Lifecourse influences on women's smoking before, during and after pregnancy

The Effectiveness of Text Support for Stopping Smoking in Pregnancy (MiQuit): Multi-Trial Pooled Analysis Investigating Effect Moderators and Mechanisms of Action

INTRODUCTION

Digital cessation support appeals to pregnant smokers. In two pooled RCTs, MiQuit, a pregnancy-specific tailored text messaging intervention, did not show effectiveness for validated prolonged abstinence. However, secondary outcomes and potential moderators and mediators have not been investigated. We aimed to determine, using pooled RCT data: (1) MiQuit effectiveness on a range of smoking outcomes; (2) whether baseline tobacco dependence or quit motivation moderate effectiveness; (3) whether hypothesized mechanisms of action (quitting determination, self-efficacy, baby harm beliefs, lapse prevention strategies) mediate effectiveness.

METHODS

Pooled data analysis from two procedurally identical RCTs comparing MiQuit (N = 704) to usual care (N = 705). Participants were smokers, <25 weeks pregnant, recruited from 40 English antenatal clinics. Outcomes included self-reported 7-day abstinence at 4 weeks post-baseline and late pregnancy, and prolonged abstinence. Late pregnancy outcomes were also biochemically validated. We used hierarchical regression and structural equation modeling.

RESULTS

MiQuit increased self-reported, 7-day abstinence at 4 weeks (OR = 1.73 [95% CI 1.10-2.74]) and was borderline significant at late pregnancy (OR = 1.34 [0.99-1.82]) but not for prolonged or validated outcomes. Effectiveness was not moderated by baseline dependence (heaviness of smoking "low" vs. "moderate-high") or motivation (planning to quit ≤30 days [high] vs. >30 days [low]), but effects on self-reported outcomes were larger for the high motivation sub-group. MiQuit had a small effect on mean lapse prevention strategies (MiQuit 8.6 [SE 0.17], UC 8.1 [SE 0.17]; P = .030) but not other mechanisms.

CONCLUSIONS

MiQuit increased short-term but not prolonged or validated abstinence and may be most effective for those motivated to quit sooner.

IMPLICATIONS

Digital cessation support appeals to pregnant smokers. MiQuit, a tailored, theory-guided text messaging program for quitting smoking in pregnancy, has not shown effectiveness for validated prolonged abstinence in two previous RCTs but its impact on other smoking outcomes and potential mechanisms of action are unknown. When pooling trial data, MiQuit increased self-reported short-term abstinence, including making a quit attempt and abstinence at 4-week follow-up, but not late pregnancy, sustained, or validated abstinence. MiQuit appeared effective at late pregnancy for participants with high quitting motivation, but its mechanisms of action remain uncertain. Additional support components are likely required to enhance effectiveness.

Imperatives of health or happiness: Narrative constructions of long-term smoking after undergoing lung screening

Tobacco control policies reinforce a health imperative that positions citizens as duty-bound to manage their health by abstaining from or quitting smoking. Limited attention is paid to the repercussions - especially for lung screening - of anti-smoking rhetoric emphasising individual responsibility. Drawing on interviews with 27 long-term smokers involved in an international lung screening trial, this study analysed Australian smokers' narratives of smoking. By attending to stigma and the use of public health rhetoric within personal narratives, we show how narratives underscoring individual responsibility for quitting were layered with conflicting explanations of biological responsibility and normative expectations. Ironically, narratives of individual responsibility potentially undermine smoking cessation. In positioning smokers as responsible for their own healthy choices, such rhetoric also positions smokers as responsible for managing their emotional health, which some did through smoking. Thus, anti-smoking campaigns pit the neoliberal imperative of health against the happiness imperative. These findings have implications for the design and delivery of lung screening campaigns. They also support calls to move beyond health messaging emphasising individual choice, towards acknowledging the moral power of structures and public health campaigns to discipline citizens in unintended ways.

Covariates of success in quitting smoking: a systematic review of studies from 2008 to 2021 conducted to inform the statistical analyses of quitting outcomes of a hospital-based tobacco dependence treatment service in the United Kingdom

Background

Smoking cessation interventions are being introduced into routine secondary care in the United Kingdom (UK), but there are person and setting-related factors that could moderate their success in quitting smoking. This review was conducted as part of an evaluation of the QUIT hospital-based tobacco dependence treatment service ( https://sybics-quit.co.uk). The aim of the review was to identify a comprehensive set of variables associated with quitting success among tobacco smokers contacting secondary healthcare services in the UK who are offered support to quit smoking and subsequently set a quit date. The results would then be used to inform the development of a statistical analysis plan to investigate quitting outcomes.

Methods

Systematic literature review of five electronic databases. Studies eligible for inclusion investigated quitting success in one of three contexts: (a) the general population in the UK; (b) people with a mental health condition; (c) quit attempts initiated within a secondary care setting. The outcome measures were parameters from statistical analysis showing the effects of covariates on quitting success with a statistically significant (i.e., p-value <0.05) association.

Results

The review identified 29 relevant studies and 14 covariates of quitting success, which we grouped into four categories: demographics (age; sex; ethnicity; socio-economic conditions; relationship status, cohabitation and social network), individual health status and healthcare setting (physical health, mental health), tobacco smoking variables (current tobacco consumption, smoking history, nicotine dependence; motivation to quit; quitting history), and intervention characteristics (reduction in amount smoked prior to quitting, the nature of behavioural support, tobacco dependence treatment duration, pharmacological aids).

Conclusions

In total, 14 data fields were identified that should be considered for inclusion in datasets and statistical analysis plans for evaluating the quitting outcomes of smoking cessation interventions initiated in secondary care contexts in the UK.

PROSPERO registration

CRD42021254551 (13/05/2021).

Development of "Baby, Me, & NRT": A Behavioral Intervention to Improve the Effectiveness of Nicotine Replacement Therapy in Pregnancy

BACKGROUND

The effectiveness of Nicotine Replacement Therapy (NRT) for smoking cessation in pregnancy is limited by inconsistent and incorrect use. This paper describes the development process for "Baby, Me, & NRT", a novel pregnancy-specific intervention aimed at enhancing adherence to NRT.

METHODS

An integrated approach to intervention development was used, combining evidence, theory, stakeholders' feedback, and tailoring principles. The process involved six iterative steps: (1) synthesizing relevant published evidence and guidance, (2) collecting primary qualitative data on barriers and facilitators to NRT adherence along with potential intervention design features, (3) identifying relevant behavioral theories and mapping the evidence against these, (4) prioritizing behavioral determinants identified in steps 1 and 2, generating intervention objectives, and identifying behavior change techniques which target the prioritized determinants, (5) consulting with stakeholders on intervention components, key content and tailoring features, and (6) producing a prototype intervention along with implementation guidance.

RESULTS

The prototype intervention comprises of a multi-component, 1-month cessation programme, which includes six enhanced behavioral support sessions delivered by a trained advisor, tailored text messages, a website, and an illustrated booklet. It promotes the uptake of high-dose and combination NRT, emphasizes the importance of adherence, addresses motivation to use NRT, proactively helps problem solve NRT use issues, and provides guidance on preventing and managing smoking lapses.

CONCLUSION

The development process generated an evidence- and theory-guided intervention, designed with stakeholder input, aimed at improving NRT effectiveness for smoking cessation in pregnancy. The prototype intervention has since been optimized and is being evaluated in a randomized controlled trial.

Fetal Origins of Health Disparities: Transgenerational Consequences of Racism

Despite advances in perinatal medicine, racial disparity in birth outcomes remains a public health problem in the USA. The underlying mechanisms for this long-standing racial disparity are incompletely understood. This review presents transgenerational risk factors for racial disparities in preterm birth, exploring the impact of interpersonal and structural racism, theoretical models of stress, and biological markers of racial disparities.

