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Higgins ST, Nighbor TD, Kurti AN, Heil SH, Slade EP, Shepard DS, Solomon LJ, Lynch ME, Johnson HK, Markesich C, Rippberger PL, Skelly JM, DeSarno M, Bunn J, Hammond JB, Roemhildt ML, Williams RK, O'Reilly DM, Bernstein IM. Randomized Controlled Trial Examining the Efficacy of Adding Financial Incentives to Best practices for Smoking Cessation Among pregnant and Newly postpartum Women. Prev Med 2022; 165:107012. [PMID: 35248683 PMCID: PMC9440164 DOI: 10.1016/j.ypmed.2022.107012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/21/2022] [Accepted: 02/26/2022] [Indexed: 11/21/2022]
Abstract
We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ2 [2] = 9.01, P = .01), with percent SGA deliveries (+SEM) greatest in BP, intermediate in BP + FI, and lowest in NS (17.65 + 4.13, 10.81 + 3.61, and 2.53 + 1.77, respectively). Reliability analyses supported the efficacy of financial incentives for increasing abstinence antepartum and postpartum and decreasing SGA deliveries; external-validity analyses supported relationships between antepartum cessation and SGA risk. Adding financial incentives to Best Practice increases smoking cessation among antepartum and postpartum women and improves other maternal-infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210832.
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Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America.
| | - Tyler D Nighbor
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Allison N Kurti
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Sarah H Heil
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Eric P Slade
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Johns Hopkins University School of Nursing, United States of America
| | - Donald S Shepard
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Heller School for Social Policy and Management, Brandeis University, United States of America
| | - Laura J Solomon
- Department of Family Medicine, Psychology Emerita, University of Vermont, United States of America
| | - Mary Ellen Lynch
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Harley K Johnson
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Catherine Markesich
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Peter L Rippberger
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
| | - Joan M Skelly
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| | - Michael DeSarno
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| | - Janice Bunn
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Department of Medical Biostatistics, University of Vermont, United States of America
| | | | | | | | - Deirdre M O'Reilly
- Department of Pediatrics, University of Vermont, United States of America
| | - Ira M Bernstein
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, United States of America
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Smoking and Smoking Relapse in Postpartum: A Systematic Review and Meta-analysis. ADDICTIVE DISORDERS & THEIR TREATMENT 2021. [DOI: 10.1097/adt.0000000000000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Breunis LJ, Been JV, de Jong-Potjer L, Steegers EA, de Beaufort ID, de Kroon ML, Ismaili M'hamdi H. Incentives for Smoking Cessation During Pregnancy: An Ethical Framework. Nicotine Tob Res 2021; 22:1553-1559. [PMID: 31848622 PMCID: PMC7443604 DOI: 10.1093/ntr/ntz231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/16/2019] [Indexed: 01/01/2023]
Abstract
Introduction Smoking during pregnancy increases the risk of morbidity and mortality of the mother and child. The inability of the unborn child to protect itself, raises the social and academic responsibility to protect the child from the harmful effects of smoking. Interventions including rewards (incentives) for lifestyle changes are an upcoming trend and can encourage women to quit smoking. However, these incentives can, as we will argue, also have negative consequences, for example the restriction of personal autonomy and encouragement of smoking to become eligible for participation. To prevent these negative consequences, we developed an ethical framework that enables to assess and address unwanted consequences of incentive-based interventions whereby moral permissibility can be evaluated. Aims and Methods The possible adverse consequences of incentives were identified through an extensive literature search. Subsequently, we developed ethical criteria to identify these consequences based on the biomedical ethical principles of Beauchamp and Childress. Results Our framework consists of 12 criteria. These criteria concern (1) effectiveness, (2) support of a healthy lifestyle, (3) motivational for the target population, (4) stimulating unhealthy behavior, (5) negative attitudes, (6) personal autonomy, (7) intrinsic motivation, (8) privacy, (9) fairness, (10) allocation of incentives, (11) cost-effectiveness, and (12) health inequity. Based on these criteria, the moral permissibility of potential interventions can be evaluated. Conclusions Incentives for smoking cessation are a response to the responsibility to protect the unborn child. But these interventions might have possible adverse effects. This ethical framework aims to identify and address ethical pitfalls in order to avoid these adverse effects. Implications Although various interventions to promote smoking cessation during pregnancy exist, many women still smoke during pregnancy. Interventions using incentives for smoking cessation during pregnancy are a promising and upcoming trend but can have unwanted consequences. This ethical framework helps to identify and address ethical pitfalls in order to avoid these adverse effects. It can be a practical tool in the development and evaluation of these interventions and in evaluating the moral permissibility of interventions using incentives for smoking cessation during pregnancy.
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Affiliation(s)
- Leonieke J Breunis
- Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands
| | - Jasper V Been
- Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands.,Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Paediatrics, Division of Neonatology, Rotterdam, The Netherlands.,Erasmus MC - University Medical Centre Rotterdam, Department of Public Health, Rotterdam, The Netherlands
| | - Lieke de Jong-Potjer
- Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands
| | - Eric Ap Steegers
- Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands
| | - Inez D de Beaufort
- Erasmus MC - University Medical Centre Rotterdam, Department of Medical Ethics and Philosophy of Medicine, Rotterdam, The Netherlands
| | - Marlou La de Kroon
- Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Department of Obstetrics and Gynaecology, Rotterdam, The Netherlands.,University Medical Centre Groningen, University of Groningen, Department of Health Sciences, Groningen, The Netherlands
| | - Hafez Ismaili M'hamdi
- Erasmus MC - University Medical Centre Rotterdam, Department of Medical Ethics and Philosophy of Medicine, Rotterdam, The Netherlands
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Benowitz NL, Bernert JT, Foulds J, Hecht SS, Jacob P, Jarvis MJ, Joseph A, Oncken C, Piper ME. Biochemical Verification of Tobacco Use and Abstinence: 2019 Update. Nicotine Tob Res 2020; 22:1086-1097. [PMID: 31570931 DOI: 10.1093/ntr/ntz132] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND The changing prevalence and patterns of tobacco use, the advent of novel nicotine delivery devices, and the development of new biomarkers prompted an update of the 2002 Society for Research on Nicotine and Tobacco (SRNT) report on whether and how to apply biomarker verification for tobacco use and abstinence. METHODS The SRNT Treatment Research Network convened a group of investigators with expertise in tobacco biomarkers to update the recommendations of the 2002 SNRT Biochemical Verification Report. RESULTS Biochemical verification of tobacco use and abstinence increases scientific rigor and is recommended in clinical trials of smoking cessation, when feasible. Sources, appropriate biospecimens, cutpoints, time of detection windows and analytic methods for carbon monoxide, cotinine (including over the counter tests), total nicotine equivalents, minor tobacco alkaloids, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol are reviewed, as well as biochemical approaches to distinguishing cigarette smoking from use of electronic nicotine delivery devices (ENDS). CONCLUSIONS Recommendations are provided for whether and how to use biochemical verification of tobacco use and abstinence. Guidelines are provided on which biomarkers to use, which biospecimens to use, optimal cutpoints, time windows to detection, and methodology for biochemical verifications. Use of combinations of biomarkers is recommended for assessment of ENDS use. IMPLICATIONS Biochemical verification increases scientific rigor, but there are drawbacks that need to be assessed to determine whether the benefits of biochemical verification outweigh the costs, including the cost of the assays, the feasibility of sample collection, the ability to draw clear conclusions based on the duration of abstinence, and the variability of the assay within the study population. This paper provides updated recommendations from the 2002 SRNT report on whether and how to use biochemical markers in determining tobacco use and abstinence.
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Affiliation(s)
- Neal L Benowitz
- Division of Clinical Pharmacology and Experimental Therapeutics, Departments of Medicine and Biopharmaceutical Sciences; Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, CA
| | - John T Bernert
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jonathan Foulds
- Departments of Public Health Sciences and Psychiatry, Penn State College of Medicine, Hershey, PA
| | - Stephen S Hecht
- Departments of Laboratory Medicine and Pathology, Pharmacology, and Medicinal Chemistry, University of Minnesota, Masonic Cancer Center, Minneapolis, MN
| | - Peyton Jacob
- Departments of Medicine and Psychiatry, University of California San Francisco, San Francisco, CA
| | - Martin J Jarvis
- Department of Behavioural Science and Health, University College London, London, UK
| | - Anne Joseph
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Cheryl Oncken
- Department of Medicine, University of Connecticut, Farmington, CT
| | - Megan E Piper
- Center for Tobacco Research and Intervention, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
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Kurti AN, Tang K, Bolivar HA, Evemy C, Medina N, Skelly J, Nighbor T, Higgins ST. Smartphone-based financial incentives to promote smoking cessation during pregnancy: A pilot study. Prev Med 2020; 140:106201. [PMID: 32652133 PMCID: PMC7680385 DOI: 10.1016/j.ypmed.2020.106201] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/13/2020] [Accepted: 07/05/2020] [Indexed: 12/28/2022]
Abstract
Cigarette smoking during pregnancy increases risk for pregnancy complications, growth restriction, and other adverse health outcomes. The most effective intervention for reducing smoking during pregnancy is financial incentives contingent on biochemically-verified smoking abstinence. The present study examined the efficacy of a smartphone-based intervention whereby smoking monitoring and incentive delivery occurred remotely using a mobile app. If efficacious, this remote intervention would allow pregnant women residing in geographically remote areas to benefit from incentives-based cessation interventions. Sixty U.S. pregnant smokers were recruited between May 2018 to May 2019 via obstetrical clinics, Women, Infants, and Children (WIC) offices, and Facebook. Participants were assigned sequentially to one of two treatments: best practices alone (N = 30) or best practices plus financial incentives (N = 30). Outcomes were analyzed using repeated measures analysis based on generalized estimating equations (GEE). Seven-day point prevalence abstinence rates were greater in the incentives versus best practices arms early- (46.7% vs 20.0%, OR = 3.50, 95%CI = 1.11,11.02) and late-antepartum (36.7% vs 13.3%, OR = 3.76, 95%CI = 1.04,13.65), and four- (36.7% vs 10.0%, OR = 5.21, 95%CI = 1.28,21.24) and eight-weeks postpartum (40.0% vs 6.7%, OR = 9.33, 95%CI = 1.87,46.68), although not at the 12- (23.3% vs 10.0%, OR = 2.74, 95%CI = 0.63,11.82) or 24-week (20.0% vs 6.7%, OR = 3.50, 95%CI = 0.65,18.98) postpartum assessments likely due to this pilot study being underpowered for discerning differences at the later assessments, especially 24-weeks postpartum which was three months after treatment completion. These results support the efficacy of this remote, incentives-based intervention for pregnant smokers. Further research evaluating its efficacy and cost-effectiveness in a well-powered, randomized controlled trial appears warranted.
