was conducted with the aim of designing, implementing and evaluating an educational program regarding the effects of second-hand smoke in pregnancy on the knowledge, attitude and performance of male smokers.

METHODOLOGY

The present study is an interventional type of pre-test and post-test. In this phase, sampling from health centers in Isfahan was done randomly between March and July 2019, the participants were 140 smoking spouses of pregnant women, who visited health centers to receive pregnancy care, and were divided into two intervention groups and control were divided. The data collection tool was a researcher-made questionnaire on men's awareness, attitude and performance regarding second-hand smoke. All data were analyzed with SPSS18 software and Chi-score, Fisher, t-test.

RESULTS

The average age of the participants was 34 years. There was no significant difference between the comparison of demographic variables in the intervention and control groups (p > 0.05). The results of the paired t-test for comparing before and after the training showed that the average score of the emotional dimension of attitude in the two groups of intervention (p < 0.001) and control (p < 0.001), awareness (p < 0.001) and behavior (p < 0.001) was significantly increased in the intervention group after the training, and according to the independent t-test, the average score of the items mentioned after the training in the intervention group was higher than the control group (p < 0.05). Regarding perceived sensitivity (p = 0.066) and perceived severity (p = 0.065), no significant difference was observed.

CONCLUSION

The awareness, emotional aspect of men's attitude and behavior regarding secondhand smoke increased, but the perceived sensitivity and severity in this regard was not significant despite the increase, so the current training package is effective in training, but considering more training sessions It is necessary with more concrete training with model or training videos in order to improve the sensitivity and perceived intensity of men.

TRIAL REGISTRATION

Registration of this randomized control trial has been completed with the Iranian Registry of Clinical Trials, IRCT20180722040555N1.

Psychosocial empowerment-based interventions for smoking reduction: concepts, measures and outcomes. A systematic review

Although empowerment is a widely used concept in health-related areas, its definition remains unclear. While there is evidence for the effectiveness of empowerment interventions in improving some psychosocial factors linked to health (e.g. patient self-care strategy, coping skills, access and effective use of health services) and some health outcomes like mental health and HIV/AIDS-related behaviour, other data appear to contradict this. Moreover, concepts, measures, and outcomes related to empowerment are operationalized in different ways. Using the case of tobacco control programmes, we wanted to explore: (a) how research on smoking reduction/prevention has conceptualized empowerment; (b) which measures and instruments have been used to assess behaviour outcomes and the empowerment process. We hypothesized that the transformative potential that characterizes empowerment is marginally considered.A total of 18 studies reporting on the effect of prevention interventions on smoking and/or empowerment outcomes were reviewed. Two kinds of study were distinguished: (a) studies reporting behaviour outcomes without data about the impact on empowerment; (b) studies analysing the empowerment process. Among this latter type, some studies did not provide information about the specific behaviour (smoking), while others examined the impact of intervention on both smoking and empowerment. In about half of all studies, empowerment strategies were found to be effective in improving smoking outcomes, while no differences were found between intervention and control groups in the remaining studies. The present review suggests that pragmatic definitions of empowerment need to be developed in order to promote its transferability and evaluation.

Reducing Secondhand Smoke Exposure Among Nonsmoking Pregnant Women: A Systematic Review

Introduction

Exposure to secondhand smoke (SHS) in pregnancy leads to an increased risk of stillbirths, congenital malformations, and low birth weight. There is a lack of evidence about how best to achieve reductions in SHS exposure among nonsmoking pregnant women. This work systematically reviews individual or household interventions to reduce pregnant women’s exposure to SHS.

Methods

MEDLINE, EMBASE, and CINAHL databases were searched from their dates of inception to April 17, 2019. Studies were included if: participants were nonsmoking pregnant women; involved an intervention to reduce SHS exposure or encourage partner quitting; and measured SHS exposure of pregnant women and/or recorded quit rates among partners. The UK National Institute for Health & Care Excellence (NICE) Quality Appraisal checklist was used to determine internal and external validity.

Results

Nine studies met the inclusion criteria. Educational interventions were primarily targeted at the pregnant woman to change her or others’ behavior, with only two studies involving the partner who smoked. Intervention delivery was mixed, spanning brief discussions through to more involving sessions with role play. The effective interventions involved multiple follow-ups. There was no standardized method of assessing exposure to SHS. Many of the included studies had moderate to high risk of bias.

Conclusion

There is mixed evidence for interventions aimed at reducing pregnant women’s exposure to SHS, though multi-component interventions seem to be more effective. The effectiveness of family-centered approaches involving creating smoke-free homes alongside partner smoking cessation, perhaps involving pharmacological support and/or financial incentives, should be explored.

Implications

• Measures to protect nonsmoking pregnant women from SHS tend to place the responsibility for “avoidance” on the woman.

• There is little work that seeks to involve the smoking partner or other smokers in protecting pregnant women from SHS.

• Interventions to create smoke-free homes and/or smoking partner cessation need to be developed: pharmacological and financial support should be explored.

An educational intervention to men for reducing environmental tobacco smoke exposure in their pregnant wives

OBJECTIVE

To determine the effect of education based on health belief model (HBM) on the level of their pregnant wives' environmental tobacco smoke exposure (ETSE).