Factors associated with ever using cannabidiol in a cohort of younger pregnant people

One in four Americans have used cannabidiol (CBD) products in the past year, and use has become prevalent in many Western countries with recent deregulation from a controlled or illicit substance to an unrestricted product. CBD is also marketed to pregnant people to treat common medical conditions. However, preclinical work has linked cannabidiol exposure to embryotoxicity, as well as neuroendocrine, reproductive, and behavioral effects in offspring. No studies have examined the prevalence or correlates of CBD use among pregnant people. Demographic, medical, and psychosocial correlates of cannabidiol use were examined in the YoungMoms study, a cohort of pregnant people under the age of 22, a population that is at high risk for cannabis use during pregnancy. Few of the participants (n = 186; 75% Black or Biracial) reported use of cannabidiol during pregnancy, but one in five had tried these products. Participants who reported ever using CBD were more likely to report alcohol and other drug use prior to pregnancy, controlling for race.As the use of CBD among people of reproductive age is increasingly prevalent, more research on CBD use in pregnant human populations is needed to investigate the effects of CBD on fetal development and infant outcomes.

Tobacco Smoking during Pregnancy: Women's Perception about the Usefulness of Smoking Cessation Interventions

Tobacco consumption during pregnancy is a serious public health problem due to its negative effects on fetal development and on pregnant women's health and well-being. Thus, it is of utmost importance to plan and implement smoking cessation interventions, to prevent the negative impact of this risk factor, namely on children's health and development. This cross-sectional study aimed at exploring the perceptions and beliefs about the usefulness of smoking cessation interventions during pregnancy, in a sample of pregnant Portuguese women. The smoking use by pregnant women, as well as the risk factors associated with tobacco smoking during pregnancy, were also analyzed. The sample included 247 pregnant Portuguese women aged between 18-43-years-old (M = 30.30, SD = 5.02): 42.5% never smoked, 18.3% quit smoking before pregnancy, 19.0% quit smoking after getting pregnant and 20.2% were current smokers. The pregnant Portuguese women who smoked during pregnancy (current smokers or who quit smoking after getting pregnant) were mostly single or divorced, with lower education levels, showed a higher prevalence of clinically significant anxiety symptoms, and perceived smoking cessation interventions during pregnancy as less useful when compared to women who never smoked or quit smoking prior pregnancy. Daily or weekly smoking cessation interventions, implemented by health professionals such as doctors, nurses, or psychologists are the ones perceived as the most useful for pregnant women. These findings provide important clues for the planning of smoking cessation interventions during pregnancy, highlighting the domains that should be carefully monitored by health professionals. Specific strategies should also be used by health professionals to promote smoking cessation considering the demands of pregnancy and postpartum.

Isolation, marginalisation and disempowerment - understanding how interactions with health providers can influence smoking cessation in pregnancy

Background

Maternal smoking during pregnancy can lead to serious adverse health outcomes for both women and their infants. While smoking in pregnancy has declined over time, it remains consistently higher in women with lower socioeconomic circumstances. Furthermore, fewer women in this group will successfully quit during pregnancy.

Aim

This study explores the barriers to smoking cessation experienced by socially disadvantaged pregnant women and investigates how interactions with health providers can influence their smoking cessation journey.

Methods

Women (either pregnant or birthed in the previous 10 years, who smoked or quit smoking in pregnancy) were recruited from a metropolitan public hospital antenatal clinic in South Australia and community organisations in surrounding suburbs. Seventeen women participated in qualitative semi-structured small focus groups or interviews. The focus groups and interviews were recorded, transcribed and thematically analysed.

Findings

Four interconnected themes were identified: 1) smoking embedded in women’s challenging lives and pregnancies, 2) cyclic isolation and marginalisation, 3) feeling disempowered, and 4) autonomy and self-determination. Themes 3 and 4 are characterised as being two sides of a single coin in that they coexist simultaneously and are inseparable. A key finding is a strong unanimous desire for smoking cessation in pregnancy but women felt they did not have the necessary support from health providers or confidence and self-efficacy to be successful.

Conclusion

Women would like improvements to antenatal care that increase health practitioners’ understanding of the social and contextual healthcare barriers faced by women who smoke in pregnancy. They seek improved interventions from health providers to make informed choices about smoking cessation and would like women-centred care. Women feel that with greater support, more options for cessation strategies and consistency and encouragement from health providers they could be more successful at antenatal smoking cessation. If such changes were made, then South Australian practice could align more with best practice international guidelines for addressing smoking cessation in pregnancy, and potentially improve outcomes for women and their children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04720-0.

Active and Passive Exposure to Tobacco and e-Cigarettes During Pregnancy

OBJECTIVES

Active and passive exposure to tobacco cigarettes during pregnancy is associated with multiple negative health outcomes for the fetus. In addition, exposure to e-cigarettes has been progressively discussed as a new threat to fetal health. Until now, there has been a lack of studies examining active and passive exposure to tobacco and e-cigarettes among pregnant women. The objective of our current STudy on E-cigarettes and Pregnancy (STEP) was to advance and complement the current knowledge regarding active and passive exposure to tobacco and e-cigarettes before pregnancy and during early and late pregnancy.

METHODS

One element of the STEP study was a quantitative cross-sectional design: A sample of 540 pregnant women recruited at an obstetrician clinic in Hamburg from April 2018 to January 2019 were surveyed once via a standardized questionnaire and provided complete information regarding their consumption of tobacco and e-cigarettes. We performed a descriptive analysis of tobacco and e-cigarette use before pregnancy and during early and late pregnancy, as well as bivariate analysis of these variables with sociodemographic determinants. Passive exposure was assessed by asking the participating pregnant women about the consumption of tobacco and e-cigarettes by their partners, in general, and in their homes.

RESULTS

Before pregnancy, 20.0% of the participants used tobacco cigarettes exclusively, 1.3% used e-cigarettes exclusively, and 6.5% were dual users. Educational level was significantly associated with tobacco cigarette use (p < 0.001) and dual use (p = 0.047) before pregnancy. During early (late) pregnancy, 8.7% (2.8%) used tobacco cigarettes and 0.4% (0.0%) used e-cigarettes exclusively. Twenty-point nine percent of women's partners consumed tobacco cigarettes exclusively, 2.7% consumed e-cigarettes exclusively, and 2.7% consumed both. A total of 8.5% (16.7%) of the partners who consumed tobacco cigarettes exclusively (e-cigarettes exclusively) did so in the women's homes.

CONCLUSIONS FOR PRACTICE

Among pregnant women, the use of tobacco cigarettes remains prominent before and during pregnancy, while e-cigarette use predominately occurs before pregnancy. Our study shows that pregnant women are frequently exposed to their partners' tobacco and e-cigarette use within their homes. Strategies to reduce such exposure should be further intensified.

Understanding Racial Disparities of Preterm Birth Through the Placenta

The racial disparity associated with preterm birth is a public health concern in the United States. The placenta is the principal metabolic, respiratory, and endocrine organ of the fetus and a key route by which environmental exposures are transmitted from mother to offspring. Available at every delivery, it may serve as a marker of differences in prenatal exposures that manifest differently by race. Recently, we described differences in placental pathology between African-American and White preterm births: the prevalence of chronic inflammation was higher among African-American women's placentas compared with those of White women. Similarly, racial differences have been shown in placental malperfusion and placental weight. Social determinants such as poverty and stress from discrimination have been implicated in racial disparities in preterm birth. To date, however, the underlying biological mechanisms, whether through inflammatory, oxidative stress, or other pathways involving epigenetic programming, remain largely unknown. The placenta, complemented by maternal and umbilical cord blood biomarkers, may provide important information on the perinatal environment that explains the origins of racial disparities in preterm birth rates and subsequent health outcomes. This article reviews existing literature and current research gaps. Opportunities are discussed for future placental research that may reveal novel mechanisms leading to the development of new approaches in the prevention and management of preterm birth and its outcomes.

Modeling Etiology of Smoking During Pregnancy in Swedish Twins, Full-, and Half-Siblings, Reared Together and Apart

INTRODUCTION

Using Swedish nationwide registry data, we investigated the contribution of genetic and environmental risk factors to the etiology of smoking status across stages of pregnancy with increasing degrees of social and psychological pressure to reduce or quit smoking, by twin and sibling modeling.

