Which measures of cigarette dependence are predictors of smoking cessation during pregnancy? Analysis of data from a randomized controlled trial

Parental cigarette smoking before and during pregnancy in a cohort of 21 472 pregnancies

Smoking during pregnancy is one of the leading causes for adverse pregnancy outcomes. We studied parental smoking both before and during pregnancy in a retrospective cohort of 21 472 singleton pregnancies. Although most smoking women (74%) ceased tobacco use, there was possible gestational exposure to maternal cigarette smoking in every fifth pregnancy. Continued smoking throughout pregnancy was more prevalent in the partners (22%) than in the pregnant women (7%). The smoking behaviour of the women, especially the number of cigarettes smoked per day (CPD), before and in early pregnancy predicted the continuation of smoking throughout the pregnancy and could be used in identifying high risk groups. In addition, their partner's smoking habits both before and during pregnancy, were associated with the likelihood that the woman would continue to smoke during her pregnancy (rs ≈ 0.4). Furthermore, continued smoking of both parents were associated with decreased birth weight, head circumference and Apgar score, and increased duration of hospital stay and need for special care after birth. Consequently, addressing the lifestyles of both parents in the health care and maternity clinics could help in reducing maternal cigarette smoking during pregnancy and the adverse pregnancy outcomes associated with smoking.

The relationship between the severity of inflammatory bowel diseases and expirium air carbon monoxide levels

INTRODUCTION

We investigated the relationship between expirium air carbon monoxide (E-CO) levels and disease severity in patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

After their first follow-ups, the E-CO levels of 162 patients with UC and 100 with CD were measured for four consecutive weeks. Blood samples were collected from all the patients, and their clinical severity was determined 1 month after their initial presentation. The clinical severity of CD was determined using the Harvey Bradshaw index (HBI), while the patients with UC completed the SEO clinical activity index (SEOI). The relationships between the disease severity and the means of these four E-CO readings were then compared.

RESULTS

The mean age of the participants was 42.28 ± 14.9 years, and 158 (60.3%) were men. In addition, 27.2% of the UC group and 44% of the CD group were smokers. The mean SEOI score was 145.7 ± 42.0 (min = 90, max = 227), and the mean HBI score was 5.75 ± 3.3 (min = 1, max = 15). Increased CO ppm (OR = -9.047 to 7.654 95% CI) and the number of cigarettes smoked per day (OR = -0.161 to 1.157 95% CI) emerged as independent risk factors for lower SEO scores in the linear regression models (p < 0.001), while the number of cigarettes smoked per day (OR = 0.271 to 1.182% 95 CI) was a risk factor for higher HBI scores (p = 0.022).

CONCLUSION

UC severity decreased with higher E-CO levels and the mean number of cigarettes smoked, while CD severity increased in line with the mean number of cigarettes smoked.

A predictive model of waterpipe smoking cessation among women in southern Iran: application of the theory of planned behavior

BACKGROUND

Today, waterpipe (WT) smoking is a rising issue worldwide, and has taken a significant and growing share of tobacco consumption in the world. Present study aimed to explore the predictors of WT cessation in the light of the theory of planned behavior (TPB).

METHODS

This cross-sectional analytical study was conducted in 2021-2022 using a multi-stratified cluster sampling on 1,764 women in Bandar Abbas, southern Iran. Data were collected through a reliable and valid questionnaire. The three-part questionnaire includes demographic information, behavioral information of WT smoking, and the constructs of the TPB along with an additional habit construct. Multivariate logistic regression analysis was run to model the predictor constructs of WT smoking. The data were analyzed statistically in STATA14.2.

RESULTS

With an increase in one attitude score, the odds of cessation increased by 31% (p < 0.001). Also, with an increase of one score in knowledge, the odds of cessation are increased by 0.05% (0.008). With an increase of one score for intention, the odds of cessation are 26% (0.000). in social norms, the odds of cessation are 0.02% (0.001). With an increase of one score in perceived control, the odds of cessation increased by 16% (0.000) and inhabit score, the odds of cessation decrease by 37% (0.000). In the model where the habit construct was present, the accuracy, sensitivity, and pseudo R2 indices were 95.69%, 77.31%, and 65%, respectively and after removing the habit construct, the so-called indices changed to 90.7%, 50.38% and 0.44%, respectively.

CONCLUSIONS

The present research confirmed the effectiveness of the TPB model in predicting waterpipe cessation behavior. The knowledge obtained from this research can help develop a systematic and effective intervention to facilitate waterpipe cessation. Focusing on the habit variable can play a critical role in waterpipe cessation in women.

Smoking and quitting characteristics of Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study

OBJECTIVE

To describe smoking characteristics, quitting behaviour and other factors associated with longest quit attempt and the use of nicotine replacement therapy (NRT) and stop-smoking medication (SSM) in a population of Indigenous Australian women of reproductive age.