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Affiliation(s)
- Allison N Kurti
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA; Psychological Science, University of Vermont, Burlington, VT, USA.
| | - Katherine Tang
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Hypatia A Bolivar
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Carolyn Evemy
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA; Psychological Science, University of Vermont, Burlington, VT, USA
| | - Norman Medina
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Joan Skelly
- Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Tyler Nighbor
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA; Departments of Psychiatry, University of Vermont, Burlington, VT, USA; Psychological Science, University of Vermont, Burlington, VT, USA
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Berveiller P, Rault E, Guerby P. [Physiological and Psychological Data influencing Pregnant Women Smoking Behavior - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:551-558. [PMID: 32247097 DOI: 10.1016/j.gofs.2020.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Nicotine is the main addictive substance in tobacco and its addictive effects mainly involve dopamine. Nicotine is mainly metabolized (C-oxidation) in the liver to cotinine by the cytochrome P450 enzyme system. Nicotine half-life is short being about 2hours. Nicotine metabolism appears to be increased during pregnancy, mainly due to an increased cytochrome activity and maternal cardiac output. Thus, the smoking behavior of the pregnant woman is subsequently modified with an increase in withdrawal syndromes and an increased desire to smoke. These pharmacological elements should be taken into account when prescribing nicotine replacement therapy. Regarding the markers of tobacco intoxication, there is a good correlation between the importance of smoking and the measurement of expired air carbon monoxide. Although there is no evidence of decreased obstetrical complications related to its use, it is simple and non-invasive and therefore may be useful in routine practice. It gives an instantaneous value of tobacco intoxication, and represents a starting point for dialogue and management and can help to highlight the reality of withdrawal. Regarding the evaluation of tobacco addiction, the most commonly used questionnaires are the Fagerström tests (FTCD, HSI…), which are well correlated with cotinine concentration. However, there is insufficient evidence of their usefulness in reducing tobacco consumption during pregnancy to recommend them in current practice. DSM-V diagnostic criteria for addiction should be known as they can also be used to characterize the intensity of this addiction.
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Affiliation(s)
- P Berveiller
- Service de gynécologie-obstétrique, CHI de Poissy St-Germain, 78300 Poissy, France.
| | - E Rault
- Service d'obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant Lyon, 69500 Bron, France
| | - P Guerby
- Service de gynécologie-obstétrique, CHU de Toulouse, 31300 Toulouse, France
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Pizent A, Lazarus M, Kovačić J, Tariba Lovaković B, Brčić Karačonji I, Živković Semren T, Sekovanić A, Orct T, Branović-Čakanić K, Brajenović N, Jurič A, Miškulin I, Škrgatić L, Stasenko S, Mioč T, Jurasović J, Piasek M. Cigarette Smoking during Pregnancy: Effects on Antioxidant Enzymes, Metallothionein and Trace Elements in Mother-Newborn Pairs. Biomolecules 2020; 10:E892. [PMID: 32532134 PMCID: PMC7356311 DOI: 10.3390/biom10060892] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/04/2020] [Accepted: 06/09/2020] [Indexed: 12/13/2022] Open
Abstract
The effect of maternal smoking as a source of exposure to toxic metals Cd and Pb on superoxide dismutase (SOD) and glutathione peroxidase (GPx) activity, metallothionein (MT), Cd, Pb, Cu, Fe, Mn, Se and Zn concentrations were assessed in maternal and umbilical cord blood and placenta in 74 healthy mother-newborn pairs after term delivery. Sparse discriminant analysis (SDA) was used to identify elements with the strongest impact on the SOD, GPx and MT in the measured compartments, which was then quantified by multiple regression analysis. SOD activity was lower in maternal and cord plasma, and higher in the placenta of smokers compared to non-smokers, whereas GPx activity and MT concentration did not differ between the groups. Although active smoking during pregnancy contributed to higher maternal Cd and Pb concentrations, its contribution to the variability of SOD, GPx or MT after control for other elements identified by SDA was not significant. However, an impaired balance in the antioxidant defence observed in the conditions of relatively low-to-moderate exposure levels to Cd and Pb could contribute to an increased susceptibility of offspring to oxidative stress and risk of disease development later in life. Further study on a larger number of subjects will help to better understand complex interactions between exposure to toxic elements and oxidative stress related to maternal cigarette smoking.
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Affiliation(s)
- Alica Pizent
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Maja Lazarus
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Jelena Kovačić
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Blanka Tariba Lovaković
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Irena Brčić Karačonji
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Tanja Živković Semren
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Ankica Sekovanić
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Tatjana Orct
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | | | - Nataša Brajenović
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Andreja Jurič
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Iva Miškulin
- University Hospital Centre, 10000 Zagreb, Croatia; (I.M.); (L.Š.)
| | - Lana Škrgatić
- University Hospital Centre, 10000 Zagreb, Croatia; (I.M.); (L.Š.)
| | - Sandra Stasenko
- Merkur University Hospital, 10000 Zagreb, Croatia; (S.S.); (T.M.)
| | - Tatjana Mioč
- Merkur University Hospital, 10000 Zagreb, Croatia; (S.S.); (T.M.)
| | - Jasna Jurasović
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
| | - Martina Piasek
- Institute for Medical Research and Occupational Health, 10000 Zagreb, Croatia; (A.P.); (J.K.); (B.T.L.); (I.B.K.); (T.Ž.S.); (A.S.); (T.O.); (N.B.); (A.J.); (J.J.); (M.P.)
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Notley C, Gentry S, Livingstone‐Banks J, Bauld L, Perera R, Hartmann‐Boyce J. Incentives for smoking cessation. Cochrane Database Syst Rev 2019; 7:CD004307. [PMID: 31313293 PMCID: PMC6635501 DOI: 10.1002/14651858.cd004307.pub6] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes. OBJECTIVES To determine the long-term effect of incentives and contingency management programmes for smoking cessation. SEARCH METHODS For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018. SELECTION CRITERIA We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. MAIN RESULTS Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I2 = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I2 = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I2 = 41%), in favour of incentives. AUTHORS' CONCLUSIONS Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.
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Affiliation(s)
- Caitlin Notley
- University of East AngliaNorwich Medical SchoolNorwichUK
| | - Sarah Gentry
- University of East AngliaNorwich Medical SchoolNorwichUK
| | | | - Linda Bauld
- University of EdinburghUsher Institute, College of Medicine and Veterinary MedicineEdinburghUK
| | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Abstract
BACKGROUND Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle. OBJECTIVES To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions. SEARCH METHODS This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018. SELECTION CRITERIA We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes. DATA COLLECTION AND ANALYSIS For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively. MAIN RESULTS Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated. AUTHORS' CONCLUSIONS At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.
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Affiliation(s)
- Thomas R Fanshawe
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | | | - Rafael Perera
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
| | - Nicola Lindson
- University of OxfordNuffield Department of Primary Care Health SciencesOxfordUK
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Bergeria CL, Heil SH, Bunn JY, Sigmon SC, Higgins ST. Comparing Smoking Topography and Subjective Measures of Usual Brand Cigarettes Between Pregnant and Non-Pregnant Smokers. Nicotine Tob Res 2018; 20:1243-1249. [PMID: 28658941 PMCID: PMC6121910 DOI: 10.1093/ntr/ntx148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/23/2017] [Indexed: 11/13/2022]
Abstract
Introduction Most pregnant smokers report abruptly reducing their cigarettes per day (CPD) by ~50% after learning of pregnancy and making further smaller reductions over the remainder of their pregnancy. Laboratory and naturalistic studies with non-pregnant smokers have found that these types of reductions often lead to changes in smoking topography (i.e., changes in smoking intensity to maintain a desired blood-nicotine level). If pregnant women smoke more intensely, they may expose themselves and their offspring to similar levels of toxicants despite reporting reductions in CPD. Methods Pregnant and non-pregnant female smokers (n = 20 and 89, respectively) participated. At the experimental session, after biochemical confirmation of acute abstinence, participants smoked one usual brand cigarette ad lib through a Borgwaldt CReSS Desktop Smoking Topography device. Carbon monoxide (CO) and measures of nicotine withdrawal, craving, and reinforcement derived from smoking were also collected. Results The two groups did not differ on demographic or smoking characteristics at screening, except nicotine metabolism rate, which as expected, was faster in pregnant smokers. Analyses suggest that none of the smoking topography parameters differed between pregnant and non-pregnant smokers, although pregnant smokers had a significantly smaller CO boost. Both groups reported similar levels of relief of withdrawal and craving after smoking, but other subjective effects suggest that pregnant smokers find smoking less reinforcing than non-pregnant smokers. Conclusions Pregnant smokers do not smoke cigarettes differently than non-pregnant women, but appear to find smoking comparatively less pleasurable. Implications This is the first study to assess smoking topography in pregnant women. Pregnant women appear to be at increased risk for smoking cigarettes with more intensity because of (1) their tendency to make significant abrupt reductions in the number of cigarettes they smoke each day after learning of pregnancy and (2) an increase in nicotine metabolism induced by pregnancy. Despite these changes, the present results suggest that pregnant women do not smoke cigarettes more intensely or in a way that causes more toxicant exposure, perhaps due to a reportedly less pleasurable smoking experience.
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Affiliation(s)
- Cecilia L Bergeria
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
- Department of Psychiatry, University of Vermont, Burlington, VT
- Department of Psychological Science, University of Vermont, Burlington, VT
| | - Sarah H Heil
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
- Department of Psychiatry, University of Vermont, Burlington, VT
- Department of Psychological Science, University of Vermont, Burlington, VT
| | - Janice Y Bunn
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
- Department of Mathematics and Statistics, University of Vermont, Joseph E. Hills Agricultural Science Building, Burlington, VT
| | - Stacey C Sigmon
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
- Department of Psychiatry, University of Vermont, Burlington, VT
- Department of Psychological Science, University of Vermont, Burlington, VT
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT
- Department of Psychiatry, University of Vermont, Burlington, VT
- Department of Psychological Science, University of Vermont, Burlington, VT
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Reynolds CME, Egan B, Kennedy RA, O'Malley EG, Sheehan SR, Turner MJ. A prospective, observational study investigating the use of carbon monoxide screening to identify maternal smoking in a large university hospital in Ireland. BMJ Open 2018; 8:e022089. [PMID: 30037878 PMCID: PMC6059262 DOI: 10.1136/bmjopen-2018-022089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES This study evaluated breath carbon monoxide (BCO) testing in identifying maternal smokers as well as the difference between disclosers and non-disclosers of smoking status. We also investigated if other extrinsic factors affected the women's BCO levels in pregnancy. DESIGN A prospective observational study. SETTING A university obstetric hospital in an urban setting in Ireland. PARTICIPANTS Women (n=250) and their partners (n=54) were recruited at their first antenatal visit. Women <18 years and those who did not understand English were excluded. A booking history, including recording of smoking status, was collected by midwives. Following this, women were recruited and completed a detailed research questionnaire on smoking and extrinsic/environmental BCO sources. A BCO test was performed on both the woman and her partner. PRIMARY AND SECONDARY OUTCOME MEASURES The number of self-reported smokers and those that were positive on the BCO test. The characteristics of women who disclosed and did not disclose smoking status. The effect of extrinsic factors on the BCO test results. RESULTS Based on the receiver-operating characteristic curve, a BCO cut-off point of ≥3 ppm was the optimal level to identify ongoing smoking. At booking history, 15% of women reported as current smokers. Based on BCO levels ≥3 ppm combined with self-reported smoking in the research questionnaire, the rate increased to 25%. Non-disclosers had similar characteristics to non-smokers. No extrinsic factors affected maternal BCO levels. CONCLUSIONS Based on self-report and BCO levels, a quarter of women presenting for antenatal care continued to smoke, but only 60% reported their smoking to midwives. BCO measurement is an inexpensive, practical method of improving identification of maternal smoking, and it was not effected by extrinsic sources of BCO. Improved identification means more smokers can be supported to stop smoking in early pregnancy potentially improving the short-term and long-term health of both mother and child.