AIMS AND METHODS

Smoking status was available before, and during early and late pregnancy from the Medical Birth Register. Twin, full-, and half-sibling pairs, both reared together and apart, born between 1960 and 1990 were obtained from national twin and genealogical registers. Genetic structural equation modeling in OpenMx was applied to the population-based data to estimate shared genetic and/or environmental covariance across stages of pregnancy, accounting for maternal birth cohort and age at pregnancy.

RESULTS

Analyses of paired data on 258 749 individuals suggested that risk factors for smoking status changed across stages of pregnancy. Results predicted substantial heritability (60-70%) and moderate contributions of shared environmental factors (10-15%) for smoking status. Whilst the same shared environmental factors were amplified from before pregnancy to late pregnancy, new primarily unique environmental factors explained ~10% of the variance during early pregnancy which was carried forward to late pregnancy.

CONCLUSIONS

Using registry data on women across pregnancy, we replicated that smoking status is highly heritable. Furthermore, we found support for increased impact of shared environmental factors during pregnancy of factors already present prior to pregnancy, and an independent set of mostly new unique environmental factors that may be triggered by increased social pressure to reduce or quit smoking during pregnancy.

IMPLICATIONS

As new factors partially explain smoking status during pregnancy and the effects of familial factors increase across pregnancy, efforts to prevent or reduce smoking during pregnancy should receive continued attention, with a focus on both the individual and the family unit.

Parenthood and smoking

Parents' smoking is harmful to infants' health. While it is well established that the fraction of mothers smoking during pregnancy is non-negligible, it is an open question of how many parents actually quit smoking to account for the adverse health effects accruing to their offspring. It is also unknown for how long smoking is reduced after first childbirth. This paper investigates these questions in a longitudinal analysis. The analyzed time period covers smoking patterns several years before childbirth and up to twenty years afterwards. Women's smoking probability already drops several years before first childbirth and it remains reduced until the first child turns 18 years old. In the second and third trimester of pregnancy, the drop is largest by around 75 percent.

Using Birth Cohort Data to Assess the Impact of the UK 2008-2010 Economic Recession on Smoking During Pregnancy

INTRODUCTION

Despite the well-known link between stress and smoking, evidence for associations between economic recession, financial stress, and smoking is contradictory. In this study, we assess whether women were more likely to continue smoking during pregnancy if they were exposed to the UK 2008-2010 economic recession during pregnancy than those who were unexposed, and whether this relationship is mediated by financial stress.

METHODS

We used cross-sectional data on 2775 pregnant women who were regular smokers before pregnancy and who were enrolled in the UK Born in Bradford cohort study between March 2007 and December 2010. The cutoff date for exposure to recession was set as August 1, 2008, based on local and national economic data. Multivariable logistic regression analysis included potential confounders: maternal age, parity, cohabitation, ethnicity, and maternal age. The mediating role of financial stress was analyzed using "worse off financially" and a "difficult financial situation" as indicators of financial stress in Sobel-Goodman mediation tests with bootstrap resampling.

RESULTS

After taking into account potential confounders, exposure to recession was associated with continued smoking during pregnancy (OR = 1.19, 95% CI = 1.01 to 1.41, p = 0.03). A worse financial situation and a difficult financial situation were identified as mediators, explaining 8.4% and 17.6%, respectively, of the relationship between exposure to recession and smoking during pregnancy.

CONCLUSIONS

Smoking during pregnancy is associated with exposure to the UK 2008-2010 economic recession during pregnancy, and this relationship is partly mediated by financial stress.

IMPLICATIONS

Health inequalities in smoking during pregnancy are affected by economic recession, as those who are most likely to smoke are also most likely to experience the financial stress resulting from economic recession. Socioeconomic conditions at the societal and individual level are important targets when aiming to reduce rates of smoking during pregnancy.

Pharmacological interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non-pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown.

OBJECTIVES

To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi-randomised, cross-over, and within-participant designs, and RCTs with additional intervention components not matched between trial arms.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well-being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate.

MAIN RESULTS

We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non-placebo (behavioural support only) controls, there was low-certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo-controlled and non-placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo-controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non-placebo-controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast-acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non-serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low-certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group.

AUTHORS' CONCLUSIONS

NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non-placebo-controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo-controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review.

The Great Disrupter: Relationship of Alexithymia to Emotion Regulation Processes and Smoking among Pregnant Women

Background: Many women continue to smoke during pregnancy, despite known risks, often in response to negative affect. Recent scholarship has begun to examine factors that decrease the success of behavioral treatments for smoking cessation in pregnancy, which are the preferred interventions. Alexithymia is one factor that may interfere with smoking cessation interventions. Alexithymia restricts access to emotional information and increases propensity toward maladaptive behaviors, including smoking. However, mechanisms underlying such effects are largely unknown. Objectives: Using data from a longitudinal treatment study, the present research examined difficulties with emotion regulation as a potential mechanism linking alexithymia and smoking. Pregnant smokers (n = 73; mean age = 24.78; SD = 4.50) completed measures related to alexithymia, smoking, emotion regulation, depression, anxiety, and anger at baseline and then again following eight sessions of Cognitive-Behavioral Smoking Cessation Treatment. Results: Nearly 40% of the sample met the criteria for alexithymia. The alexithymia group reported higher depression, anxiety, and anger. They also reported more difficulties with emotion regulation. In a path analysis, baseline alexithymia had a significant positive indirect effect on number of cigarettes smoked at the end of treatment through difficulties with emotion regulation. Conclusions/Importance: Similar to other studies, alexithymia limits the understanding of emotional information necessary for selection and implementation of adaptive coping responses. Our results extend the literature by suggesting that smoking may be an attempt to manage undifferentiated and unpleasant sensations created by alexithymia.

Racial differences in placental pathology among very preterm births

INTRODUCTION

African American women are at higher risk for preterm birth compared to white women, but no placental pathology has characterized this disparity. The objective of this study was to examine the association of race with placental pathology among very preterm births.

METHODS

We conducted an eight-year retrospective cohort study of very preterm infants born at ≤32 weeks at Northwestern Prentice Women's Hospital in Chicago, Illinois. Archived placental slides underwent standardized masked histopathologic review. Logistic regression was performed for placental pathology, adjusting for available relevant covariates and stratified by infant sex and gestational age.

RESULTS

Placentas were available for 296 white and 224 African American mother-infant pairs among births at ≤32 weeks gestation. Compared to placentas from white births, the adjusted OR (aOR) for acute inflammation in placentas from African American births was 1.95 (95% CI 0.87-4.37), the aOR for chronic inflammation was 3.35 (1.49-7.54), the aOR for fetal vascular pathology was 0.82 (0.29-2.32), and the aOR for maternal vascular pathology was 1.01 (0.51-1.99). Stratified analysis showed associations between all placental pathologies and race among male births. Across gestational age groups (<28 and ≥ 28 weeks), the association between race and placental pathology was present for chronic inflammation and fetal vascular pathology.

DISCUSSION

Race is associated with placental pathology, and in particular, with chronic inflammation among very preterm births. The effect is modified by infant sex and gestational age. Placental histopathology may be useful markers for understanding the biological processes that shape disparities in pregnancy outcomes.

Prevalence and predictors of maternal smoking prior to and during pregnancy in a regional Danish population: a cross-sectional study

BACKGROUND

Maternal smoking is still a major public health problem posing the risk of several negative health outcomes for both the pregnant woman and her offspring. The prevalence of maternal smoking in Denmark and other high-income countries has decreased continuously since the 1980s, and a prevalence below 10% of women who continue to smoke during pregnancy has been reported in studies after 2010. Previous studies have shown that low socioeconomic status is associated with maternal smoking. Information from the Danish Birth Register about maternal smoking shows that the prevalence of women who report to smoke in pregnancy has decreased continuously with 23.3% who reported ever smoking in pregnancy in 2000, 12.9% in 2010 and 9.0% in 2017. The aim of this study was to estimate the prevalence of maternal smoking at the time of conception and at 20 weeks of gestation in a regional Danish population, to describe differences in maternal characteristics among smokers, quitters and never-smokers, and to estimate predictors of smoking at the time of conception.