DESIGN, SETTING AND PARTICIPANTS

A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020.

MAIN OUTCOME MEASURES

Quitting experience: attempt to cut down, time since last quit attempt, longest period without smoking, attempt to cut down during last quit attempt, any use of NRT and/or SSM.

RESULTS

Most of the 428 participating women (302 [70.6%]) reported using an Aboriginal health service. Younger women (16-20-year-olds) smoked fewer cigarettes daily (24/42 [57.1%], 0-5 cigarettes per day), waited longer to smoke after waking (20/42 [47.6%], > 60 minutes after waking), and were categorised as low smoking dependency compared with those aged 35 years and over. One-third of women (153 [35.7%]) had ever used NRT and/or SSM. A greater proportion of older women (35-49-year-olds) had sustained a quit attempt for years (62/149 [45.6%]) and reported trying NRT and/or SSM (78/149 [52.4%]) than women in younger age groups. Quitting suddenly rather than gradually was significantly associated with sustained abstinence (prevalence ratio, 1.27 [95% CI, 1.10-1.48]). Among women who had never used NRT or SSM, most (219/275 [79.6%]) reported reasons for this in the category of attitudes and beliefs. NRT and SSM use was also more likely among women who were confident talking to their doctor about quitting (odds ratio, 2.50 [95% CI, 1.23-5.10]) and those who received most of their information from a health professional (odds ratio, 1.71 [95% CI, 1.11-2.63]).

CONCLUSION

Aboriginal and Torres Strait Islander women want to quit smoking and are making attempts to quit. Quitting suddenly, rather than reducing cigarette consumption, is associated with increased sustained abstinence. Health providers can enable access and uptake of NRT and/or SSM and should recognise that NRT and/or SSM use may change over time. Consistent messaging, frequent offers of smoking cessation support, and access to a range of smoking cessation supports should be provided to Aboriginal and Torres Strait Islander women to enable them to be smoke-free.

Effectiveness of offering tailored text message, self-help smoking cessation support to pregnant women who want information on stopping smoking: MiQuit3 randomised controlled trial and meta-analysis

AIMS

To test the efficacy of 'MiQuit', a tailored, self-help, text message stop smoking programme for pregnancy, as an adjunct to usual care (UC) for smoking cessation in pregnancy.

DESIGN

Multicentre, open, two-arm, parallel-group, superiority randomised controlled trial (RCT) and a trial sequential analysis (TSA) meta-analysis combining trial findings with two previous ones.

SETTING

Twenty-four English hospital antenatal clinics.

PARTICIPANTS

A total of 1002 pregnant women who were ≥16 years old, were ≤25 weeks gestation and smoked ≥1 daily cigarette and accepted information on cessation with no requirement to set quit dates.

INTERVENTIONS

UC or UC plus 'MiQuit': 12 weeks of tailored, smoking cessation text messages focussed on inducing and aiding cessation.

MEASUREMENTS

Primary outcome: biochemically validated cessation between 4 weeks after randomisation and late pregnancy.

SECONDARY OUTCOMES

shorter and non-validated abstinence periods, pregnancy outcomes and incremental cost-effectiveness ratios.

FINDINGS

RCT: cessation was 5.19% (26/501) and 4.59% (23/501) in MiQuit and UC groups (adjusted odds ratio [adj OR] for quitting with MiQuit versus UC, 95% CI = 1.15 [0.65-2.04]); other abstinence findings were similar, with higher point estimates. Primary outcome ascertainment was 61.7% (309) and 67.3% (337) in MiQuit and UC groups with 71.1% (54/76) and 69.5% (41/59) abstinence validation rates, respectively. Pregnancy outcomes were similar and the incremental cost per quality-adjusted life year was -£1118 (95% CI = -£4806-£1911). More MiQuit group women reported making at least one quit attempt (adj OR [95% CI]) for making an attempt, 1.50 (1.07-2.09). TSA meta-analysis: this found no significant difference in prolonged abstinence between MiQuit and UC (pooled OR = 1.49, adjusted 95% CI = 0.62-3.60).

CONCLUSIONS

Irrespective of whether they want to try quitting, when offered a tailored, self-help, text message stop smoking programme for pregnancy (MiQuit) as an adjunct to usual care, pregnant women are not more likely to stop smoking until childbirth but they report more attempts at stopping smoking.

Smoking and vaping patterns during pregnancy and the postpartum: A longitudinal UK cohort survey

INTRODUCTION

There is limited information about longitudinal patterns of vaping during pregnancy and the postpartum. We describe the prevalence, frequency, and reasons for vaping throughout pregnancy and postpartum. We also describe temporal patterns in pregnant women's vaping.