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Affiliation(s)
- Ciara Marie Edel Reynolds
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Brendan Egan
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- School of Health and Human Performance, Dublin City University, Dublin, Ireland
| | - Rachel Ak Kennedy
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Eimer G O'Malley
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Sharon R Sheehan
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Michael J Turner
- UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland
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12
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Lee SW, Han YJ, Cho DH, Kwak HS, Ko K, Park MH, Han JY. Smoking Exposure in Early Pregnancy and Adverse Pregnancy Outcomes: Usefulness of Urinary Tobacco-Specific Nitrosamine Metabolite 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol Levels. Gynecol Obstet Invest 2018; 83:365-374. [PMID: 29739005 DOI: 10.1159/000485617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 11/21/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim was to investigate the effect of -maternal smoking exposure assessed by urinary tobacco-specific nitrosamine metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-a1-butanol (NNAL) with adverse pregnancy outcomes. METHODS A total of 251 pregnant women were recruited. Urinary cotinine and NNAL were measured. Participants' sociodemographics were obtained by questionnaire and pregnancy outcomes were collected by charts review after delivery. RESULTS The prevalence of smoking was 8.4% (21 of 249), 1.2% (3 of 241), and 3.7% (9 of 241) in pregnant women according to questionnaire, cotinine, and NNAL, respectively. As compared with questionnaire positivity and cotinine levels, women with positive NNAL were independent determinants for spontaneous abortion (adjusted OR 12.357, 95% CI 2.053-74.368), preterm birth (adjusted OR 22.239, 95% CI 3.737-132.357), and small for gestational age (adjusted OR 6.915, 95% CI 1.385-34.524). CONCLUSIONS Urinary NNAL might be a useful biomarker in detection of maternal smoking status in association with adverse pregnancy outcomes. Use of this marker in preconception and pregnancy counselling before planning pregnancy may allow prevention of several adverse pregnancy outcomes.
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Affiliation(s)
- Si Won Lee
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea.,Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - You Jung Han
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Dong Hee Cho
- Laboratory of Laboratory Medicine, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Ho-Seok Kwak
- Laboratory of Laboratory Medicine, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Kinarm Ko
- Department of Stem Cell Biology, Center for Stem Cell Research, Institute of Advanced Biochemical Science, Research Institute of Medical Science, Konkuk University, Seoul, Republic of Korea
| | - Mi Hye Park
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jung Yeol Han
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
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Ashford K, Rayens E, Wiggins AT, Kay Rayens M, Sayre MM, O’Brien J. Associations of Demographic Factors and Tobacco Use With Progesterone and Estradiol During Pregnancy. SAGE Open Nurs 2018; 4:2377960818806285. [PMID: 33415210 PMCID: PMC7774417 DOI: 10.1177/2377960818806285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 09/18/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the association of biochemically validated prenatal tobacco use with serum progesterone and estradiol in the second trimester of pregnancy, controlling for demographic and personal factors. STUDY DESIGN This secondary analysis of a multicenter longitudinal study included 114 women with singleton pregnancies. Multiple regression analysis assessed whether prenatal tobacco use was related to hormone levels during the second trimester, controlling for covariates (age, body mass index, and race or ethnicity, with gestational age added to subsequent models). RESULT In the initial regressions, tobacco users had significantly lower progesterone level compared with nonsmokers (p = .037), while estradiol was unrelated to prenatal tobacco use. Women with greater body mass index also had significantly lower progesterone (p = .028), but body mass index was unrelated to estradiol. With gestational age as an additional covariate, prenatal tobacco use was no longer a significant predictor of progesterone, but both body mass index and gestational age were significant (F = 10.6, p < .001, R 2 = 0.35). For estradiol, the overall regression of estradiol on age, body mass index, and race or ethnicity was not significant (F = 1.2, p = .31). With gestational age added to the model, the overall model was significant (F = 7.2, p < .001, R 2 = 0.27). CONCLUSION This study provides additional evidence that prenatal tobacco use may influence lower serum progesterone during the second trimester. This is of particular concern given the link between depressed progesterone activity and risk for preterm birth.
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Affiliation(s)
- Kristin Ashford
- University of Kentucky Perinatal
Research and Wellness Center, College of Nursing, Lexington, KY, USA
| | - Emily Rayens
- Department of Infectious Disease,
University of Georgia, Athens, GA, USA
| | - Amanda T. Wiggins
- University of Kentucky Perinatal
Research and Wellness Center, College of Nursing, Lexington, KY, USA
| | - Mary Kay Rayens
- University of Kentucky Perinatal
Research and Wellness Center, College of Nursing, Lexington, KY, USA
- University of Kentucky College of Public
Health, Lexington, KY, USA
| | | | - John O’Brien
- Maternal Fetal Medicine Division,
University of Kentucky College of Medicine, Lexington, KY, USA
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14
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Ashford K, Wiggins A, Rayens E, Assef S, Fallin A, Rayens MK. Perinatal Biochemical Confirmation of Smoking Status by Trimester. Nicotine Tob Res 2017; 19:631-635. [PMID: 28403470 PMCID: PMC7450522 DOI: 10.1093/ntr/ntw332] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 01/01/2017] [Indexed: 11/13/2022]
Abstract
Introduction: Tobacco use during pregnancy is the most modifiable risk factor associated with poor pregnancy outcomes. Self-reported tobacco use has been demonstrated to have high misclassification rates. The aims were to examine misclassification rates of perinatal tobacco use during each trimester of pregnancy and 8 weeks postpartum, and to evaluate characteristics associated with misclassification of tobacco use status. Methods: This is secondary analysis of a prospective, multicenter trial of pregnant women, and it includes participants who were biochemically identified as tobacco users during their first trimester (N = 103). Each trimester and once postpartum, tobacco use was assessed via self-report and validated using a cutoff of 100 ng/mL for urine cotinine via NicAlert test strips to indicate current use. Those who self-reported as nonusers but were identified as users via urine cotinine were considered misclassified; misclassification rates were determined for each time period. Logistic regression assessed maternal factors associated with misclassification status. Results: Misclassification rates declined from 35.0% at first trimester to 31.9% and 26.6% at the second and third; the postpartum rate was 30.4%. These rates did not differ significantly from each other at the 0.05 level. Race/ethnicity was associated with misclassification status; white/non-Hispanic women were 87% less likely to be misclassified (p < .001). Conclusion: Misclassification of prenatal smoking status decreases as pregnancy progresses, though the observed rate change was not significant. Minority women may be at particular risk for non-disclosure of tobacco use. Biochemical validation should be considered when assessing perinatal tobacco use via self-report, given high misclassification rates throughout the perinatal period. Implications: These results demonstrate that regardless of trimester, more than one-quarter of tobacco-using pregnant women may not disclose tobacco use throughout pregnancy and early postpartum. Although the rate of misclassification decreased from first to third trimester and then increased in the immediate postpartum, these changes in misclassification rates were not significant. Minority groups may be at particular risk of misclassification compared with white/non-Hispanic women. Biochemical validation is warranted throughout pregnancy to encourage cessation as tobacco use is one of the most easily-modified risk factors for poor birth outcomes.
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Affiliation(s)
| | - Amanda Wiggins
- University of Kentucky, College of Nursing, Lexington, KY
| | - Emily Rayens
- University of Georgia, Department of Infectious Diseases, Athens, GA
| | - Sara Assef
- University of Kentucky, College of Nursing, Lexington, KY
| | - Amanda Fallin
- University of Kentucky, College of Nursing, Lexington, KY
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15
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Saliva Cotinine as a Measure of Smoking Abstinence in Contingency Management – A Feasibility Study. PSYCHOLOGICAL RECORD 2017. [DOI: 10.1007/s40732-017-0240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Nanovskaya TN, Oncken C, Fokina VM, Feinn RS, Clark SM, West H, Jain SK, Ahmed MS, Hankins GDV. Bupropion sustained release for pregnant smokers: a randomized, placebo-controlled trial. Am J Obstet Gynecol 2017; 216:420.e1-420.e9. [PMID: 27890648 PMCID: PMC5376363 DOI: 10.1016/j.ajog.2016.11.1036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/02/2016] [Accepted: 11/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Bupropion is used to treat depression during pregnancy. However, its usefulness as a smoking cessation aid for pregnant women is not fully known. OBJECTIVE The objective of the study was to evaluate the preliminary efficacy of bupropion sustained release for smoking cessation during pregnancy. STUDY DESIGN We conducted a randomized, prospective, double-blind, placebo-controlled, pilot trial. Pregnant women who smoked daily received individualized behavior counseling and were randomly assigned to a 12 week, twice-a-day treatment with 150 mg bupropion sustained release or placebo. The primary study objectives were to determine whether bupropion sustained release reduces nicotine withdrawal symptoms on the quit date and during the treatment period compared with placebo and whether it increases 7 day point prevalence abstinence at the end of the treatment period and at the end of pregnancy. RESULTS Subjects in the bupropion (n = 30) and placebo (n = 35) groups were comparable in age, smoking history, number of daily smoked cigarettes, and nicotine dependence. After controlling for maternal age and race, bupropion sustained release reduced cigarette cravings (1.5 ± 1.1 vs 2.1 ± 1.2, P = .02) and total nicotine withdrawal symptoms (3.8 ± 4.3 vs 5.4 ± 5.1, P = .028) during the treatment period. Administration of bupropion sustained release reduced tobacco exposure, as determined by levels of carbon monoxide in exhaled air (7.4 ± 6.4 vs 9.1 ± 5.8, P = .053) and concentrations of cotinine in urine (348 ± 384 ng/mL vs 831 ± 727 ng/mL, P = .007) and increased overall abstinence rates during treatment (19% vs 2%, P = .003). However, there was no significant difference in 7 day point prevalence abstinence rates between the 2 groups at the end of medication treatment (17% vs 3%, P = .087) and at the end of pregnancy (10% vs 3%, P = .328). CONCLUSION Individual smoking cessation counseling along with the twice-daily use of 150 mg bupropion sustained release increased smoking cessation rates and reduced cravings and total nicotine withdrawal symptoms during the treatment period. However, there was no significant difference in abstinence rates between groups at the end of medication treatment and at the end of pregnancy, likely because of the small sample size. A larger study is needed to confirm these findings and to examine the potential benefit/ risk ratio of bupropion sustained release for smoking cessation during pregnancy.