METHODS

A cross-sectional study was conducted among pregnant women receiving antenatal care at the Department of Obstetrics, Zealand University Hospital, Denmark from August 2015 to March 2016 (n = 566). The main outcome was smoking at the time of conception and at 20 weeks of gestation. The questionnaire also collected information about maternal, health-related and sociodemographic characteristics. Descriptive analysis was conducted, and multivariate logistic regression analysis was used to assess the potential associated predictors (adjusted odds ratio).

RESULTS

The prevalence of self-reported smoking at the time of conception was 16% (n = 90) and 6% smoked at 20 weeks of gestation (n = 35), as 61% of smokers quit smoking during early pregnancy. Multiple logistic regression analysis showed that significant predictors for smoking at conception were the socioeconomic factors; ≤12 years of education, shift work and being unemployed.

CONCLUSION

The prevalence of self-reported maternal smoking in this regional Danish population of pregnant women is lower than seen in previous studies. However, predictors for smoking at the time of conception remain to be factors of low socioeconomic status confirming a social inequality in maternal smoking. Women at risk of smoking during pregnancy must be identified in early pregnancy or even before pregnancy and be offered interventions to help them quit smoking.

Spiritual Health and Physical Activity Among Iranian Pregnant Women

This study was aimed to investigate the relationship between spiritual health and physical activity among Iranian pregnant women during 2015. A cross-sectional descriptive-analytic design was adopted. A total number of 411 participants were selected by convenience sampling from Iranian women who regularly attended health centers for prenatal care. Data were collected using demographic questionnaire and Health-Promoting Lifestyle Profile questionnaire, 2nd edition. (Spiritual health and physical activity are two components of health-promoting lifestyle.) The data were analyzed, using descriptive statistics, t test, one-way ANOVA, Pearson's correlation coefficient, and regression. p values <0.05 were considered significant. The mean age of pregnant women was 27.90 ± 6.03 years. Spiritual health had the highest score (25.86 ± 4.7) and physical activity had the lowest score (11.31 ± 3.27), among six Health-Promoting Lifestyle Profile subscales. In fact, there was a statistically significant correlation between spiritual health and physical activity (p = 0.000). According to results, pregnant women have higher spiritual health and lower physical activity scores. There was a statistically significant correlation between spiritual health and physical activity. The findings of this study can be used in prenatal care, midwifery education, and maternal health policies.

Education is the strongest socio-economic predictor of smoking in pregnancy

AIMS

To investigate socio-economic disparities in smoking in pregnancy (SIP) by the mother's education, occupational class and current economic conditions.

DESIGN

Cross-sectional analysis with linked survey and register data.

SETTING

South-western Finland.

PARTICIPANTS

A total of 2667 pregnant women [70% of the original sample (n = 3808)] from FinnBrain, a prospective pregnancy cohort study.

MEASUREMENTS

The outcome was smoking during the first pregnancy trimester, measured from the Finnish Medical Birth Register. Education and occupational class were linked from population registers. Income support recipiency and subjective economic wellbeing were questionnaire-based measures of current economic conditions. These were adjusted for age, partnership status, residential area type, parental separation, parity, childhood socio-economic background, childhood adversities (the Trauma and Distressing Events During Childhood scale) and antenatal stress (Edinburgh Postnatal Depression Scale). Logistic regressions and attributable fractions (AF) were estimated.

FINDINGS

Mother's education was the strongest socio-economic predictor of SIP. Compared with university education, adjusted odds ratios (aORs) of SIP were: 2.2 [95% confidence interval (CI) = 1.2-3.9; P = 0.011] for tertiary vocational education, 4.4 (95% CI = 2.1-9.0; P < 0.001) for combined general and vocational secondary education, 2.9 (95% CI = 1.4-6.1; P = 0.006) for general secondary education, 9.5 (95% CI 5.0-18.2; P < 0.001) for vocational secondary education and 14.4 (95% CI = 6.3-33.0; P < 0.001) for compulsory schooling. The total AF of education was 0.5. Adjusted for the other variables, occupational class and subjective economic wellbeing did not predict SIP. Income support recipiency was associated positively with SIP (aOR = 1.8; 95% CI = 1.1-3.1; P = 0.022). Antenatal stress predicted SIP (aOR = 2.0; 95% CI = 1.4-2.8; P < 0.001), but did not attenuate its socio-economic disparities.

CONCLUSIONS

In Finland, socio-economic disparities in smoking in pregnancy are attributable primarily to differences in the mother's educational level (low versus high) and orientation (vocational versus general).

Pregnancy, parity and periodontal disease

Many women believe that their dental condition deteriorated during pregnancy or as a result of having children. Epidemiological studies have reported an association between higher parity and tooth loss, and higher parity and periodontal attachment loss. Several possible explanations for this association exist. First, hormonal changes during pregnancy affect the immune response to bacterial plaque and drive vascular and gingival changes that may contribute to heightened gingival inflammation. These changes are transient, without irreversible loss of periodontal attachment, and post-partum resolution can be expected for most women. For women with destructive periodontal disease, the effects of pregnancy and parity are unclear. Second, it is also plausible that parity and socioeconomic position (SEP) have shared risk factors, increasing the incidence of disease or influencing its management. Education, one aspect of SEP, is an important determining factor for women's fertility rate, with a gradient of fewer children with higher educational attainment. Higher levels of education are also favourably associated with behaviours conducive to oral health, and a lower incidence of damaging health behaviours. Thus, the potential for confounding is considerable. This review examines the literature on the association between pregnancy, parity and periodontal health, and explores sociobehavioural mechanisms for the observed association.

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.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Smoking and Smoking Cessation During Pregnancy. An Analysis of a Hospital Based Cohort of Women in Romania

Perinatal smoking is associated with a wide range of negative reproductive and pregnancy outcomes. The aim of the current study was to examine the prevalence and characteristics of women who report smoking prenatally and quit during pregnancy in a large sample of Romanian women. Understanding which women are more likely to quit will contribute to public health knowledge that will help more women stop smoking prior to or during pregnancy and prevent relapse postpartum. This cross-sectional analysis was conducted based on cross-sectional data collected between May 2012 and April 2015 as part of a cohort study of pregnancy implemented in six clinical settings in central Romania (N = 2370). Approximately 28 % of the sample reported smoking in the 6 months prior to learning they were pregnant. Half of the women who reported smoking 6 months before learning of their pregnancy, also reported that they stopped smoking by the time of the interview. Overall, tobacco consumption decreased from a sample mode of 10 cigarettes/day (range: 1-30) before pregnancy, to a sample mode of 5 cigarettes/day (range: 1-25) at the time of the interview. Women who quit had a higher socioeconomic position, were more likely to live in urban areas, partnered, primigravid, nulliparous, and reported lower anxiety and more social support. The combination of a socioeconomic gradient, less anxiety, and more social support suggests that efforts should be increased to target lower income, less educated, multigravid, and multiparous women and to develop programs that heighten social support and alleviate anxiety.

A longitudinal examination of US teen childbearing and smoking risk

BACKGROUND

Teenage motherhood and smoking have important health implications for youth in the United States and globally, but the link between teen childbearing and subsequent smoking is inadequately understood. The selection of disadvantaged young women into early childbearing and smoking may explain higher smoking levels among teen mothers, but teen motherhood may also shape subsequent smoking through compromised maternal depression or socioeconomic status, and race/ethnicity may condition these processes.

OBJECTIVE

This study examines the relationship between US teen childbearing and subsequent daily smoking, accounting for prior smoking and selection processes related to social disadvantage. Analyses investigate whether socioeconomic status and depression in young adulthood explained any relationship between teen childbearing and daily smoking, as well as examining racial/ethnic heterogeneity in these processes.

METHODS

Multivariate binary logistic regression analyses employ the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 7,529).

RESULTS

The highest daily smoking prevalence occurred among non-Hispanic White teen mothers, with lower prevalence among Hispanic and non-Hispanic Black teen mothers. Compared to other women, teenage mothers are 2.5 times as likely to smoke daily in young adulthood. Their greater likelihood of daily smoking is due in part to selection and is also mediated by socioeconomic status in ways that differ by race/ethnicity.