METHODS

A longitudinal cohort study across England and Scotland, with questionnaires in early pregnancy (8-24 weeks gestation), late pregnancy (34-38 weeks) and 3 months postpartum. A total of 750 women, aged 16 years or over, who were either current smokers, vapers or had smoked in the 3 months before pregnancy, were recruited between June and November 2017.

RESULTS

Vaping prevalence was 15.9% (n = 119/750) in early pregnancy: 12.4% (n = 93/750) were dual users and 3.5% (n = 26/750) exclusive vapers. Late pregnancy vaping prevalence was 17.8% (n = 68/383): 12.5% (n = 48/383) were dual users and 5.2% (n = 20/383) exclusive vapers. Postpartum vaping prevalence was 23.1% (n = 95/411): 14.6% (n = 60/411) were dual users and 8.5% (n = 35/411) exclusive vapers. The most frequently reported reason to vape among all vapers was to quit smoking. A total of 316 women completed all three surveys: 2.6% (n = 8/316) were exclusive vapers in early pregnancy with most remaining exclusive vapers postpartum (n = 6/8, 75%). Of the 11.5% (n = 35/316) dual users in early pregnancy, 31.4% (n = 11/35) were exclusive smokers by the postpartum.

CONCLUSION

Vaping prevalence was between 15.9% and 23.1% during pregnancy and the postpartum period, and the majority were dual users. Vaping habits of exclusive vapers remains stable throughout pregnancy and the postpartum. However, the vaping habits of dual users varies, with a third exclusively smoking in the postpartum.

Factors Associated with Smoke-Free Pregnancy among Aboriginal and Torres Strait Women and Their Experience of Quitting Smoking in Pregnancy: A Mixed Method Cross-Sectional Study

Smoke-free pregnancies have long-term health benefits for mothers and babies. This paper quantitatively examines factors associated with smoke-free pregnancies among Aboriginal and Torres Strait Islander women (hereafter Aboriginal women) and qualitatively explores their smoking cessation (SC) experiences during pregnancy. An Aboriginal-led online cross-sectional study on SC was conducted with Aboriginal women and in partnership with Aboriginal communities, between July and October 2020. The present analysis includes participants who made a pregnancy-related quit attempt (N = 103). Chi-squared tests, logistic regression models, and thematic analysis of free-form text responses were performed. The adjusted odds of having smoke-free pregnancies were 4.54 times higher among participants who used Aboriginal Health Services (AHS) (AOR = 4.54, p-value 0.018). Participants living in urban settings had 67% lower odds of having smoke-free pregnancies compared to their regional/remote counterparts (AOR = 0.33, p-value 0.020). Qualitative data revealed strong motivations to reduce tobacco-related harms to the fetus and variability in quitting experiences at different stages of and across pregnancies. Smoking cessation care (SCC) can support Aboriginal women meaningfully if their quitting experiences are considered in SCC development and implementation. Consistent funding for AHS-led SCC is needed to garner health benefits for Aboriginal peoples. More research into urban versus regional/remote differences in maternal SC is recommended.

Early Life Exposure to Nicotine: Postnatal Metabolic, Neurobehavioral and Respiratory Outcomes and the Development of Childhood Cancers

Cigarette smoking during pregnancy is associated with numerous obstetrical, fetal, and developmental complications, as well as an increased risk of adverse health consequences in the adult offspring. Nicotine replacement therapy and electronic nicotine delivery systems (e-cigarettes) have been developed as a pharmacotherapy for smoking cessation and are considered safer alternatives for women to smoke during pregnancy. The safety of nicotine replacement therapy use during pregnancy has been evaluated in a limited number of short-term human trials, but there is currently no information on the long-term effects of developmental nicotine exposure in humans. However, animal studies suggest that nicotine alone may be a key chemical responsible for many of the long-term effects associated with maternal cigarette smoking on the offspring and increases the risk of adverse neurobehavioral outcomes, dysmetabolism, respiratory illness, and cancer. This review will examine the long-term effects of fetal and neonatal nicotine exposure on postnatal health.

Which Method of Assessing Depression and Anxiety Best Predicts Smoking Cessation: Screening Instruments or Self-Reported Conditions?

INTRODUCTION

Affective disorders and symptoms (ADS) are predictive of lower odds of quitting smoking. However, it is unknown which approach to assessing ADS best predicts cessation. This study compared a battery of ADS screening instruments with a single, self-report question on predicting cessation. Among those who self-reported ADS, we also examined if an additional question regarding whether participants believed the condition(s) might interfere with their ability to quit added predictive utility to the single-item question.

METHODS

Participants (N = 2637) enrolled in a randomized controlled trial of web-based smoking treatments completed a battery of five ADS screening instruments and answered a single-item question about having ADS. Those with a positive self-report on the single-item question were also asked about their interference beliefs. The primary outcome was complete-case, self-reported 30-day point prevalence abstinence at 12 months.