METHODS

This interventional randomized study was conducted on 60 cigarette smoking men who have exposed their pregnant wives to smoke during of their pregnancy. The HBM constructs and weekly ETSE were evaluated by using questionnaire. The intervention group received education with emphasis on the risks of cigarette's smoke on the pregnancy. Then right after the training and 6 weeks after that, HBM constructs and 6 weeks after the training the weekly ETSE were evaluated again.

RESULTS

Results showed a significant difference between the mean of perceived susceptibility, perceived benefits and barriers at intake and 6 weeks after the intervention in the intervention group. Also, the level of perceived susceptibility/severity and perceived barriers in both groups were significantly different 6 weeks after the intervention compared to intake time. The ETSE was significantly lower in the intervention group 6 weeks after the intervention in comparison to before the intervention and also to the control group.

CONCLUSIONS

This study showed that education husbands would relatively improve their health beliefs and reduce the ETSE of their pregnant wives.

The relationship between husbands' health belief and environment tobacco smoke exposure among their pregnant wife

OBJECTIVE

The aim of the present study was to evaluate the relationship between health belief structures of men and environment tobacco smoke (ETS) exposure among pregnant women.

METHODS

This cross-sectional research was conducted on 120 smoking men who had pregnant wives. Data were gathered through a questionnaire that measured health belief structures related to pregnant women's exposure to cigarette's smoke including perceived susceptibility/severity, benefits, barriers and self-efficacy. Number of exposures to cigarette's smoke was defined by the number of smoked cigarettes in the presence of the pregnant wife.

RESULTS

The number of smoked cigarettes in the presence of pregnant wife had a negative relation with perceived susceptibility/severity and perceived benefits and a positive relation with perceived barriers. The number of smoked cigarettes in men had no relation with health belief constructs. Using multiple regression test showed the perceived barrier for not smoking was the strongest factor in men to anticipate the level of women's ETS exposure.

CONCLUSIONS

Results of this study showed that the level of ETS exposure among pregnant women was dependent on men's health beliefs about the ETS exposure treats among pregnant women.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Randomized comparison of group versus individual educational interventions for pregnant women to reduce their secondhand smoke exposure

BACKGROUND

Secondhand smoke (SHS) exposure is deleterious to pregnant women and their unborn children. The prevalence of SHS exposure among pregnant women is particularly high in many Asian countries where approximately half of the male population smokes. We aim to investigate the efficacy of an intervention based on an expanded Health Belief Model (HBM) incorporating self-efficacy to educate and empower pregnant women to reduce their SHS exposure.

METHODS

We conducted a 3-arm randomized controlled trial (N = 50 in each arm) comparing the effectiveness of group-based and individual-based interventions with a treatment-as-usual group. A questionnaire tapping into constructs of the expanded HBM was administered at baseline and 1- and 2-month follow-ups. Exhaled carbon monoxide was used to determine SHS exposure (>=6 ppm). ANOVA was used to compare HBM construct scores, self-efficacy for rejecting SHS exposure, and SHS rejection behavior among the 3 groups at baseline and the 1- and 2-month follow-ups, while logistic regression analysis was used to compare the risk of exposure to SHS at each follow-up.

RESULTS

The group-based intervention significantly improved health beliefs, self-efficacy, and self-reported rejection behaviors. The individual-based intervention effect was limited to some health belief constructs and SHS rejection behaviors. Both group- and individual-based interventions showed significant reductions in SHS exposure 2 months after the intervention (P < 0.0001).

CONCLUSION

Group-based educational interventions based on the HBM are particularly effective in training pregnant women to avoid and refuse exposure to SHS. Policy makers should consider offering group-delivered programs to educate and empower pregnant women to reduce their SHS exposure.

Understanding motivation to implement smoking bans among mothers with a hospitalized infant

OBJECTIVE

Secondhand smoke exposure (SHSe) poses risks to hospitalized children upon discharge and no uniformly effective interventions have been identified. Understanding change-related processes and social-contextual factors related to motivation for implementing home and car smoking bans may inform interventions to reduce infant SHSe among mothers with a hospitalized infant.

METHODS

In this cross-sectional, secondary analysis, mothers of neonatal ICU infants who reported smoking or living with a smoker (N=205) were assigned to stages of change (pre-contemplation, contemplation, preparation, or action) based on behaviors and intentions for establishing smoking bans in their homes and cars. Processes of change (POC) for SHSe reduction practices, self-efficacy, depressive symptoms, generalized anxiety, and social support for not smoking in the home were examined across all four stages.

RESULTS

The majority of mothers were in the action stage for having a home smoking ban in place (55%); only 35% of participants were in action for a car smoking ban. POC use differed across the stages of change for having a home ban (p=0.004) and car ban (p=0.02), with earlier stages using fewer overall and relatively fewer cognitive/affective processes. Earlier stage women also reported lower self-efficacy to change, less familial and partner support for in-home smoking bans, and more depressive symptoms.

CONCLUSIONS

Novel intervention targets were identified, including cognitive/affective change processes, mental health, and familial/social contingencies for implementing SHSe protective practices. Creative ways in which to affect change at the individual and household level are needed in order to fully address the complexity of child SHSe.