CONCLUSIONS

The findings suggest that preventing teen pregnancy or ameliorating its socioeconomic consequences may decrease daily smoking in this vulnerable population. Reducing teen smoking, especially during pregnancy, could improve teen, maternal, and infant health and thereby increase US health and longevity.

CONTRIBUTION

This study provides new, nationally representative information about selection, mediation, and heterogeneity processes in the relationship between teen childbearing and subsequent smoking.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Evaluation of a federally funded mass media campaign and smoking cessation in pregnant women: a population-based study in three states

OBJECTIVES

In 2012, theCenters for Disease Control and Prevention initiated a national anti-smoking campaign, Tips from Former Smokers (Tips). As a result of the campaign, quit attempts among smokers increased in the general population by 3.7 percentage points. In the current study, we assessed the effects of Tips on smoking cessation in pregnant women.

METHODS

We used 2009-2013 certificates of live births in three US states: Indiana, Kentucky and Ohio. Smoking cessation by the third trimester of pregnancy was examined among women who smoked in the 3 months prepregnancy. Campaign exposure was defined as overlap between the airing of Tips 2012 (March 19-June 10) and the prepregnancy and pregnancy periods. Women who delivered before Tips 2012 were not exposed. Adjusted logistic regression was used to determine whether exposure to Tips was independently associated with smoking cessation.

RESULTS

Cessation rates were stable during 2009-2011 but increased at the time Tips 2012 aired and remained elevated. Overall, 32.9% of unexposed and 34.7% of exposed smokers quit by the third trimester (p<0.001). Exposure to Tips 2012 was associated with increased cessation (adjusted OR: 1.07, 95% CI 1.05 to 1.10).

CONCLUSIONS

Exposure to a national anti-smoking campaign for a general audience was associated with smoking cessation in pregnant women.

Joint effect of education and age at childbirth on the risk of caesarean delivery: findings from Germany 2008-2015

OBJECTIVES

This article aims at assessing the joint effect of maternal age and education on the risk of having a caesarean delivery. As high maternal education is often associated with lower caesarean-birth rates, but high-educated women tend to postpone motherhood, these effects may offset each other in traditional analyses.

STUDY DESIGN

Secondary analysis of the data from the German Family Panel pairfam.

METHODS

The interview-based data refer to 1020 births between 2008 and 2015. We analyse only reports from mothers and calculate logistic regression models.

RESULTS

The caesarean delivery rate differs strongly between education levels, and low-educated women are at higher risk of having a caesarean delivery when controlling for parity and age. A positive age gradient is found, indicating a higher risk of caesarean section for older mothers. Without controlling for age, the association of education and caesarean section risk is weaker, i.e., effects of age and education partially level each other out. A model including an interaction term between age and education confirms this result.

CONCLUSIONS

The risk of having a caesarean delivery does not differ between levels of education when maternal age is not taken into account. Lower maternal education and higher age are both positively associated with the risk of experiencing a caesarean section in Germany. However, as higher educated women tend to have their children later, effects of education and age weigh each other out. Preventive campaigns should target women with lower education and raise women's awareness on the risks associated with late motherhood.

Smoking and quit attempts during pregnancy and postpartum: a longitudinal UK cohort

OBJECTIVES

Pregnancy motivates women to try stopping smoking, but little is known about timing of their quit attempts and how quitting intentions change during pregnancy and postpartum. Using longitudinal data, this study aimed to document women's smoking and quitting behaviour throughout pregnancy and after delivery.

DESIGN

Longitudinal cohort survey with questionnaires at baseline (8-26 weeks' gestation), late pregnancy (34-36 weeks) and 3 months after delivery.

SETTING

Two maternity hospitals in one National Health Service hospital trust, Nottingham, England.

PARTICIPANTS

850 pregnant women, aged 16 years or over, who were current smokers or had smoked in the 3 months before pregnancy, were recruited between August 2011 and August 2012.

OUTCOME MEASURES

Self-reported smoking behaviour, quit attempts and quitting intentions.

RESULTS

Smoking rates, adjusting for non-response at follow-up, were 57.4% (95% CI 54.1 to 60.7) at baseline, 59.1% (95% CI 54.9 to 63.4) in late pregnancy and 67.1% (95% CI 62.7 to 71.5) 3 months postpartum. At baseline, 272 of 488 current smokers had tried to quit since becoming pregnant (55.7%, 95% CI 51.3 to 60.1); 51.3% (95% CI 44.7 to 58.0) tried quitting between baseline and late pregnancy and 27.4% (95% CI 21.7 to 33.2) after childbirth. The percentage who intended to quit within the next month fell as pregnancy progressed, from 40.4% (95% CI 36.1 to 44.8) at baseline to 29.7% (95% CI 23.8 to 35.6) in late pregnancy and 14.2% (95% CI 10.0 to 18.3) postpartum. Postpartum relapse was lower among women who quit in the 3 months before pregnancy (17.8%, 95% CI 6.1 to 29.4) than those who stopped between baseline and late pregnancy (42.9%, 95% CI 24.6 to 61.3).

CONCLUSIONS

Many pregnant smokers make quit attempts throughout pregnancy and postpartum, but intention to quit decreases over time; there is no evidence that smoking rates fall during gestation.

Paternal Acculturation and Maternal Health Behaviors: Influence of Father's Ethnicity and Place of Birth

OBJECTIVES

Studies show disparities in maternal health behaviors according to acculturation, but whether paternal factors influence these patterns is unknown. We assessed the relationships between fathers' ethnicity and place of birth with maternal smoking during pregnancy and breastfeeding initiation overall and for 30 major ethnic groups.

MATERIALS AND METHODS

Data were from the Standard Certificate of Live Births on 1,053,096 births in Massachusetts between 1996 through 2010. We examined the concordance of maternal and paternal ethnicity and place of birth across three categories (United States-born white, United States-born Other ethnicity, and foreign-born), and then in relation to maternal smoking during pregnancy and breastfeeding initiation. Multivariable models adjusted for maternal age, marital status, education, plurality, parity, prenatal care, delivery source of payment, and year of birth.

RESULTS

United States-born white mothers were less likely to smoke during pregnancy (adjusted odds ratio [AOR] 0.66; 95% confidence interval [CI]: 0.60, 0.73) and more likely to initiate breastfeeding (AOR 1.56; 95% CI: 1.46, 1.66) if their partners were foreign-born. In contrast, foreign-born mothers whose partners were United States-born of Other ethnicity or United States-born white had a 1.65-5.12 higher odds of smoking during pregnancy and were 26%-41% less likely (AORs 0.59-0.74) to initiate breastfeeding than if their partners were also foreign-born. Results were consistent across most racial/ethnic groups.

CONCLUSIONS

Our findings offer new insight into the social pathways by which acculturation impacts maternal health behaviors and add to growing evidence that fathers are valuable to maternal health. Future efforts to understand how acculturation results in poorer maternal health behaviors should account for paternal influences.

Factors across the life course predict women's change in smoking behaviour during pregnancy and in midlife: results from the National Child Development Study

BACKGROUND

Tobacco smoking before, during and after pregnancy remains one of the few preventable factors associated with poor health outcomes for mothers and their children. We investigate predictors across the life course for change in smoking behaviour during pregnancy and whether this change predicts smoking status in midlife.

METHODS

Data were from the National Child Development Study (1958 British birth cohort). We included female cohort members who reported a first pregnancy up to age 33 years. Among 1468 women who smoked before pregnancy, we examined predictors reported in childhood (age 11 years), adolescence (age 16 years) and early adulthood (age 23 years) of change in smoking behaviour from 12 months before to during pregnancy using log-binomial regression. The association between change in smoking behaviour during pregnancy and smoking status in midlife (age 55 years) was examined while adjusting for predictors across the life course.