RESULTS

Both assessment approaches significantly predicted cessation. Screening positive for ≥ one ADS in the battery was associated with 23% lower odds of quitting than not screening positive for any (p = .023); those with a positive self-report on the single-item had 39% lower odds of quitting than self-reporting no mental health conditions (p < .001). Area under the receiver operating characteristic curve values for the two assessment approaches were similar (p = .136). Adding the interference belief question to the single-item assessment significantly increased the area under the receiver operating characteristic curve value (p = .042).

CONCLUSIONS

The single-item question assessing ADS had as much predictive validity, and possibly more, than the battery of screening instruments for identifying participants at risk for failing to quit smoking. Adding a question about interference beliefs significantly increased the predictive utility of the single-item question.

IMPLICATIONS

This is the first study to demonstrate that a single-item question assessing ADS has at least as much predictive validity, and possibly more, than a battery of validated screening instruments for identifying smokers at highest risk for cessation failure. This study also demonstrates adding a question about interference beliefs significantly adds to the predictive utility of a single, self-report question about mental health conditions. Findings from this study can be used to inform decisions regarding how to assess ADS in the context of tobacco treatment settings.

[Physiological and Psychological Data influencing Pregnant Women Smoking Behavior - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

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.

Effect of Intensive Personalized "5As+5Rs" Intervention on Smoking Cessation in Hospitalized Acute Coronary Syndrome Patients Not Ready to Quit Immediately: A Randomized Controlled Trial

Introduction

The acute coronary syndrome (ACS) patients who are not ready to quit smoking immediately have an extremely low rate of cessation. This study aims to investigate the efficacy of intensive personalized '5As+5Rs'intervention (IPANR intervention) on smoking cessation in this population.

Methods

A parallel-group randomized controlled trial was carried out, which compared IPANR intervention with routine 5Rs (control) at Fu Xing Hospital, Capital Medical University, Bei Jing, China. Three hundred and twenty hospitalized ACS smokers who were not ready to quit were randomly distributed to IPANR intervention group comprising three individual counseling during hospitalization and 15 intensive follow-up sessions (weekly during months 1, 2, 3, and monthly thereafter until month 6) or 5Rs group in a 1:1 fashion by 8 cardiologists who were blinded to the allocation sequence. Primary end point was carbon monoxide-confirmed continuous abstinence rate (CAR) through week 9 to week 12. Secondary outcome included abstinence rate at 24 weeks.

Results

Overall, 97.5% (312/320) participants completed the trial. An intention-to-treat analysis showed statistically significant advantage of IPANR compared with control group at 4 weeks CAR (27.5% vs. 17.5%, RR = 1.571, 95% CI = 1.032-2.392, p = 0.032, number needed to treat (NNT) = 10), and abstinence rate at 24 weeks (23.8% vs.15.0%, RR 1.583, 95% CI = 0.998-2.512, p = 0.048, NNT: 11.36). At 24 weeks, cigarettes smoked per day by the patients who failed to quit were significant lower in IPANR group than 5Rs group (13.21 ± 8.23 vs. 17.45 ± 10.71; p < 0.001).

Conclusions

The IPANR initiated during hospitalization, is a feasible and effective approach for smoking cessation in ACS patients not ready to quit immediately.

Implications

Smoking has a major impact on acute stages of ACS for recurrent ischemic events and long-term outcomes. However, there are few evidence-based treatments for smokers who are not ready to quit. This study described a cessation intervention initiated during hospitalization and included 15 intensive follow-up aimed at enabling ACS smokers who were not ready to quit immediately to deliver adequate motivational and behavior change counseling. Given its effectiveness demonstrated in this prospective study, this intervention in hospitalized ACS smokers might have the potential to substantially improve the cessation rate of ACS patients who are not ready to quit smoking immediately.

Carboxyhemoglobin in umbilical cord blood and maternal smoking

Background Smoking during pregnancy still exists in daily life but the effect on the newborn in the early stage of life is still unclear. This study investigates the normal reference range of carboxyhemoglobin (HbCO) in umbilical cord blood gas (UBG). Methods A single center retrospective cross-sectional cohort study was performed with 1172 cases. We analyzed HbCO values in umbilical cord blood, maternal smoking, birth weight percentiles, duration of amenorrhea and maternal admission duration prior to delivery. Results HbCO levels in newborns range from 0 to 7.7% with a mean of 0.6% (standard deviation 0.6). Newborns from women who smoked during pregnancy have a significant higher HbCO value compared to newborns from women who did not smoke. Birth weight is negatively correlated with HbCO (P = 0.001). Conclusion Our results show the normal reference range in this study is 0-1.2% for HbCO in the umbilical blood of newborns. Smoking prior to delivery leads to a higher HbCO value in the UBG sample of the newborn, a lower birth weight and may be potential harmful.