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Affiliation(s)
- Tatiana N Nanovskaya
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
| | - Cheryl Oncken
- University of Connecticut School of Medicine, Farmington, CT
| | - Valentina M Fokina
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
| | - Richard S Feinn
- Quinnipiac University, Frank H Netter, MD, School of Medicine, North Haven, CT
| | - Shannon M Clark
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
| | - Holly West
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
| | - Sunil K Jain
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
- Department of Pediatrics, The University of Texas Medical Branch at Galveston, TX
| | - Mahmoud S Ahmed
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
| | - Gary D V Hankins
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, TX
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Chamberlain C, O'Mara‐Eves A, Porter J, Coleman T, Perlen SM, Thomas J, McKenzie JE. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2017; 2:CD001055. [PMID: 28196405 PMCID: PMC6472671 DOI: 10.1002/14651858.cd001055.pub5] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Catherine Chamberlain
- La Trobe UniversityJudith Lumley Centre251 Faraday StreetMelbourneVicAustralia3000
- University of MelbourneMelbourne School of Population and Global HealthMelbourneAustralia
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneAustralia
- Murdoch Childrens Research InstituteHealthy Mothers Healthy Families Research GroupMelbourneVictoriaAustralia3052
| | - Alison O'Mara‐Eves
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Jessie Porter
- University of MelbourneMelbourne School of Population and Global HealthMelbourneAustralia
| | - Tim Coleman
- University of NottinghamDivision of Primary CareD1411, Medical SchoolQueen's Medical CentreNottinghamUKNG7 2UH
| | - Susan M Perlen
- Murdoch Childrens Research InstituteHealthy Mothers Healthy Families Research GroupMelbourneVictoriaAustralia3052
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education18 Woburn SquareLondonUKWC1H 0NR
| | - Joanne E McKenzie
- Monash UniversitySchool of Public Health & Preventive MedicineMelbourneAustralia
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Kurti AN, Davis DR, Skelly JM, Redner R, Higgins ST. Comparison of nicotine dependence indicators in predicting quitting among pregnant smokers. Exp Clin Psychopharmacol 2016; 24:12-7. [PMID: 27046504 PMCID: PMC4822339 DOI: 10.1037/pha0000056] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Research in the general population of smokers indicates that across various measures of nicotine dependence, time to first cigarette (TTFC) is the strongest single-item predictor of quitting success. Whether those findings generalize to pregnant smokers is unclear. To investigate this matter, we compared TTFC with cigarettes per day (CPD) and the Heaviness of Smoking Index (HSI; Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994) in predicting late-pregnancy abstinence among 289 pregnant women enrolled in 4 smoking-cessation trials assessing the efficacy of financial incentives. Logistic regression was used to compare predictors, with model fit measured using the c statistic (range = 0.5, poor prediction to 1.0, perfect prediction). In simple regressions, model fit was comparable across the 3 measures although strongest for CPD alone (c = 0.70, 0.68, 0.66 for CPD, HSI, and TTFC, respectively). In a stepwise multiple regression, treatment was entered first (c = 0.67), then CPD (c = 0.77), quit attempts prepregnancy (c = .81), TTFC (c = .82), and quit attempts during pregnancy (c = .83). We saw no evidence supporting TTFC as the optimal predictor of quitting among pregnant smokers. Instead, the evidence supported using CPD and TTFC together or CPD alone if using only a single predictor.
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Affiliation(s)
- Allison N. Kurti
- Vermont Center on Behavior and Health, University of Vermont,Department of Psychiatry, University of Vermont
| | - Danielle R. Davis
- Vermont Center on Behavior and Health, University of Vermont,Department of Psychiatry, University of Vermont,Department of Psychology, University of Vermont
| | - Joan M. Skelly
- Department of Medical Biostatistics, University of Vermont
| | - Ryan Redner
- Vermont Center on Behavior and Health, University of Vermont,Department of Psychiatry, University of Vermont
| | - Stephen T. Higgins
- Vermont Center on Behavior and Health, University of Vermont,Department of Psychiatry, University of Vermont,Department of Psychology, University of Vermont
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Morgan H, Hoddinott P, Thomson G, Crossland N, Farrar S, Yi D, Hislop J, Moran VH, MacLennan G, Dombrowski SU, Rothnie K, Stewart F, Bauld L, Ludbrook A, Dykes F, Sniehotta FF, Tappin D, Campbell M. Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design. Health Technol Assess 2016; 19:1-522, vii-viii. [PMID: 25897655 DOI: 10.3310/hta19300] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby. AIM To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design. DESIGN Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout. SETTING UK. PARTICIPANTS The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking. METHODS (1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test. RESULTS Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage. LIMITATIONS Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population. CONCLUSIONS Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important. STUDY REGISTRATION This study is registered as PROSPERO CRD42012001980. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Heather Morgan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pat Hoddinott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gill Thomson
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Nicola Crossland
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Shelley Farrar
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Deokhee Yi
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jenni Hislop
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Hall Moran
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Kieran Rothnie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Fiona Stewart
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Linda Bauld
- The Institute of Social Marketing, University of Stirling, Stirling, UK
| | - Anne Ludbrook
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Fiona Dykes
- Maternal and Infant Nutrition and Nurture Unit, University of Central Lancashire, Preston, UK
| | - Falko F Sniehotta
- Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - David Tappin
- Perinatal Epidemiology and Child Health Unit, School of Medicine, University of Glasgow, Glasgow, UK
| | - Marion Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Emery RL, Levine MD. Optimal Carbon Monoxide Criteria to Confirm Smoking Status Among Postpartum Women. Nicotine Tob Res 2015; 18:966-70. [PMID: 26386471 DOI: 10.1093/ntr/ntv196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 09/01/2015] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Although expired-air carbon monoxide (CO) is a well characterized biomarker of cigarette smoking, limited research has assessed whether the standard clinical CO cutoffs need to be altered for postpartum women and whether these cutoffs remain constant across the postpartum year. Accordingly, the present study evaluated the effectiveness of using CO as a method to confirm smoking status relative to salivary cotinine among postpartum women and assessed optimal CO criteria to confirm smoking status across the postpartum year. Differences in optimal CO criteria to confirm smoking status also were examined between black and white postpartum women. METHODS Women (N = 208) for the present study had quit smoking for their current pregnancy and were enrolled in a larger postpartum relapse prevention intervention. Smoking status was assessed at 12, 24, and 52 weeks postpartum using both expired-air CO and salivary cotinine. RESULTS Receiver-operating characteristic analyses indicated that CO provided moderately high diagnostic accuracy to distinguish between women who were and were not smoking when using salivary cotinine as the reference criterion to confirm smoking status. CO cutoffs of 2 and 3 parts per million (ppm) had the highest overall efficiency and combined sensitivity and specificity across the postpartum year. Results were consistent for black and white women. CONCLUSIONS These findings indicate that optimal CO criteria to confirm smoking status remains stable throughout the postpartum year and support a need to utilize CO cutoffs much lower than the standard clinical CO criterion of 8 ppm to confirm abstinence among postpartum women. IMPLICATIONS Findings from the present study confirm the value of CO as a biomarker of smoking status among postpartum women. Results indicate that CO cutoffs of 2 and 3 ppm were optimal for confirming smoking status across the entire postpartum year in both black and white women. These findings offer a replication and extension of previous work and indicate that optimal CO criteria to confirm smoking status remain stable throughout the postpartum period and further support a need to utilize CO cutoffs much lower than the standard clinical criterion of 8 ppm to confirm smoking status among postpartum women.
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Affiliation(s)
- Rebecca L Emery
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA;
| | - Michele D Levine
- Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA
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Abstract
BACKGROUND Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers. OBJECTIVES To determine whether incentives and contingency management programmes lead to higher long-term quit rates. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015. SELECTION CRITERIA We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers. DATA COLLECTION AND ANALYSIS One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy. MAIN RESULTS Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates. AUTHORS' CONCLUSIONS Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.
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Affiliation(s)
- Kate Cahill
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK, OX2 6GG
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22
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Ierfino D, Mantzari E, Hirst J, Jones T, Aveyard P, Marteau TM. Financial incentives for smoking cessation in pregnancy: a single-arm intervention study assessing cessation and gaming. Addiction 2015; 110:680-8. [PMID: 25727238 PMCID: PMC4413044 DOI: 10.1111/add.12817] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/12/2014] [Accepted: 11/19/2014] [Indexed: 12/01/2022]
Abstract
AIMS Financial incentives were the single most effective intervention for smoking cessation in pregnancy in a recent Cochrane Review, but based on a few small trials in the United States using only 7-day point prevalence measures of cessation. This study estimates (a) prolonged cessation in an unselected population of English pregnant smokers who are offered financial incentives for quitting and (b) 'gaming', i.e. false reporting of smoking status to enter the scheme or gain an incentive. DESIGN Single-arm intervention study SETTING Antenatal clinic and community PARTICIPANTS A total of 239 pregnant smokers enrolled into the financial incentive scheme, attending for maternity care at one hospital in an area of high deprivation in England over a 42-week period. MEASUREMENTS Smoking cessation at delivery and 6 months postpartum, assessed using salivary cotinine; gaming assessed using urinary and salivary cotinine at enrolment, 28 and 36 weeks gestation, and 2 days and 6 months postpartum. FINDINGS Thirty-nine per cent (239 of 615) of smokers were enrolled into the scheme, 60% (143 of 239) of whom made a quit attempt. Of those enrolled, 20% [48 of 239; 95% confidence interval (CI) = 14.9%, 25.1%] were quit at delivery and 10% (25 of 239; 95% CI = 6.2%, 13.8%) at 6 months postpartum. There was no evidence that women gamed to enter the scheme, but evidence that 4% (10 of 239) of those enrolled gamed on one or more occasions to gain vouchers. CONCLUSIONS Enrolment on an incentive scheme in an unselected English cohort of pregnant smokers was associated with prolonged cessation rates comparable to those reported in US trials. Rates of gaming were arguably insufficiently high to invalidate the use of such schemes.
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Affiliation(s)
- Diana Ierfino
- Centre for the Study of Incentives in Health, King's College London, London, UK
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23
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Poulsen PB, Spillemose H, Nielsen G, Hergel LL, Wedell-Wedellsborg D, Strand M, Ringbæk T. Real-life effectiveness of smoking-cessation treatments in general practice clinics in Denmark. The Escape Smoke project. Respir Med 2015; 109:218-27. [DOI: 10.1016/j.rmed.2014.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 12/19/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022]
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Higgins ST, Washio Y, Lopez AA, Heil SH, Solomon LJ, Lynch ME, Hanson JD, Higgins TM, Skelly JM, Redner R, Bernstein IM. Examining two different schedules of financial incentives for smoking cessation among pregnant women. Prev Med 2014; 68:51-7. [PMID: 24704135 PMCID: PMC4183736 DOI: 10.1016/j.ypmed.2014.03.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/19/2014] [Accepted: 03/24/2014] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To examine whether an efficacious voucher-based incentives intervention for decreasing smoking during pregnancy and increasing fetal growth could be improved without increasing costs. The strategy was to redistribute the usual incentives so that higher values were available early in the quit attempt. METHOD 118 pregnant smokers in greater Burlington, Vermont (studied December, 2006-June, 2012) were randomly assigned to the revised contingent voucher (RCV) or usual contingent voucher (CV) schedule of abstinence-contingent vouchers, or to a non-contingent voucher (NCV) control condition wherein vouchers were provided independent of smoking status. Smoking status was biochemically verified; serial sonographic estimates of fetal growth were obtained at gestational weeks 30-34. RESULTS RCV and CV conditions increased point-prevalence abstinence above NCV levels at early (RCV: 40%, CV: 46%, NCV: 13%, p=.007) and late-pregnancy (RCV: 45%; CV: 36%; NCV, 18%; p=.04) assessments, but abstinence levels did not differ between the RCV and CV conditions. The RCV intervention did not increase fetal growth above control levels while the CV condition did so (p<.05). CONCLUSION This trial further supports the efficacy of CV for increasing antepartum abstinence and fetal growth, but other strategies (e.g., increasing overall incentive values) will be necessary to improve outcomes further.