RESULTS

Among prepregnancy smokers (39%), 26% reduced and 35% quit smoking during pregnancy. Parental smoking and lower social class during childhood, and early adulthood lower social class, depression, early smoking initiation, high smoking intensity, living with a smoker, no pregnancy planning and early motherhood were associated with lower probability of smoking reduction or cessation in pregnancy. Compared with women who smoked before and during pregnancy, women who reduced or quit were two times more likely to be non-smoker at age 55 years (95% CI 1.76 to 2.20).

CONCLUSIONS

Findings from this population-based birth cohort study lend support for smoking cessation strategies that target those at risk at various stages across the life course.

Specification of Change Mechanisms in Pregnant Smokers for Malleable Target Identification: A Novel Approach to a Tenacious Public Health Problem

Maternal smoking during pregnancy (MSDP) continues to be a leading modifiable risk factor for perinatal complications and a range of neurodevelopmental and cardio-metabolic outcomes across the lifespan. Despite 40 years of intervention research less than one in five pregnant smokers who receive an intervention quit by delivery. Within this context, recognition of pregnancy is commonly associated with abrupt suspension or reduction of smoking in the absence of intervention, yet has not been investigated as a volitional target. The goal of this article is to provide the empirical foundation for a novel direction of research aimed at identifying malleable targets for intervention through the specification of behavior change mechanisms specific to pregnant women. To do so, we: (1) summarize progress on MSDP in the United States generated from conventional empirical approaches to health behavior change; (2) discuss the phenomenon of spontaneous change in the absence of intervention among pregnant smokers to illustrate the need for mechanistic specification of behavior change motivated by concern for fetal well-being; (3) summarize component processes in neurobiological models of parental and non-parental social behaviors as a conceptual framework for understanding change mechanisms during pregnancy; (4) discuss the evidence for the malleability of these processes to support their translational relevance for preventive interventions; and (5) propose a roadmap for validating the proposed change mechanism using an experimental medicine approach. A greater understanding of social and interpersonal processes that facilitate health behavior change among expectant mothers and how these processes differ interindividually could yield novel volitional targets for prenatal interventions. More broadly, explicating other-oriented mechanisms of behavior change during pregnancy could serve as a paradigm for understanding how social and interpersonal processes positively influence health behaviors across the lifespan.

Assessing Variations in Developmental Outcomes Among Teenage Offspring of Teen Mothers: Maternal Life Course Correlates

This study investigated potential heterogeneity in development among offspring (age 17) of teen mothers and maternal life course as correlates of variation. Using latent class analysis, subgroups of developmental outcomes were identified. Maternal standing in two life course realms (i.e., socioeconomic and domestic) was considered as a potential explanation for heterogeneity in offspring's development. Offspring reported on measures assessing their psychological, academic, and behavioral development. Teen mothers reported on measures of life course realms. Three subgroups of developmental outcomes were identified: on track (52%), at risk (37%), and troubled (11%). Findings suggest that economic hardship and number of pregnancies among teen mothers distinguish developmental patterns among teenage offspring, whereas teen mothers' educational attainment and marital status do not.

Ethnic differences in the clustering and outcomes of health behaviours during pregnancy: results from the Born in Bradford cohort

Background

Pregnancy is a time of optimal motivation for many women to make positive behavioural changes. We aim to describe pregnant women with similar patterns of self-reported health behaviours and examine associations with birth outcomes.

Methods

We examined the clustering of multiple health behaviours during pregnancy in the Born in Bradford cohort, including smoking physical inactivity, vitamin d supplementation and exposure to second-hand smoke. Latent class analysis was used to identify groups of individuals with similar patterns of health behaviours separately for White British (WB) and Pakistani mothers. Multinomial regression was then used to examine the association between group membership and birth outcomes, which included preterm birth and mean birthweight.

Results

For WB mothers, offspring of those in the 'Unhealthiest' group had lower mean birthweight than those in the 'Mostly healthy but inactive' class, although no association was observed for preterm birth. For Pakistani mothers, group membership was not associated with birthweight differences, although the odds of preterm birth was higher in 'Inactive smokers' compared to the 'Mostly healthy but inactive' group.

Conclusions

The use of latent class methods provides important information about the clustering of health behaviours which can be used to target population segments requiring behaviour change interventions considering multiple risk factors. Given the dominant negative association of smoking with the birth outcomes investigated, latent class groupings of other health behaviours may not confer additional risk information for these outcomes.

Cognitive and Behavioral Predictors of Quit Attempts and Biochemically-Validated Abstinence During Pregnancy

Introduction:

Initiating a quit attempt and achieving abstinence are distinct behaviors that have distinct correlates in general smokers. Studies predicting prenatal smoking have not addressed this.

Methods:

Pregnant smokers (N = 207), recruited to a cessation intervention trial, were used as an observational cohort. Women completed measures at baseline and 12-week follow-up (mid-late pregnancy). Outcomes were having made at least one quit attempt since baseline, and cotinine-validated 7-day abstinence at follow-up in attempters. Baseline predictors included demographics (age, deprivation, partner’s smoking), smoking behaviors (nicotine dependence, quit attempt history, previous prenatal smoking), and smoking beliefs (self-efficacy, determination, intention to quit, nonsmoker identity, social support, pregnancy-outcome beliefs). For each outcome, variables reaching p < .1 in logistic regression analyses were entered into a multivariate model controlling for trial arm. A complete case analysis was undertaken, with missing data assumptions tested in sensitivity analyses.

Results:

One hundred seventy-five women (85%) completed follow-up. Intention and determination to quit (p < .001), self-efficacy, nonsmoker identity, and not having previously smoked in pregnancy (p < .05) were univariate predictors of making a quit attempt, with stronger intention to quit the only independent predictor (multivariate odds ratio [OR] = 2.41, 95% confidence interval [CI] 1.19–4.87). Only nicotine dependence predicted validated abstinence among those who made a quit attempt (multivariate OR = 0.25, 95% CI 0.10–0.60).

Conclusions:

Initiating a quit attempt and achieving abstinence during pregnancy were found to have different correlates. For women yet to make a quit attempt in their pregnancy, smoking beliefs may be important intervention targets, but once they are engaged in quitting, nicotine dependence appears of prime importance.

Implications:

This study suggests that cognitive, particularly motivational, variables predict whether pregnant smokers will make a quit attempt, but they do not predict successful abstinence in those who attempt to quit, where nicotine dependence dominates. Interventions should facilitate quit attempts by targeting motivational variables among pregnant women who continue to smoke, but should focus on managing withdrawal once a woman initiates a quit attempt.

Changes in Smoking Behavior over Family Transitions: Evidence for Anticipation and Adaptation Effects

The study of changes in smoking behaviors over the life course is a promising line of research. This paper aims to analyze the temporal relation between family transitions (partnership formation, first childbirth, separation) and changes in smoking initiation and cessation. We propose a discrete-time logistic model to explore the timing of changes in terms of leads and lags effects up to three years around the event in order to measure both anticipation and adaptation mechanisms. Retrospective biographical data from the Santé et Itinéraires Professionnels (SIP) survey conducted in France in 2006 are used. Partnership formation was followed for both genders by a fall in smoking initiation and an immediate rise in smoking cessation. Childbirth was associated with increased smoking cessation immediately around childbirth, and additionally, females showed an anticipatory increase in smoking cessation up to two years before childbirth. Couple separation was accompanied by an anticipatory increase in smoking initiation for females up to two years prior to the separation, but this effect only occurred in males during separation. Our findings highlight opportunities for more targeted interventions over the life course to reduce smoking, and therefore have relevance for general practitioners and public policy elaboration.

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.

Maternal trajectories of cigarette use as a function of maternal age and race

BACKGROUND

Patterns of smoking vary as a function of age and race. The goals of this study were to identify trajectories of maternal cigarette use over a 17-year span, and to determine if maternal age at first birth and race were associated with smoking trajectories.

METHODS

Pregnant women (N=690) were recruited at an urban prenatal clinic. The women (13-42years old; 62% African-American, 38% White) were interviewed about cigarette use during pregnancy and 6, 10, 14, and 16years postpartum. Growth mixture modeling (GMM) was used to identify trajectories. Regressions were used to determine if maternal age at first birth and race predicted trajectory class membership.