Cigarette smoking quit ratios among adults in the USA with cannabis use and cannabis use disorders, 2002-2016

BACKGROUND

The prevalence of cigarette smoking is nearly three times higher among persons who use cannabis and have cannabis use disorders (CUDs), relative to those who do not. The current study examined cigarette quit ratios from 2002 to 2016 among US adults with and without cannabis use and CUDs.

METHODS

The current study analysed US adults aged 18 years and older from the National Survey on Drug Use and Health, an annual cross-sectional study. Quit ratios (ie, proportion of former smokers among ever-smokers) were calculated annually from 2002 to 2016. Time trends in quit ratios by cannabis use/CUDs were tested using logistic regression.

RESULTS

In 2016, the quit ratios for people with any cannabis use (23%) and CUDs (15%) were less than half the quit ratios of those without cannabis use and CUDs (51% and 48%, respectively). After controlling for demographics and substance use disorders, the quit ratio did not change from 2002 to 2016 among persons with CUD, though it non-linearly increased among persons with cannabis use, without cannabis use and without CUDs. Quit ratios increased more rapidly among those who reported past-month cannabis use compared with those without past-month cannabis use.

CONCLUSIONS

Cigarette smoking quit ratios remain dramatically lower among people who use cannabis and have CUDs and quit ratios did not change significantly from 2002 to 2016 among those with CUDs. Public health and clinical attention are needed to increase quit ratios and reduce harmful cigarette smoking consequences for persons with cannabis use and CUDs.

Predictors of Smoking Cessation Among College Students in a Pragmatic Randomized Controlled Trial

An effective strategy to quit smoking should consider demographic aspects, smoking-related characteristics and psychological factors. This study examined potential predictors of smoking cessation in Spanish college students. A total of 255 college student smokers (18-24 years old), recruited to a cessation trial (Spain, 2013-2014), comprised an observational cohort. The main outcome was biochemically verified (urine cotinine) abstinence at the 6-month follow-up. Baseline potential predictors included socio-demographic, smoking-related and psychological variables (Fagerström Test for Nicotine Dependence (FTND), expired monoxide level (CO), intention to quit, previous quit attempts, participation in previous multicomponent programmes and confidence in quitting). Logistic regression models were used to identify potential predictors, the area under the ROC curve (AUC) was used to discriminate the capacity of the predictors and the Hosmer-Lemeshow goodness-of-fit test was used to assess model calibration. After 6 months of follow-up, variables related to high nicotine dependence, FTND and expired CO levels were associated with lower odds of quitting smoking (OR = 0.69 [95% CI 0.54-0.89] and 0.84 [0.77-0.92], respectively). Furthermore, being prepared to change (OR = 3.98 [1.49-10.64], p = 0.006) and being confident to quit (OR = 4.73 [2.12-10.55], p < 0.001) were also potential predictors of smoking cessation. The model that combined all these variables had the best predictive validity (AUC = 0.84 [0.78-0.91], p = 0.693) and showed good predictive capacity (χ² = 10.36, p = 0.241). Findings highlight that, in this population of college student smokers, having a lower level of nicotine dependence, being prepared to quit and having the confidence in the ability to quit were associated with smoking cessation, and these factors had good predictive capacity.

Emotion regulation difficulties and social control correlates of smoking among pregnant women trying to quit

Approximately 15% of US women currently smoke during pregnancy. An important step toward providing effective smoking cessation interventions during pregnancy is to identify individuals who are more likely to encounter difficulty quitting. Pregnant smokers frequently report smoking in response to intrapersonal factors (e.g., negative emotions), but successful cessation attempts can also be influenced by interpersonal factors (i.e., influence from close others). This study examined the association between emotion regulation difficulties, positive and negative social control (e.g., encouragement, criticism), and smoking cessation-related variables (i.e., smoking quantity, withdrawal symptoms) among pregnant smokers. Data were drawn from the pretreatment wave of a smoking cessation trial enrolling low-income pregnant women who self-reported smoking in response to negative affect (N = 73). Greater emotion regulation difficulties were related to greater smoking urges (b = 0.295, p = .042) and withdrawal symptoms (b = 0.085, p = .003). Additionally, more negative social control from close others was related to fewer smoking days (b = -0.614, p = .042) and higher smoking abstinence self-efficacy (b = 0.017, p = .002). More positive social control from close others interacted with negative affect smoking (b = -0.052, p = .043); the association between negative affect smoking and nicotine dependence (b = 0.812, p < .001) only occurred at low levels of positive social control. Findings suggest that emotion regulation difficulties may contribute to smoking during pregnancy by exacerbating women's negative experiences related to smoking cessation attempts. Negative social control was related to lower smoking frequency and greater confidence in quitting smoking, suggesting that it may assist pregnant smokers' cessation efforts. Positive social control buffered women from the effects of negative affect smoking on nicotine dependence. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01163864.