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Affiliation(s)
- Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA; Department of Psychology, University of Vermont, USA.
| | - Yukiko Washio
- Department of Psychiatry, University of Vermont, USA
| | - Alexa A Lopez
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA; Department of Psychology, University of Vermont, USA
| | - Sarah H Heil
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA; Department of Psychology, University of Vermont, USA
| | | | - Mary Ellen Lynch
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA
| | | | | | - Joan M Skelly
- Department of Medical Biostatistics, University of Vermont, USA
| | - Ryan Redner
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Psychiatry, University of Vermont, USA
| | - Ira M Bernstein
- Vermont Center on Behavior and Health, University of Vermont, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, USA
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Smoking patterns, depression, and sociodemographic variables among Flemish women during pregnancy and the postpartum period. Nurs Res 2014; 62:394-404. [PMID: 24165215 DOI: 10.1097/nnr.0b013e3182a59d96] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Relationships among feelings of depression, smoking behavior, and educational level during pregnancy have been documented. Feelings of depression may contribute to persistent smoking during pregnancy. No longitudinal studies assessing feelings of depression in women with different antepartum and postpartum smoking patterns are available. OBJECTIVES The aim was to determine relationships between depressive symptoms, sociodemographic characteristics, and smoking pattern during and after pregnancy. METHODS An observational, prospective, noninterventional study was conducted. Data were collected during two stages of pregnancy (T0: <;16 weeks and T1: 32-34 weeks) and postpartum (T2: >6 weeks) in 523 Flemish women. Feelings of depression (measured using the Beck Depression Inventory [BDI]), smoking behavior, and sociodemographic variables were analyzed using a general linear mixed model implemented in SAS Proc MIXED. RESULTS Smokers and initial smokers reported significantly more depressive symptoms at all time points compared with recent ex-smokers, nonsmokers, and initial nonsmokers (p <; .001). The three-way interaction among time point, smoking pattern, and educational level was significant (p = .02). Evolution of mean BDI over time differed by educational level. Among participants with a secondary school certificate or less, differences were observed between smokers and nonsmokers, recent ex-smokers and initial nonsmokers, and nonsmokers and initial nonsmokers. Among participants with a college or university degree, no differences were observed. DISCUSSION A wide variety of smoking patterns were observed during pregnancy and early postpartum. Smoking patterns were associated with depression and showed complex interactions with educational level. Assessment and intervention for both smoking and depression are needed throughout the perinatal period to support the health of mothers, their infants, and families.
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Chamberlain C, O’Mara-Eves A, Oliver S, Caird JR, Perlen SM, Eades SJ, Thomas J. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev 2013; 10:CD001055. [PMID: 24154953 PMCID: PMC4022453 DOI: 10.1002/14651858.cd001055.pub4] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth 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 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 fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data. SELECTION CRITERIA Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) 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, and subgroup analyses and sensitivity analysis were conducted in SPSS. MAIN RESULTS Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing. 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 reduce low birthweight and preterm births.
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Affiliation(s)
- Catherine Chamberlain
- Global Health and Society Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alison O’Mara-Eves
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Jenny R Caird
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Susan M Perlen
- Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Sandra J Eades
- School of Public Health, Sydney School of Medicine, University of Sydney, Sydney, Australia
| | - James Thomas
- EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK
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Bailey BA. Using expired air carbon monoxide to determine smoking status during pregnancy: preliminary identification of an appropriately sensitive and specific cut-point. Addict Behav 2013; 38:2547-50. [PMID: 23793041 DOI: 10.1016/j.addbeh.2013.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 05/03/2013] [Accepted: 05/16/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Measurement of carbon monoxide in expired air samples (ECO) is a non-invasive, cost-effective biochemical marker for smoking. Cut points of 6ppm-10ppm have been established, though appropriate cut-points for pregnant woman have been debated due to metabolic changes. This study assessed whether an ECO cut-point identifying at least 90% of pregnant smokers, and misidentifying fewer than 10% of non-smokers, could be established. METHODS Pregnant women (N=167) completed a validated self-report smoking assessment, a urine drug screen for cotinine (UDS), and provided an expired air sample twice during pregnancy. RESULTS Half of women reported non-smoking status early (51%) and late (53%) in pregnancy, confirmed by UDS. Using a traditional 8ppm+cut-point for the early pregnancy reading, only 1% of non-smokers were incorrectly identified as smokers, but only 56% of all smokers, and 67% who smoked 5+ cigarettes in the previous 24h, were identified. However, at 4ppm+, only 8% of non-smokers were misclassified as smokers, and 90% of all smokers and 96% who smoked 5+ cigarettes in the previous 24h were identified. False positives were explained by heavy second hand smoke exposure and marijuana use. Results were similar for late pregnancy ECO, with ROC analysis revealing an area under the curve of .95 for early pregnancy, and .94 for late pregnancy readings. CONCLUSIONS A lower 4ppm ECO cut-point may be necessary to identify pregnant smokers using expired air samples, and this cut-point appears valid throughout pregnancy. Work is ongoing to validate findings in larger samples, but it appears if an appropriate cut-point is used, ECO is a valid method for determining smoking status in pregnancy.
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Affiliation(s)
- Beth A Bailey
- Department of Family Medicine, East Tennessee State University, P.O. Box 70621, Johnson City, TN 37614, United States.
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Ashford KB, Rayens MK. Ethnicity, smoking status, and preterm birth as predictors of maternal locus of control. Clin Nurs Res 2013; 24:172-87. [PMID: 23960252 DOI: 10.1177/1054773813498268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A woman's psychological health can affect prenatal behaviors. The purpose of this study was to examine the relationship between maternal beliefs, prenatal behaviors, and preterm birth (PTB) in a multiethnic population. This was a planned secondary analysis of a cross-sectional trial of postpartum women with singleton gestation. In all, 210 participants were given the Fetal Health Locus of Control (FHLC) scale to measure three primary maternal beliefs that influenced their prenatal behaviors (Internal Control, Chance, Powerful Others). Women who experienced preterm delivery and those who smoked during pregnancy scored the Chance category significantly higher than those who delivered term infants (p = .05; p = .004, respectively). This suggests those who smoked during pregnancy had a greater degree of belief that Chance influenced their infant's health status. Cultural differences also emerged specific to the impact of health care providers on PTB; with Hispanic women scoring Powerful Others the highest among the groups (p = .02). Nurses can plan a critical role in identifying at-risk women (smoking, strong Chance beliefs) while providing a clear message that taking action and modifying high-risk behaviors can reduce risk for adverse pregnancy outcome.
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Aurrekoetxea JJ, Murcia M, Rebagliato M, López MJ, Castilla AM, Santa-Marina L, Guxens M, Fernández-Somoano A, Espada M, Lertxundi A, Tardón A, Ballester F. Determinants of self-reported smoking and misclassification during pregnancy, and analysis of optimal cut-off points for urinary cotinine: a cross-sectional study. BMJ Open 2013; 3:bmjopen-2012-002034. [PMID: 23355667 PMCID: PMC3563144 DOI: 10.1136/bmjopen-2012-002034] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To estimate the prevalence and factors associated with smoking and misclassification in pregnant women from INMA (INfancia y Medio Ambiente, Environment and Childhood) project, Spain, and to assess the optimal cut-offs for urinary cotinine (UC) that best distinguish daily and occasional smokers with varying levels of second-hand smoke (SHS) exposure. DESIGN We used logistic regression models to study the relationship between sociodemographic variables and self-reported smoking and misclassification (self-reported non-smokers with UC >50 ng/ml). Receiver operating characteristic (ROC) curves were used to calculate the optimal cut-off point for discriminating smokers. The cut-offs were also calculated after stratification among non-smokers by the number of sources of SHS exposure. The cut-off points used to discriminate smoking status were the level of UC given by Youden's index and for 50 and 100 ng/ml for daily smokers, or 25 and 50 ng/ml for occasional smokers. PARTICIPANTS At the third trimester of pregnancy, 2263 pregnant women of the INMA Project were interviewed between 2004 and 2008 and a urine sample was collected. RESULTS Prevalence of self-reported smokers at the third trimester of pregnancy was 18.5%, and another 3.9% misreported their smoking status. Variables associated with self-reported smoking and misreporting were similar, including born in Europe, educational level and exposure to SHS. The optimal cut-off was 82 ng/ml (95% CI 42 to 133), sensitivity 95.2% and specificity 96.6%. The area under the ROC curve was 0.986 (95% CI 0.982 to 0.990). The cut-offs varied according to the SHS exposure level being 42 (95% CI 27 to 57), 82 (95% CI 46 to 136) and 106 ng/ml (95% CI 58 to 227) for not being SHS exposed, exposed to one, and to two or more sources of SHS, respectively. The optimal cut-off for discriminating occasional smokers from non-smokers was 27 ng/ml (95% CI 11 to 43). CONCLUSIONS Prevalence of smoking during pregnancy in Spain remains high. UC is a reliable biomarker for classifying pregnant women according to their smoking status. However, cut-offs would differ based on baseline exposure to SHS.
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Affiliation(s)
- Juan J Aurrekoetxea
- Public Health Department, Basque Government, San Sebastian, Spain
- University of Basque Country UPV/EHU, San Sebastian, Spain
- Health Research Institute (BIODONOSTIA), San Sebastian, Spain
| | - Mario Murcia
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Center for Public Health Research (CSISP), Valencia, Spain
| | - Marisa Rebagliato
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Center for Public Health Research (CSISP), Valencia, Spain
| | - María José López
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Public Health Agency of Barcelona, Barcelona, Spain
- Institute of Biomedical Research (IIB Sant Pau), Barcelona, Spain
| | - Ane Miren Castilla
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Public Health Laboratory of Bilbao, Bilbao, Spain
| | - Loreto Santa-Marina
- Public Health Department, Basque Government, San Sebastian, Spain
- Health Research Institute (BIODONOSTIA), San Sebastian, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
| | - Mónica Guxens
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Ana Fernández-Somoano
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Department of Preventive Medicine and Public Health, University of Oviedo, Oviedo, Spain
| | | | - Aitana Lertxundi
- University of Basque Country UPV/EHU, San Sebastian, Spain
- Health Research Institute (BIODONOSTIA), San Sebastian, Spain
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
| | - Adonina Tardón
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Department of Preventive Medicine and Public Health, University of Oviedo, Oviedo, Spain
| | - Ferran Ballester
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain
- Center for Public Health Research (CSISP), Valencia, Spain
- Department of Nursing, University of Valencia, Valencia, Spain
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Lynagh M, Bonevski B, Sanson-Fisher R, Symonds I, Scott A, Hall A, Oldmeadow C. An RCT protocol of varying financial incentive amounts for smoking cessation among pregnant women. BMC Public Health 2012. [PMID: 23181988 PMCID: PMC3520690 DOI: 10.1186/1471-2458-12-1032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Smoking during pregnancy is harmful to the unborn child. Few smoking cessation interventions have been successfully incorporated into standard antenatal care. The main aim of this study is to determine the feasibility of a personal financial incentive scheme for encouraging smoking cessation among pregnant women. Design A pilot randomised control trial will be conducted to assess the feasibility and potential effectiveness of two varying financial incentives that increase incrementally in magnitude ($20 vs. $40AUD), compared to no incentive in reducing smoking in pregnant women attending an Australian public hospital antenatal clinic. Method Ninety (90) pregnant women who self-report smoking in the last 7 days and whose smoking status is biochemically verified, will be block randomised into one of three groups: a. No incentive control group (n=30), b. $20 incremental incentive group (n=30), and c. $40 incremental incentive group (n=30). Smoking status will be assessed via a self-report computer based survey in nine study sessions with saliva cotinine analysis used as biochemical validation. Women in the two incentive groups will be eligible to receive a cash reward at each of eight measurement points during pregnancy if 7-day smoking cessation is achieved. Cash rewards will increase incrementally for each period of smoking abstinence. Discussion Identifying strategies that are effective in reducing the number of women smoking during pregnancy and are easily adopted into standard antenatal practice is of utmost importance. A personal financial incentive scheme is a potential antenatal smoking cessation strategy that warrants further investigation. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) number: ACTRN12612000399897
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Affiliation(s)
- Marita Lynagh
- Priority Research Centre for Health Behaviour, The University of Newcastle & Hunter Medical Research Institute, Callaghan, NSW, Australia.