RESULTS

A GMM of maternal cigarette use delineated 5 groups: none/unlikely to use (33%), decreasing likelihood of use (6%), late desistance (5%), increasing likelihood of use (17%), and chronic use (39%). Women who became mothers at a younger age were more likely to be classified as late desisters or increasingly likely to smoke. White mothers were more likely to be chronic smokers. Different smoking trajectories and predictors of trajectories were identified for the African-American and White mothers. Covariates including prenatal substance use, hostility, education, and economic hardship also differentiated smoking trajectories.

CONCLUSIONS

Both prevention and treatment of smoking should be targeted to specific groups by age of first pregnancy and race. Pregnant smokers should be provided with more information and resources to help them avoid cigarettes during pregnancy and maintain abstinence after pregnancy.

Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States

Widening of educational disparities and a narrowing female advantage in mortality stem in good part from disparities in smoking. The changes in smoking and mortality disparities across cohorts and countries have been explained by an epidemic model of cigarette use but are also related to life course changes. To better describe and understand changing disparities over the life course, we compare age patterns of smoking in three cohorts and two nations (France and the United States) using smoking history measures from the 2010 French Health Barometer (N = 20,940) and the 2010 U.S. National Health Interview Survey Sample Adult File (N = 20,444). The results demonstrate statistically significant widening of gender and educational differences from adolescence to early and middle adulthood, thus accentuating the disparities already emerging during adolescence. In addition, the widening disparities over the life course have been changing across cohorts: Age differences in educational disparities have grown in recent cohorts (especially in France), while age differences in gender disparities have narrowed. The findings highlight the multiple sources of inequality in smoking and health in high-income nations.

Are digital interventions for smoking cessation in pregnancy effective? A systematic review protocol

BACKGROUND

Behavioural support for smoking cessation in pregnancy can be effective; however, many pregnant women face barriers to seeking support to stop smoking. Some digital interventions have been found to be effective for smoking cessation in the general population and may be effective for supporting cessation in pregnancy due to their flexibility and the potential for personalisation. To date, there is limited evidence of the effectiveness of digital interventions for smoking cessation in pregnancy. This review aims to assess the following: (1) whether digital interventions are effective at promoting smoking cessation among pregnant women; (2) which behaviour change techniques (BCTs) or combinations of BCTs are associated with the effectiveness of digital interventions for smoking cessation in pregnancy; and (3) whether the number of BCTs used is associated with the effectiveness of digital interventions for smoking cessation in pregnancy.

METHODS

This review will include digital interventions delivered largely through computer (PC or laptop), video/DVD, mobile phone (including smartphones) or portable handheld device (e.g. tablet, iPad) and include websites, mobile or tablet applications and SMS text messages. Interventions must be randomised or quasi-randomised controlled trials aimed at women who smoke in pregnancy, with smoking cessation as a measured outcome (preferably the latest available point prevalence smoking status measure taken during pregnancy, biochemically verified if available). Electronic bibliographic databases will be searched to identify suitable studies indexed in the following: Academic Search Complete, ASSIA, CINAHL, The Cochrane Library, EMBASE, Medline, PsycINFO, Scopus, and Web of Science. The search strategy will include key words and database-specific subject headings relating to 'pregnancy' and 'smoking' and synonyms for the terms 'digital' and 'randomised controlled trial'. Where required and where possible, the first and second authors will independently code interventions and control groups for BCTs. If data allows, meta-analyses will be used to assess intervention effectiveness and the effectiveness of BCTs.

DISCUSSION

This systematic review will provide a detailed synthesis of the effectiveness of current research using digital interventions for smoking cessation in pregnancy, to build on the evidence base and guide the development of future research in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016036201.

Social disparities in parental smoking and young children's exposure to secondhand smoke at home: a time-trend analysis of repeated cross-sectional data from the German KiGGS study between 2003-2006 and 2009-2012

Background

Children who are exposed to secondhand smoke (SHS) have an increased risk of a wide range of health problems and illnesses. Smoke-free legislation aims to improve indoor air quality and in this way protect the health of people who do not smoke. This paper examines trends in SHS exposure at home among children in Germany since the introduction of smoking bans in public places. Special focus is placed on the importance of the family of origin’s socioeconomic status (SES) and on parental smoking behaviour.

Methods

The analyses are based on two waves of the “German Health Interview and Examination Survey for Children and Adolescents” (KiGGS)—one of which was conducted immediately before the introduction of central smoke-free legislation in the 2003-2006 period, the other approximately 6 years later from 2009 to 2012. A comparison is made between the answers given by the parents of children aged between 0 to 6 (KiGGS baseline study, n = 6680; KiGGS Wave 1, n = 4455). Domestic SHS exposure is covered in the parent interviews by asking whether anyone is allowed to smoke at home in the presence of their child. Parental smoking behaviour is determined separately for mothers and fathers. SES is determined on the basis of the parents’ education, occupational status and income.

Results

The percentage of 0- to 6-year-old children exposed to SHS in the parental home fell from 23.9 to 6.6 % in the period from 2003-2006 to 2009-2012. At the same time, the percentage of children with at least one parent who smokes decreased from 49.8 to 41.8 %. While relative social inequalities in parental smoking behaviour have tended to increase over time, inequalities in domestic SHS exposure have persisted. Children whose parents smoke and children from low-SES families are still most likely to be exposed to tobacco smoke. In both study periods and after statistical adjustment for parental smoking behaviour, children with a low SES had a 6.6-fold higher risk for SHS exposure in the parental home than children from high-SES households.

Conclusions

The results of the KiGGS study show that the proportion of children in Germany who are exposed to SHS at home has declined significantly over the last few years. There is much to suggest that the smoke-free legislation that has been introduced in Germany has led to a heightened awareness of the health risks of SHS both in public and in the private sphere, as well as to a denormalization of smoking. Children whose parents smoke, and among them particularly children from socially disadvantaged families, should be recognised as key target groups when implementing future tobacco-control measures.

Staying a smoker or becoming an ex-smoker after hospitalisation for unstable angina or myocardial infarction

The aim of our study was to better understand processes of ongoing smoking or smoking cessation (quitting) following hospitalisation for myocardial infarction or unstable angina (acute cardiac syndromes). In-depth interviews were used to elicit participants’ stories about ongoing smoking and quitting. In total, 18 interviews with smokers and 14 interviews with ex-smokers were analysed. Our findings illustrate the complex social nature of smoking practices including cessation. We found that smoking cessation following hospitalisation for acute cardiac syndromes is to some extent a performative act linked to ‘doing health’ and claiming a new identity, that of a virtuous ex-smoker in the hope that this will prevent further illness. For some ex-smokers hospitalisation had facilitated this shift, acting as a rite of passage and disrupting un-contemplated habits. Those participants who continued to smoke had often considered quitting or had even stopped smoking for a short period of time after hospitalisation; however, they did not undergo the identity shift described by ex-smokers and smoking remained firmly entrenched in their sense of self and the pattern of their daily lives. The ongoing smokers described feeling ashamed and stigmatised because of their smoking and felt that quitting was impossible for them. Our study provides an entry point into the smokers’ world at a time when their smoking has become problematised and highly visible due to their illness and when smoking cessation or continuance carries much higher stakes and more immediate consequences than might ordinarily be the case.

Smoking during pregnancy in association with maternal emotional well-being

OBJECTIVE

The aim of the study was to investigate psychosocial predictors of smoking during pregnancy.

MATERIALS AND METHODS

It was a cross-sectional analysis of a prospective birth-cohort study. The participants were 514 mothers of full-term infants. Women completed questionnaires during hospital stay after delivery. Questionnaire included items on sociodemographic characteristics, planning and emotional acceptance of pregnancy, reproductive history, health-related behavior, emotional well-being, and relationships with a partner.

RESULTS

Smoking during pregnancy was reported by 14.8% of the participants. Prenatal smoking was associated with secondary or lower education, maternal age less than 20 years, childbirth outside of marriage, history of elective abortion, unplanned pregnancy, lack of positive emotional acceptance of pregnancy by mother and father, emotional distress and alcohol consumption during pregnancy. Smoking during pregnancy remained significantly associated with prenatal alcohol consumption, previous elective abortion, and lack of positive emotional acceptance of pregnancy by mother even after adjustment for maternal age, education, and family structure.