Nicotine replacement therapy for smoking cessation during pregnancy

Nicotine replacement therapy (NRT) is recommended in current Australian clinical guidelines for pregnant women who are unable to quit smoking unassisted. Clinicians report low levels of prescribing NRT during pregnancy, due to safety concerns and low levels of confidence in their ability to prescribe NRT. Animal models show that nicotine is harmful to the fetus, especially for brain and lung development, but human studies have not found any harmful effects on fetal and pregnancy outcomes. Studies of efficacy and effectiveness in the real world suggest that NRT use during pregnancy increases smoking cessation rates. These rates may be hampered by the fact that studies so far have used an NRT dose that does not adequately account for the higher nicotine metabolism during pregnancy and, therefore, does not adequately treat withdrawal symptoms. Further research is needed to assess the safety and efficacy of higher dosages of NRT in pregnancy, specifically of combination treatment using dual forms of NRT. As NRT is safer than smoking, clinicians need to offer this option to all pregnant women who smoke. A practical guide for initiating and tailoring the dose of NRT in pregnancy is suggested.

Smoking cessation strategies in pregnancy: Current concepts and controversies

Smoking during pregnancy is a risk factor associated with adverse pregnancy outcomes. Despite the fact that these outcomes are well known, a considerable proportion of pregnant women continue to smoke during this critical period. This paper evaluates critically smoking cessation interventions targeting pregnant women. We describe the findings of key published studies, review papers and expert statements to report the efficacy and safety of strategies for smoking cessation in pregnancy, including counselling and pharmacotherapy. Counselling appears to improve quit rates but mainly when used in combination with pharmacological therapy. Pharmacotherapy is recommended for women who are heavy smokers and are unable to quit smoking on their own. Nicotine replacement therapy is a reasonable first-line drug option. It is recommended that women who are pregnant, or planning to become pregnant, should be informed of potential risks for the foetus before considering smoking cessation therapy with bupropion or varenicline. Pregnant women view electronic nicotine delivery systems as being safer than combustible cigarettes, and this indeed may be the case; however, further evidence is required to assess their effectiveness as a smoking cessation aid and their safety for the mother and the child. Postpartum relapse is a significant problem, with approximately one out of two quitters relapsing in the first 2 months after delivery. These women should be considered 'at risk' and provided with ongoing support.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Want, need and habit as drivers of smoking behaviour: A preliminary analysis

BACKGROUND AND AIMS

Models of tobacco smoking behaviour propose that anticipated pleasure or satisfaction, the need to alleviate a nicotine-induced drive state and a stimulus-driven impulse potentially play an important role. This study aimed to provide a preliminary assessment of how far urges to smoke are reported by smokers and whether the strength of such urges prior to a quit attempt predicts short-term success at quitting.

METHODS

In a prospective study, 566 smokers attending a treatment programme to help smokers quit completed a written questionnaire covering frequency of different types of urge to smoke (automatic impulse - 'automatic urges', anticipated pleasure - 'pleasure urges', and fulfilling a need - 'need urges'). They were asked to rate this for whichever of these urges was dominant for them. The questionnaire also assessed daily cigarette consumption, time to first cigarette of the day, age and gender. Carbon monoxide verified smoking status was recorded at 1 and 4weeks after the target quit date.

FINDINGS

A total of 47.9% (271) of smokers reported that automatic urges were dominant, 21.7% (123) reported pleasure urges to be dominant, and 30.4% (172) reported need urges to be dominant. The strength of automatic urges predicted abstinence at both 1week (OR=0.74, p=0.005, 95%CI=0.60-0.92) and 4weeks (OR=0.73, p=0.008, 95%CI=0.59-0.92). Associations between other urge types and abstinence were not statistically significant.

CONCLUSIONS

A substantial proportion of smokers attending a clinic for help with quitting report that their dominant urges to smoke occur without any anticipation of pleasure or relief and the strength of the automatic urges predicts failure to sustain abstinence following a quit attempt.

Comparison of the Fagerström Test for Cigarette Dependence and the Heaviness of Smoking Index in the Second and Third Trimester of Pregnancy

Introduction

Smoking cessation at any stage of pregnancy can benefit the mother and fetus. Cigarette dependence is a significant factor in women who continue to smoke during pregnancy and accurate assessment of cigarette dependence can be helpful in planning smoking cessation programs. The objective of our study was to investigate the validity of the Fagerstrom Test for Cigarette Dependence (FTCD) and Heaviness of Smoking Index (HSI) as measures of cigarette dependence in the second and third trimesters of pregnancy by comparing them to serum cotinine levels.