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Sigmon SC, Patrick ME. The use of financial incentives in promoting smoking cessation. Prev Med 2012; 55 Suppl:S24-32. [PMID: 22525802 PMCID: PMC3411852 DOI: 10.1016/j.ypmed.2012.04.007] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Cigarette smoking is the leading cause of preventable death in the United States and world. Despite the availability of numerous therapies for smoking cessation, additional efficacious interventions are greatly needed. We provide a narrative review of published studies evaluating financial incentives for smoking cessation and discuss the parameters important for ensuring the efficacy of incentive interventions for smoking cessation. METHODS Published studies that evaluated the impact of incentives to promote smoking cessation and included an appropriate control or comparison condition were identified and reviewed. RESULTS Incentives are efficacious for promoting smoking abstinence across the general population of smokers as well as substance abusers, adolescents, patients with pulmonary disease, patients with serious mental illness and other challenging subgroups. To develop and implement an effective incentive treatment for smoking, special attention should be paid to biochemical verification of smoking status, incentive magnitude and the schedule of incentive delivery. CONCLUSION Consistent with the extensive literature showing that incentives are effective in reducing illicit drug use, a large body of evidence supports their effectiveness in reducing smoking. Continued efforts are warranted to further develop and disseminate incentive-based treatments for smoking cessation across clinical settings and populations.
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Affiliation(s)
- Stacey C Sigmon
- Department of Psychiatry, University of Vermont, University Health Center Campus, 1 S. Prospect St, Burlington, VT 05401, USA.
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Brandon TH, Simmons VN, Meade CD, Quinn GP, Lopez Khoury EN, Sutton SK, Lee JH. Self-help booklets for preventing postpartum smoking relapse: a randomized trial. Am J Public Health 2012; 102:2109-15. [PMID: 22994170 PMCID: PMC3477952 DOI: 10.2105/ajph.2012.300653] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2012] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We tested a series of self-help booklets designed to prevent postpartum smoking relapse. METHODS We recruited 700 women in months 4 through 8 of pregnancy, who quit smoking for their pregnancy. We randomized the women to receive either (1) 10 Forever Free for Baby and Me (FFB) relapse prevention booklets, mailed until 8 months postpartum, or (2) 2 existing smoking cessation materials, as a usual care control (UCC). Assessments were completed at baseline and at 1, 8, and 12 months postpartum. RESULTS We received baseline questionnaires from 504 women meeting inclusion criteria. We found a main effect for treatment at 8 months, with FFB yielding higher abstinence rates (69.6%) than UCC (58.5%). Treatment effect was moderated by annual household income and age. Among lower income women (< $30 000), treatment effects were found at 8 and 12 months postpartum, with respective abstinence rates of 72.2% and 72.1% for FFB and 53.6% and 50.5% for UCC. No effects were found for higher income women. CONCLUSIONS Self-help booklets appeared to be efficacious and offered a low-cost modality for providing relapse-prevention assistance to low-income pregnant and postpartum women.
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Affiliation(s)
- Thomas H Brandon
- Tobacco Research & Intervention Program, Moffitt Cancer Center, 4115 E. Fowler Ave., Tampa, FL 33617, USA.
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D’Souza DC, Esterlis I, Carbuto M, Krasenics M, Seibyl J, Bois F, Pittman B, Ranganathan M, Cosgrove K, Staley J. Lower ß2*-nicotinic acetylcholine receptor availability in smokers with schizophrenia. Am J Psychiatry 2012; 169:326-34. [PMID: 22193533 PMCID: PMC3881431 DOI: 10.1176/appi.ajp.2011.11020189] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There is a strong association between cigarette smoking and schizophrenia. Nicotine's actions in the brain are mediated through nicotinic acetylcholine receptors. Those containing α(4) and β(2) subunits are the most abundant ones in the brain, have the highest affinity for nicotine, and are critical in mediating nicotine's reinforcing properties. Healthy tobacco smokers have significantly higher levels of β(2)*-nicotinic acetylcholine receptors than do nonsmokers. However, in postmortem studies, smokers with schizophrenia do not show these higher levels. The purpose of this study was to measure β(2)*-nicotinic acetylcholine receptors in vivo and to relate levels to concurrent behavioral measures of smoking and schizophrenia. METHOD By using single-photon emission computed tomography with the β(2)*-nicotinic acetylcholine receptor agonist radiotracer [(123)I]5-IA-85380, the availability of receptors was measured in smokers with schizophrenia (11 men) and matched comparison smokers after 1 week of confirmed smoking abstinence. RESULTS Smokers with schizophrenia showed significantly lower (21%-26%) β(2)*-nicotinic acetylcholine receptor availability relative to comparison smokers in the frontal cortex, parietal cortex, and thalamus (in descending order). There was a specific and robust negative correlation between regional β(2)*-nicotinic acetylcholine receptor availability and negative symptoms. CONCLUSIONS These are the first in vivo findings of lower β(2)*-nicotinic acetylcholine receptor availability in smokers with schizophrenia. The relationship between β(2)*-nicotinic acetylcholine receptor availability and negative symptoms may explain the high rates of smoking in schizophrenia and the relationship between smoking and negative symptoms. Findings support the development of medications targeting the β(2)*-nicotinic acetylcholine receptor system for the treatment of negative symptoms.
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Affiliation(s)
- Deepak Cyril D’Souza
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Irina Esterlis
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Michelle Carbuto
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Maegan Krasenics
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - John Seibyl
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Institute for Neurodegenerative Disorders, New Haven, T 06510, USA
| | - Frederic Bois
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Brian Pittman
- Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Mohini Ranganathan
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Kelly Cosgrove
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Julie Staley
- Psychiatry Service, VA Connecticut Healthcare System, West Haven, CT, USA
,Abraham Ribicoff Research Facilities, Connecticut Mental Health Center, New Haven, CT, USA
,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Gaalema DE, Higgins ST, Bradstreet MP, Heil SH, Bernstein IM. Using NicAlert strips to verify smoking status among pregnant cigarette smokers. Drug Alcohol Depend 2011; 119:130-3. [PMID: 21652155 PMCID: PMC3205243 DOI: 10.1016/j.drugalcdep.2011.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Decreasing smoking during pregnancy is an important public health priority. An important step towards decreasing smoking during pregnancy is wider dissemination of evidence-based smoking cessation interventions. One such intervention is contingency management wherein mothers earn vouchers exchangeable for retail items contingent on biochemically verified smoking abstinence. Wider dissemination may be possible by using smoking verification methods that require minimal training and equipment. One possibility is to use a cotinine-sensitive dipstick (NicAlert) rather than a bench-top cotinine analyzer, which is expensive and requires relatively extensive technician expertise, or breath carbon monoxide analysis, which is relatively nonspecific. The present study was conducted to begin examining the utility of cotinine-sensitive dipsticks for this purpose. METHODS Fifty urine samples from pregnant women enrolled in a smoking cessation program were analyzed to compare three different methods for verifying smoking status: NicAlert strips, a bench-top enzyme multiplied immunoassay technique (EMIT) analyzer, and gas chromatography (GC), the current gold standard for determining cotinine levels in urine. RESULTS Agreement between GC and NicAlert results were high (96%) and comparable to agreement between GC and EMIT results (94%). Semi-quantitative measurements using NicAlert were low with only 30% of samples in agreement between GC and specific ranges given on the strips. CONCLUSIONS NicAlert strips appear to be a valid measure of determining smoking status among pregnant smokers although not of absolute cotinine concentration. With minimal training and equipment required, NicAlert strips provide a potentially practical method for using urine cotinine to verify smoking status in community treatment settings.
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Affiliation(s)
- Diann E. Gaalema
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Stephen T. Higgins
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401, University of Vermont, Department of Psychology, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Matthew P. Bradstreet
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Sarah H. Heil
- University of Vermont, Department of Psychiatry, 1 South Prospect Street UHC, Burlington, VT 05401, University of Vermont, Department of Psychology, 1 South Prospect Street UHC, Burlington, VT 05401
| | - Ira M. Bernstein
- University of Vermont, Department of Obstetrics, Gynecology and Reproductive Sciences, Smith 410, MCHV Campus 111 Colchester Avenue, Burlington, VT 05401
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Raum E, Küpper-Nybelen J, Lamerz A, Hebebrand J, Herpertz-Dahlmann B, Brenner H. Tobacco smoke exposure before, during, and after pregnancy and risk of overweight at age 6. Obesity (Silver Spring) 2011; 19:2411-7. [PMID: 21617637 DOI: 10.1038/oby.2011.129] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Maternal smoking during pregnancy has been associated with overweight and obesity in childhood and is strongly correlated with children's tobacco smoke exposure before and after pregnancy. We investigated the independent association of tobacco smoke exposure at various pre- and postnatal periods and overweight at age 6. A total of 1,954 children attending the 2001-2002 school entrance health examination in the city of Aachen, Germany, were included into this study. Height and weight were measured, BMI was calculated. Tobacco smoke exposure at various periods, other lifestyle and sociodemographic factors were ascertained by questionnaire. Multiple logistic regression models were used to assess the association between tobacco smoke exposure and overweight. Prevalence of overweight was 8.9%. Significant positive associations were found with maternal smoking before and during pregnancy and during the first and sixth year of life. When all smoking periods were included into one logistic model simultaneously, secondhand smoke exposure after birth remained positively associated with overweight at age 6 at either one of the two time periods (first year only: odds ratio (OR) (95% confidence interval (CI)): 2.94 (1.30-6.67), sixth year only: 2.57 (1.64-4.04), respectively) or at both (4.43 (2.24-8.76)). Exposure to tobacco smoke during the first years of life appears to be a key risk factor for development of childhood overweight.
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Affiliation(s)
- Elke Raum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.