CONCLUSIONS

Results support an idea of complexity of the relationships among smoking, alcohol use, and emotional well-being. Lack of positive emotional acceptance of pregnancy by mother and history of elective abortions can be considered as possible associates of smoking during pregnancy and suggest that strengthening of positive attitudes toward motherhood could add to lower smoking rates among pregnant women.

Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women

Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes and immediate and longer-term adverse health outcomes among exposed offspring. Developing more effective smoking-cessation interventions for pregnant women has been a public-health priority for more than thirty years. We review developments over the past three years (2012-15) on the use of financial incentives to promote smoking cessation among pregnant women. We searched the literature for reports on primary and secondary analyses and reviews of controlled trials on this topic published in peer-reviewed journals using the search engine PubMed, reviewed bibliographies of published articles, and consulted expert colleagues. The search revealed several important developments, with the following three being especially noteworthy. First, the review identified four new randomized controlled trials, three of which further supported the efficacy of this treatment approach. One of the three trials supporting efficacy also included the first econometric analysis of this treatment approach showing financial incentives with pregnant smokers to be highly cost-effective. Second, two Cochrane reviews were published during this 3-year period covering the more recent and earlier efficacy trials. Meta-analyses in both reviews supported the efficacy of the approach. Lastly, the first effectiveness trial was reported demonstrating that financial incentives increased abstinence rates above control levels when implemented by obstetrical clinic staff in a large urban hospital working with community tobacco interventionists. Overall, there is a growing and compelling body of evidence supporting the efficacy and cost-effectiveness of financial incentives for smoking cessation among pregnant women.

Pharmacological interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking in pregnancy is a public health problem. When used by non-pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion and varenicline) are effective for smoking cessation, however, their efficacy and safety in pregnancy remains unknown. Electronic Nicotine Delivery Systems (ENDS), or e-cigarettes, are becoming widely used but their efficacy and safety when used for smoking cessation in pregnancy are also unknown.

OBJECTIVES

To determine the efficacy and safety of smoking cessation pharmacotherapies (including NRT, varenicline and bupropion), other medications, or ENDS when used for smoking cessation in pregnancy.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (11 July 2015), checked references of retrieved studies, and contacted authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) conducted in pregnant women with designs that permit the independent effects of any type of pharmacotherapy or ENDS on smoking cessation to be ascertained were eligible for inclusion.The following RCT designs are included.Placebo-RCTs: any form of NRT, other pharmacotherapy, or ENDS, with or without behavioural support/cognitive behaviour therapy (CBT), or brief advice, compared with an identical placebo and behavioural support of similar intensity.RCTs providing a comparison between i) any form of NRT, other pharmacotherapy, or ENDS added to behavioural support/CBT, or brief advice and ii) behavioural support of similar (ideally identical) intensity.Parallel- or cluster-randomised trials were eligible for inclusion. Quasi-randomised, cross-over and within-participant designs were not, due to the potential biases associated with these designs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and also independently extracted data and cross checked individual outcomes of this process to ensure accuracy. The primary efficacy outcome was smoking cessation in later pregnancy (in all but one trial, at or around delivery); safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well-being; and we also collated data on adherence with trial treatments.

MAIN RESULTS

This review includes a total of nine trials which enrolled 2210 pregnant smokers: eight trials of NRT and one trial of bupropion as adjuncts to behavioural support/CBT. The risk of bias was generally low across trials with virtually all domains of the 'Risk of bias' assessment tool being satisfied for the majority of studies. We found no trials investigating varenicline or ENDS. Compared to placebo and non-placebo controls, there was a difference in smoking rates observed in later pregnancy favouring use of NRT (risk ratio (RR) 1.41, 95% confidence interval (CI) 1.03 to 1.93, eight studies, 2199 women).  However, subgroup analysis of placebo-RCTs provided a lower RR in favour of NRT (RR 1.28, 95% CI 0.99 to 1.66, five studies, 1926 women), whereas within the two non-placebo RCTs there was a strong positive effect of NRT, (RR 8.51, 95% CI 2.05 to 35.28, three studies, 273 women; P value for random-effects subgroup interaction test = 0.01). There were no differences between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities or neonatal death. Compared to placebo group infants, at two years of age, infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' (one trial). Generally, adherence with trial NRT regimens was low. Non-serious side effects observed with NRT included headache, nausea and local reactions (e.g. skin irritation from patches or foul taste from gum), but these data could not be pooled.

AUTHORS' CONCLUSIONS

NRT used in pregnancy for smoking cessation increases smoking cessation rates measured in late pregnancy by approximately 40%. There is evidence, suggesting that when potentially-biased, non-placebo RCTs are excluded from analyses, NRT is no more effective than placebo. There is no evidence that NRT used for smoking cessation in pregnancy has either positive or negative impacts on birth outcomes. However, evidence from the only trial to have followed up infants after birth, suggests use of NRT promotes healthy developmental outcomes in infants. Further research evidence on NRT efficacy and safety is needed, ideally from placebo-controlled RCTs which achieve higher adherence rates and which monitor infants' outcomes into childhood. Accruing data suggests that it would be ethical for future RCTs to investigate higher doses of NRT than those tested in the included studies.

Postpartum smoking relapse--a thematic synthesis of qualitative studies

BACKGROUND AND AIMS

Many women quit smoking during pregnancy, but relapse after the baby is born. To understand why and identify ways of preventing this, this study reviewed the qualitative literature on women's experience of postpartum smoking relapse.

METHODS

A systematic review of qualitative studies and process evaluations of trials. We undertook a thematic synthesis of published qualitative data.

RESULTS

We screened 1336 papers. Twenty-two papers reporting on 16 studies were included, reporting on the views of 1031 postpartum women. Factors affecting relapse and barriers and facilitators to relapse prevention were identified around the key themes of beliefs, social influences, motivation, physiological factors and identity. Women's beliefs about smoking as a means of coping with stress and the need for social support, especially from a partner, emerged as important. Extrinsic motivation to quit during the pregnancy (for the health of the fetus) appeared to be a factor in prompting relapse after the baby was born. During the immediate postpartum period women believed that physiological changes influence cigarette cravings. The stress of caring for a newborn, sleeplessness and adjusting to a new mothering identity were also reported to be important.

CONCLUSIONS

Among women who quit smoking during pregnancy, those who relapse postpartum talk commonly about no longer needing to protect the baby and the effects of stress. Partner support and a sense of changed identity are cited as factors preventing relapse.

Exploring the experiences of pregnant women using an NHS stop smoking service: a qualitative study

AIM

The purpose of this article was to explore women's experiences of attempting to stop smoking while pregnant using National Health Service (NHS) support.

METHOD

A qualitative methodological approach was adopted to enable the researcher to develop an understanding of the women's experiences. Six individual semi-structured interviews were conducted with women who accessed an NHS stop smoking service while pregnant. The data were analysed using comparative analysis.

RESULTS

Five themes were identified: health risks, motivations to stop smoking, influences on smoking behaviour, feelings about smoking and experiences of using NHS stop smoking support. Motivation to stop smoking was predominantly due to concerns about their unborn baby's health, and knowledge of health risks was generally good. Limited information relating to the associated health risks of continued smoking in pregnancy from healthcare professionals appeared to be a common experience. External pressures both positively and negatively influenced the smoking status of the women. Stress was cited by all the women as a significant challenge to smoking cessation and something which they all struggled with. The women's experiences of using NHS support while pregnant was varied; some felt it adequately met their needs, while others felt that their expectations were not met.

CONCLUSION

Continued smoking in pregnancy is complex, and it appears that successful smoking cessation is related to a number of internal and external factors which present significant challenges for expectant mothers who smoke. Stress was found to be a major contributor in continued smoking; therefore, NHS stop smoking services should incorporate stress management techniques into stop smoking interventions. In addition, services should be flexible, adapting service provision to meet women's needs.