Methods

Prospective cohort study of 167 women in their second and third trimester of pregnancy who self-reported cigarette smoking. They were administered the FTCD questionnaire and blood was drawn for cotinine measurements using a direct enzyme linked immunoassay. Linear regression was used to adjust for maternal age, body mass index, gestation, and parity to investigate the association between cotinine levels and the two scores.

Results

Both the FTCD and HSI correlated significantly with serum cotinine levels (Spearman coefficient 0.42 and 0.37, respectively, p < .001). The correlation coefficients of both scores were higher in primigravidas (n = 51) compared to multigravidas, but the difference was statistically nonsignificant. Using multiple linear regression, both scores were significantly related to serum cotinine levels. For each unit increase in the FTCD and HSI, the serum cotinine level increased by 21.4 ng/mL (95% confidence interval 10.1-32.7, p <0.001) and 37 ng/mL (95% confidence interval 18.6-55.4, p < 0.001), respectively.

Conclusions

Both the FTCD and HSI can be used to assess cigarette dependence in the second and third trimester of pregnancy.

Implications

There is lack of data on the validity of the FTCD and the HSI as markers of cigarette dependence during the second and third trimester of pregnancy. Our study suggests that both the FTCD and HSI perform well in assessing cigarette dependence in the second and third trimester of pregnancy and can be used to plan smoking cessation programs.

The Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy Pilot Study protocol: a feasibility step-wedge cluster randomised trial to improve health providers' management of smoking during pregnancy

INTRODUCTION

Indigenous women have the highest smoking prevalence during pregnancy (47%) in Australia. Health professionals report lack of knowledge, skills and confidence to effectively manage smoking among pregnant women in general. We developed a behaviour change intervention aimed to improve health professionals' management of smoking in Indigenous pregnant women-the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy. This intervention includes webinar training for health professionals, an educational resources package for health professionals and pregnant women, free oral nicotine replacement therapy (NRT) for pregnant women, and audit and feedback on health professionals' performance.The aim of this study is to test the feasibility and acceptability of the ICAN QUIT in Pregnancy intervention to improve health professionals' provision of evidence-based culturally responsive smoking cessation care to Australian Indigenous pregnant smokers.

METHODS AND ANALYSIS

This protocol describes the design of a step-wedge cluster randomised pilot study. Six Aboriginal Medical Services (AMSs) are randomised into three clusters. Clusters receive the intervention staggered by 1 month. Health professionals report on their knowledge and skills pretraining and post-training and at the end of the study. Pregnant women are recruited and followed up for 3 months. The primary outcome is the recruitment rate of pregnant women. Secondary outcomes include feasibility of recruitment and follow-up of participating women, and webinar training of health professionals, measured using a designated log; and measures of effectiveness outcomes, including quit rates and NRT prescription rates.

ETHICS AND DISSEMINATION

In accordance with the Aboriginal Health and Medical Research Council guidelines, this study has been developed in collaboration with a Stakeholder and Consumer Aboriginal Advisory Panel (SCAAP). The SCAAP provides cultural consultation, advice and direction to ensure that implementation is acceptable and respectful to the Aboriginal communities involved. Results will be disseminated to AMSs, Aboriginal communities and national Aboriginal bodies.

REGISTRATION DETAILS

This protocol (version 4, 14 October 2016) is registered with the Australian and New Zealand Clinical Trials Registry (Ref #: ACTRN12616001603404).

Large multi-centre pilot randomized controlled trial testing a low-cost, tailored, self-help smoking cessation text message intervention for pregnant smokers (MiQuit)

AIMS

To estimate the effectiveness of pregnancy smoking cessation support delivered by short message service (SMS) text message and key parameters needed to plan a definitive trial.

DESIGN

Multi-centre, parallel-group, single-blinded, individual randomized controlled trial.

SETTING

Sixteen antenatal clinics in England.

PARTICIPANTS

Four hundred and seven participants were randomized to the intervention (n = 203) or usual care (n = 204). Eligible women were < 25 weeks gestation, smoked at least one daily cigarette (> 5 pre-pregnancy), were able to receive and understand English SMS texts and were not already using text-based cessation support.

INTERVENTION

All participants received a smoking cessation leaflet; intervention participants also received a 12-week programme of individually tailored, automated, interactive, self-help smoking cessation text messages (MiQuit).

OUTCOME MEASUREMENTS

Seven smoking outcomes, including validated continuous abstinence from 4 weeks post-randomization until 36 weeks gestation, design parameters for a future trial and cost-per-quitter.