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Effects of contingency management and bupropion on cigarette smoking in smokers with schizophrenia. Psychopharmacology (Berl) 2011; 217:279-87. [PMID: 21475970 PMCID: PMC3685403 DOI: 10.1007/s00213-011-2282-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022]
Abstract
RATIONALE Individuals with schizophrenia have high smoking-related morbidity and mortality rates and need powerful and innovative smoking cessation interventions. OBJECTIVES This proof-of-concept study investigated the feasibility and initial efficacy of combining a contingency management intervention with bupropion to reduce smoking in people with schizophrenia. METHODS Using a double-blind, placebo-controlled, between-groups design, 57 non-treatment-seeking participants were randomized to receive 300 mg/day bupropion or placebo. One week later, participants were randomized to a contingency management (CM) intervention in which reductions in urinary cotinine levels were reinforced, or a non-contingent reinforcement (NR) condition in which session attendance was reinforced, regardless of cotinine level. Over the 22-day study period, participants visited the laboratory approximately three times per week to provide urine samples for analysis of cotinine levels, to give breath samples for analysis of carbon monoxide (CO) levels, and to report number of cigarettes smoked per day, nicotine withdrawal symptoms, cigarette craving, and psychiatric symptoms. RESULTS Cotinine and CO levels significantly decreased during the study period in participants randomized to the CM condition, but not the NR condition. Bupropion did not reduce cotinine levels or increase the efficacy of CM. Cigarette craving and psychiatric symptom levels significantly decreased during the study in all groups. CONCLUSIONS The results of this study indicate the efficacy and feasibility of this CM intervention for reducing smoking in individuals with schizophrenia.
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Javors MA, Hatch JP, Lamb RJ. Sequential combination of self-report, breath carbon monoxide, and saliva cotinine to assess smoking status. Drug Alcohol Depend 2011; 113:242-4. [PMID: 20822867 PMCID: PMC3004995 DOI: 10.1016/j.drugalcdep.2010.07.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 07/19/2010] [Accepted: 07/22/2010] [Indexed: 11/27/2022]
Abstract
The purpose of this analysis was to develop an algorithm for the cost effective and accurate assessment of smoking during the previous few days by combining self-report, breath carbon monoxide (BCO), and saliva cotinine (sCOT). These measurements are convenient, quantitative, and do not require invasive procedures. The data used to devise the algorithm were gathered during a treatment trial of participants seeking to stop smoking. Self-report of smoking was determined using a written questionnaire, BCO was measured with a handheld breathalyzer, and sCOT was quantified using a high sensitivity ELISA. Participants were 130 males and 97 females between the ages of 19 and 67 years who reported smoking at least 15 cigarettes a day and had a BCO level ≥ 15 ppm. Self-reports and BCO levels were collected at each of 6 visits (V0-V5) and sCOT levels were determined at V0 and V5. Based on the data collected, we recommend that the sequential determination of self-reported smoking, BCO level, and sCOT level be employed to assess smoking during the previous few days to minimize the higher cost and longer turnaround time associated with the sCOT test while maximizing accuracy.
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Affiliation(s)
- M A Javors
- Department of Psychiatry, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
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Ashford KB, Hahn E, Hall L, Rayens MK, Noland M, Ferguson JE. The effects of prenatal secondhand smoke exposure on preterm birth and neonatal outcomes. J Obstet Gynecol Neonatal Nurs 2010; 39:525-35. [PMID: 20919999 PMCID: PMC2951268 DOI: 10.1111/j.1552-6909.2010.01169.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the relationship between prenatal secondhand smoke (SHS) exposure, preterm birth and immediate neonatal outcomes by measuring maternal hair nicotine. DESIGN Cross-sectional, observational design. SETTING A metropolitan Kentucky birthing center. PARTICIPANTS Two hundred and ten (210) mother-baby couplets. METHODS Nicotine in maternal hair was used as the biomarker for prenatal SHS exposure collected within 48 hours of birth. Smoking status was confirmed by urine cotinine analysis. RESULTS Smoking status (nonsmoking, passive smoking, and smoking) strongly correlated with low, medium, and high hair nicotine tertiles (ρ=.74; p<.001). Women exposed to prenatal SHS were more at risk for preterm birth (odds ratio [OR]=2.3; 95% Confidence Interval [CI] [.96, 5.96]), and their infants were more likely to have immediate newborn complications (OR=2.4; 95% CI [1.09, 5.33]) than nonexposed women. Infants of passive smoking mothers were at increased risk for respiratory distress syndrome (RDS) (OR=4.9; 95% CI [1.45, 10.5]) and admission to a Neonatal Intensive Care Unit (NICU) (OR=6.5; CI [1.29, 9.7]) when compared to infants of smoking mothers (OR=3.9; 95% CI [1.61, 14.9]; OR=3.5; 95% CI [2.09, 20.4], respectively). Passive smokers and/or women with hair nicotine levels greater than .35 ng/ml were more likely to deliver earlier (1 week), give birth to infants weighing less (decrease of 200-300 g), and deliver shorter infants (decrease of 1.1-1.7 cm). CONCLUSIONS Prenatal SHS exposure places women at greater risk for preterm birth, and their newborns are more likely to have RDS, NICU admissions, and immediate newborn complications.
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Affiliation(s)
- Kristin B Ashford
- College of Nursing, University of Kentucky, Lexington, KY 40536-0232, USA.
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Bennett IM, Culhane JF, Webb DA, Coyne JC, Hogan V, Mathew L, Elo IT. Perceived discrimination and depressive symptoms, smoking, and recent alcohol use in pregnancy. Birth 2010; 37:90-7. [PMID: 20557531 PMCID: PMC3627361 DOI: 10.1111/j.1523-536x.2010.00388.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Perceived discrimination is associated with poor mental health and health-compromising behaviors in a range of vulnerable populations, but this link has not been assessed among pregnant women. We aimed to determine whether perceived discrimination was associated with these important targets of maternal health care among low-income pregnant women. METHODS Face-to-face interviews were conducted in English or Spanish with 4,454 multiethnic, low-income, inner-city women at their first prenatal visit at public health centers in Philadelphia, Penn, USA, from 1999 to 2004. Perceived chronic everyday discrimination (moderate and high levels) in addition to experiences of major discrimination, depressive symptomatology (CES-D >or= 23), smoking in pregnancy (current), and recent alcohol use (12 months before pregnancy) were assessed by patients' self-report. RESULTS Moderate everyday discrimination was reported by 873 (20%) women, high everyday discrimination by 238 (5%) women, and an experience of major discrimination by 789 (18%) women. Everyday discrimination was independently associated with depressive symptomatology (moderate = prevalence ratio [PR] of 1.58, 95% CI: 1.38-1.79; high = PR of 1.82, 95% CI: 1.49-2.21); smoking (moderate = PR of 1.19, 95% CI: 1.05-1.36; high = PR of 1.41, 95% CI: 1.15-1.74); and recent alcohol use (moderate = PR of 1.23, 95% CI: 1.12-1.36). However, major discrimination was not independently associated with these outcomes. CONCLUSIONS This study demonstrated that perceived chronic everyday discrimination, but not major discrimination, was associated with depressive symptoms and health-compromising behaviors independent of potential confounders, including race and ethnicity, among pregnant low-income women.
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Affiliation(s)
- Ian M. Bennett
- Department of Family Medicine and Community Health, Philadelphia
| | - Jennifer F. Culhane
- Department of Obstetrics and Gynecology, Drexel University School of Medicine, Philadelphia
| | - David A. Webb
- Department of Obstetrics and Gynecology, Drexel University School of Medicine, Philadelphia
| | - James C. Coyne
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia
| | - Vijaya Hogan
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Leny Mathew
- Children's Hospital of Philadelphia, Philadelphia
| | - Irma T. Elo
- Department of Sociology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Cinciripini PM, Blalock JA, Minnix JA, Robinson JD, Brown VL, Lam C, Wetter DW, Schreindorfer L, McCullough JP, Dolan-Mullen P, Stotts AL, Karam-Hage M. Effects of an intensive depression-focused intervention for smoking cessation in pregnancy. J Consult Clin Psychol 2010; 78:44-54. [PMID: 20099949 PMCID: PMC2881321 DOI: 10.1037/a0018168] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. METHOD Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies-Depression Scale (Radloff, 1977). RESULTS At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. CONCLUSIONS The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.
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Affiliation(s)
| | | | | | | | | | - Cho Lam
- Department of Behavioral Science
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Smoking prevalence and smoking cessation services for pregnant women in Scotland. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2010; 5:1. [PMID: 20092650 PMCID: PMC2843678 DOI: 10.1186/1747-597x-5-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 01/21/2010] [Indexed: 11/10/2022]
Abstract
Background Over 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later. Methods This was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services. Results 13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006. Conclusions In Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision - identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.
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Ashford KB, Hahn E, Hall L, Rayens MK, Noland M, Collins R. Measuring prenatal secondhand smoke exposure in mother-baby couplets. Nicotine Tob Res 2009; 12:127-35. [PMID: 20038509 DOI: 10.1093/ntr/ntp185] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Pregnant women often underreport their smoking status and extent of secondhand smoke (SHS) exposure. Biomarker confirmation is the recommended method to assess smoking behaviors and SHS exposure in both mothers and infants. OBJECTIVES The primary aims are to (a) examine the relationship between smoking behaviors and SHS exposure in mother-baby couplets using maternal and infant hair nicotine and maternal urine cotinine analyses and (b) determine whether there is an association between maternal and infant hair nicotine samples obtained shortly after birth. DISCUSSION A cross-sectional study with a multiethnic sample of 210 mother-baby couplets assessing SHS exposure. RESULTS The level of maternal hair nicotine (MHN) was significantly different among three groups: nonsmoking, nonsmoking/passive exposed, and smoking (p < .0001), with nonsmoking and nonexposed women having the lowest level. Urine cotinine was strongly associated with self-reported smoking status (rho = .88; p < .0001). Maternal and infant hair nicotine were correlated, although MHN correlated more strongly with smoking status (rho = .46, p < .0001) than infant hair nicotine (rho = .39, p < .0001). CONCLUSIONS MHN was a more precise biomarker of prenatal SHS exposure than infant hair nicotine; mothers' urine cotinine was strongly correlated with self-reported smoking status.
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Affiliation(s)
- Kristin B Ashford
- University of Kentucky College of Nursing, Lexington, KY 40536-0232, USA.