FINDINGS

Using the validated, continuous abstinence outcome, 5.4% (11 of 203) of MiQuit participants were abstinent versus 2.0% (four of 204) of usual care participants [odds ratio (OR) = 2.7, 95% confidence interval (CI) = 0.93-9.35]. The Bayes factor for this outcome was 2.23. Completeness of follow-up at 36 weeks gestation was similar in both groups; provision of self-report smoking data was 64% (MiQuit) and 65% (usual care) and abstinence validation rates were 56% (MiQuit) and 61% (usual care). The incremental cost-per-quitter was £133.53 (95% CI = -£395.78 to 843.62).

CONCLUSIONS

There was some evidence, although not conclusive, that a text-messaging programme may increase cessation rates in pregnant smokers when provided alongside routine NHS cessation care.

The effect of prenatal smoking exposure on daily smoking among teenage offspring

AIMS

To study the predictive associations between maternal smoking and the impact of quitting smoking during pregnancy and offspring daily smoking at age 15-16 years.

DESIGN

The Northern Finland Birth Cohort 1986 (NFBC86) includes 99% of all births in the region and has an ongoing follow-up. Data were collected using questionnaires at 24th gestational week during pregnancy and after delivery, and at follow-up in 2001-02, when the offspring were aged 15-16 years.

SETTING

Northern Finland.

PARTICIPANTS

NFBC86 included 9432 live born children. Data regarding maternal smoking during pregnancy and offspring smoking at age 15-16 years were available for 4462 subjects (47.3% of the original sample).

MEASUREMENTS

The outcome was offspring's self-reported daily smoking. Maternal smoking during pregnancy was considered using a four-class variable: (1) no smoking, (2) mother had smoked, but had quit smoking before becoming pregnant, (3) mother quit smoking during the 1st trimester and (4) mother quit smoking after the 1st trimester or continued smoking throughout the pregnancy. Information regarding paternal smoking during pregnancy, maternal and paternal smoking and education level, family structure and dwelling at offspring's age 15-16 years were considered potential confounding variables.

FINDINGS

Continuing smoking after the 1st trimester increased the odds of daily smoking among offspring, independently of confounding factors [odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.3-2.5]. Continuing to smoke after the 1st trimester was associated with higher odds compared with quitting smoking during the 1st trimester. Also, parental smoking at offspring age 15-16 years increased the odds of offspring daily smoking, independently of prenatal smoking exposure.

CONCLUSIONS

Prenatal smoking exposure increases the risk for offspring adolescent daily smoking. Quitting smoking during the early stages of pregnancy may decrease the odds for offspring smoking.

Which measures of cigarette dependence are predictors of smoking cessation during pregnancy? Analysis of data from a randomized controlled trial

AIMS

To examine the ability of different common measures of cigarette dependence to predict smoking cessation during pregnancy.

DESIGN

Secondary analysis of data from a parallel-group randomized controlled trial of physical activity for smoking cessation. The outcomes were biochemically validated smoking abstinence at 4 weeks post-quit and end-of-pregnancy.

SETTING

Women identified as smokers in antenatal clinics in 13 hospital trusts predominantly in southern England, who were recruited to a smoking cessation trial.

PARTICIPANTS

Of 789 pregnant smokers recruited, 784 were included in the analysis.

MEASUREMENTS

Using random-effect logistic regression models, we analysed the effects of baseline measures of cigarette dependence, including numbers of cigarettes smoked daily, Fagerström Test of Cigarette Dependence (FTCD) score, the two FTCD subscales of Heaviness of Smoking Index (HSI) and non-Heaviness of Smoking Index (non-HSI), expired carbon monoxide (CO) level and urges to smoke (strength and frequency) on smoking cessation. Associations were adjusted for significant socio-demographic/health behaviour predictors and trial variables, and area under the receiver operating characteristic (ROC) curve was used to determine the predictive ability of the model for each measure of dependence.

FINDINGS

All the dependence variables predicted abstinence at 4 weeks and end-of-pregnancy. At 4 weeks, the adjusted odds ratio (OR) (95% confidence interval) for a unit standard deviation increase in FTCD was 0.59 (0.47-0.74), expired CO = 0.54 (0.41-0.71), number of cigarettes smoked per day 0.65 (0.51-0.84) and frequency of urges to smoke 0.79 (0.63-0.98); at end-of-pregnancy they were: 0.60 (0.45-0.81), 0.55 (0.37-0.80), 0.70 (0.49-0.98) and 0.69 (0.51-0.94), respectively. HSI and non-HSI exhibited similar results to the full FTCD.

CONCLUSIONS

Four common measures of dependence, including number of cigarettes smoked per day, scores for Fagerström Test of Cigarette Dependence and frequency of urges and level of expired CO, all predicted smoking abstinence in the short term during pregnancy and at end-of-pregnancy with very similar predictive validity.