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Smoking Among Pregnant Women with Medicaid Insurance: Are Mental Health Factors Related? Matern Child Health J 2009; 14:971-7. [DOI: 10.1007/s10995-009-0530-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Heil SH, Linares Scott T, Higgins ST. An overview of principles of effective treatment of substance use disorders and their potential application to pregnant cigarette smokers. Drug Alcohol Depend 2009; 104 Suppl 1:S106-14. [PMID: 19540679 PMCID: PMC2738623 DOI: 10.1016/j.drugalcdep.2009.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 05/09/2009] [Accepted: 05/21/2009] [Indexed: 11/20/2022]
Abstract
Cigarette smoking remains a leading preventable cause of poor pregnancy outcomes and infant morbidity and mortality. Despite three decades of research encompassing more than 60 trials and 20,000 pregnant women, cessation rates produced by existing interventions are often low (<20%), especially among socioeconomically disadvantaged women. This has led to a call for the development and testing of novel interventions. One strategy for identifying novel interventions for pregnant smokers is to examine efficacious interventions for other types of substance use disorders (SUDs). Pregnant smokers share many sociodemographic similarities with other sub-populations of individuals with SUDs, suggesting that interventions efficacious with the latter may also benefit the former. The National Institute on Drug Abuse's guide, "Principles of Drug Addiction Treatment: A Research-based Guide", presents empirically validated principles of effective treatments for other SUDs. The present report enumerates these principles, briefly describes some of the empirical evidence supporting them, and explores their potential application to the treatment of smoking during pregnancy. Overall, the results of this exercise suggest much promise for enhancing treatment outcomes for pregnant smokers by borrowing from and extending what has been learned with other populations with SUDs.
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Affiliation(s)
- Sarah H Heil
- Department of Psychiatry, University of Vermont, Burlington, VT 05401, USA.
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Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009:CD001055. [PMID: 19588322 PMCID: PMC4090746 DOI: 10.1002/14651858.cd001055.pub3] [Citation(s) in RCA: 353] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness. OBJECTIVES To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data. SELECTION CRITERIA Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention. DATA COLLECTION AND ANALYSIS Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used. MAIN RESULTS Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. AUTHORS' CONCLUSIONS Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.
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Affiliation(s)
- Judith Lumley
- Mother and Child Health Research, La Trobe University, Melbourne, Australia
| | - Catherine Chamberlain
- 3Centres Collaboration, Women and Children’s Program, Southern Health, Clayton South, Australia
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK
| | - Sandy Oliver
- Social Science Research Unit, Institute of Education, University of London, London, UK
| | - Laura Oakley
- Non-communicable Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Lyndsey Watson
- Mother and Child Health Research, La Trobe University, Melbourne, Australia
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Plebani JG, Kampman KM, Lynch KG. Early abstinence in cocaine pharmacotherapy trials predicts successful treatment outcomes. J Subst Abuse Treat 2009; 37:313-7. [PMID: 19339141 DOI: 10.1016/j.jsat.2009.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 02/16/2009] [Accepted: 02/19/2009] [Indexed: 11/29/2022]
Abstract
There is a robust relationship between early and later abstinence in smoking cessation, but that relationship has not been explored among other substances of abuse. To assess whether early abstinence during treatment, as opposed to baseline abstinence, predicted later abstinence among cocaine-dependent patients, data from two randomized double-blind controlled clinical pharmacotherapy trials were analyzed. Similar to the findings in the smoking cessation literature, results indicate that abstinence in the first 2 weeks of pharmacotherapy predicted later in-trial abstinence. This finding has implications both for treatment research and for clinical practice, suggesting that patients who do not respond early in treatment may need a more intensive intervention.
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Affiliation(s)
- Jennifer G Plebani
- Department of Psychiatry, University of Pennsylvania, Treatment Research Center, 3900 Chestnut Street, Philadelphia, PA 19104, USA.
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Ussher M, Aveyard P, Coleman T, Straus L, West R, Marcus B, Lewis B, Manyonda I. Physical activity as an aid to smoking cessation during pregnancy: two feasibility studies. BMC Public Health 2008; 8:328. [PMID: 18811929 PMCID: PMC2559842 DOI: 10.1186/1471-2458-8-328] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 09/23/2008] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pharmacotherapies for smoking cessation have not been adequately tested in pregnancy and women are reluctant to use them. Behavioural support alone has a modest effect on cessation rates; therefore, more effective interventions are needed. Even moderate intensity physical activity (e.g. brisk walk) reduces urges to smoke and there is some evidence it increases cessation rates in non-pregnant smokers. Two pilot studies assessed i) the feasibility of recruiting pregnant women to a trial of physical activity for smoking cessation, ii) adherence to physical activity and iii) women' perceptions of the intervention. METHODS Pregnant smokers volunteered for an intervention combining smoking cessation support, physical activity counselling and supervised exercise (e.g. treadmill walking). The first study provided six weekly treatment sessions. The second study provided 15 sessions over eight weeks. Physical activity levels and continuous smoking abstinence (verified by expired carbon monoxide) were monitored up to eight months gestation. RESULTS Overall, 11.6% (32/277) of women recorded as smokers at their first antenatal booking visit were recruited. At eight months gestation 25% (8/32) of the women achieved continuous smoking abstinence. Abstinent women attended at least 85% of treatment sessions and 75% (6/8) achieved the target level of 110 minutes/week of physical activity at end-of-treatment. Increased physical activity was maintained at eight months gestation only in the second study. Women reported that the intervention helped weight management, reduced cigarette cravings and increased confidence for quitting. CONCLUSION It is feasible to recruit pregnant smokers to a trial of physical activity for smoking cessation and this is likely to be popular. A large randomised controlled trial is needed to examine the efficacy of this intervention.
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Affiliation(s)
- Michael Ussher
- Division of Community Health Sciences, St. George's University of London, London, SW17 0RE, UK
| | - Paul Aveyard
- Department of Primary Care and General Practice, University of Birmingham, Edgbaston, B15 2TT, UK
| | - Tim Coleman
- School of Community Health Sciences, Division of Primary Care, Queen's University Medical Centre, Nottingham, NG7 2UH, UK
| | - Lianne Straus
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic de Barcelona, Universitat de Barcelona, Rosselló 132, 4a planta, 08036 Barcelona, Spain
| | - Robert West
- Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 2-16 Torrington Place, London, WC1E 6BT, UK
| | - Bess Marcus
- Department of Community Health and Department of Psychiatry and Human Behavior, Brown University, 121 South Main Street, Providence, Rhode Island, 02903, USA
| | - Beth Lewis
- School of Kinesiology, University of Minnesota, 209 Cooke Hall, 1900 University Ave, Minneapolis, MN 55455, USA
| | - Isaac Manyonda
- Department of Obstetrics and Gynecology, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
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Heil SH, Higgins ST, Bernstein IM, Solomon LJ, Rogers RE, Thomas CS, Badger GJ, Lynch ME. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction 2008; 103:1009-18. [PMID: 18482424 PMCID: PMC2731575 DOI: 10.1111/j.1360-0443.2008.02237.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS This study examined whether voucher-based reinforcement therapy (VBRT) contingent upon smoking abstinence during pregnancy is an effective method for decreasing maternal smoking during pregnancy and improving fetal growth. DESIGN, SETTING AND PARTICIPANTS A two-condition, parallel-groups, randomized controlled trial was conducted in a university-based research clinic. A total of 82 smokers entering prenatal care participated in the trial. INTERVENTION Participants were assigned randomly to either contingent or non-contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non-contingent condition, vouchers were earned independent of smoking status. MEASUREMENTS Smoking outcomes were evaluated using urine-toxicology testing and self-report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester. FINDINGS Contingent vouchers significantly increased point-prevalence abstinence at the end-of-pregnancy (41% versus 10%) and at the 12-week postpartum assessment (24% versus 3%). Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight, femur length and abdominal circumference in the contingent compared to the non-contingent conditions. CONCLUSIONS These results provide further evidence that VBRT has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health.
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Affiliation(s)
- Sarah H. Heil
- Department of Psychiatry, University of Vermont, Department of Psychology, University of Vermont
| | - Stephen T. Higgins
- Department of Psychiatry, University of Vermont, Department of Psychology, University of Vermont
| | | | - Laura J. Solomon
- Department of Psychology, University of Vermont, Department of Family Practice, University of Vermont
| | | | | | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont
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Usmani ZC, Craig P, Shipton D, Tappin D. Comparison of CO breath testing and women's self-reporting of smoking behaviour for identifying smoking during pregnancy. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2008. [PMCID: PMC2265678 DOI: 10.1186/1747-597x-3-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Healthcare services often use a carbon monoxide (CO) breath test to validate self-reported smoking and to assess reductions in smoking habit. A cut-off level of ≥ 8 parts per million (p.p.m.) is used to identify smoking. This cut-off requires further validation in pregnant women. Methods Data on self-reported smoking were assessed in conjunction with breath CO levels. Subjects in the study were 2548 women attending antenatal booking during 12 months. Results 546/2584 (21.4%) women self-reported as current smokers. A cut-off of 8 ppm identified only 325/546 self-reported smokers (sensitivity 59.4%). 27/2002 self-reported non-smokers had levels greater than 8 ppm (specificity 98.7%). Sensitivity and specificity analysis revealed that CO cut-off levels of 2 or 3 p.p.m. resulted in the best sensitivity and specificity for discriminating apparent smokers and non-smokers. A cut-off of 2 p.p.m. would have identified 468/546 of self-reported smokers (sensitivity 86%). 206/2002 self-reported non-smokers had levels > 2 ppm (specificity 90 %). If all these women were 'true' smokers, the real prevalence of smoking in pregnancy was 26.5% (752/2548) and 27% of true smokers provided false answers to the self-reported question at maternity booking. Conclusion At 8 ppm, many smokers are missed and there may be gross underestimating of levels of smoking in a pregnant population. Results emphasise the need to support a lower cut-off level for the breath CO test closer to 2 or 3 p.p.m. These cut-offs may be more appropriate in the antenatal clinic setting, and are in line with recent recommendations in the non-pregnant population.
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Pipkin FB. Smoking in moderate/severe preeclampsia worsens pregnancy outcome, but smoking cessation limits the damage. Hypertension 2008; 51:1042-6. [PMID: 18259022 DOI: 10.1161/hypertensionaha.107.106559] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We studied phenotypic and clinical outcome data in an observational, multicenter cohort study of 1001 Western European white women and their singleton babies, with stringently defined moderate-to-severe preeclampsia. Ninety women admitted to being current smokers; 71 had stopped smoking before entry to the study. Across the categories of never-smoker, stopped, and current smoker there were significant increases in the proportion of women delivering before 34 weeks' gestation (P=0.011), delivering a baby below the third birth weight centile (P<0.001), or delivering a baby with any adverse outcome (P=0.011). By comparison with never-smokers, smoking during pregnancy was associated with a doubling of risk of being delivered before 34 weeks' (odds ratio: 1.98; 95% CI: 1.24 to 3.16; P=0.004), of delivering babies below the third centile of corrected birth weight (odds ratio: 2.20; 95% CI 1.41 to 3.44; P<0.0001), or for their babies to have any adverse outcome (odds ratio: 1.87; 95% CI: 1.19 to 2.95; P<0.006). Worryingly, the risk of developing eclampsia was increased 5-fold (odds ratio: 4.88; 95% CI: 1.44 to 16.61; P=0.005). The proportion of smokers in these preeclamptic women was lower than in our pregnant population generally. However, preeclampsia still carries significant perinatal morbidity, and cigarette smoking in preeclamptic pregnancies exacerbates this. Stopping smoking decreases the risks. Smoking in young women should be a particular target for advice by general practitioners before pregnancy, with active encouragement after conception to enroll in such trials as the current Smoking, Nicotine and Pregnancy Trial to support cessation.
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Affiliation(s)
- F Broughton Pipkin
- Department of Obstetrics and Gynaecology, Maternity Unit, City Hospital, Nottingham NG5 1PB, United Kingdom.
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