Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions

First Nations Peoples' perceptions, knowledge and beliefs regarding stillbirth prevention and bereavement practices: A mixed methods systematic review

BACKGROUND

First Nations Peoples endure disproportionate rates of stillbirth compared with non-First Nations Peoples. Previous interventions have aimed at reducing stillbirth in First Nations Peoples and providing better bereavement care without necessarily understanding the perceptions, knowledge and beliefs that could influence the design of the intervention and implementation.

AIM

The aim of this review was to understand the perceptions, knowledge and beliefs about stillbirth prevention and bereavement of First Nations Peoples from the US, Canada, Aotearoa/New Zealand, and Australia.

METHODS

This review was conducted in accordance with the JBI methodology for a convergent integrated mixed method systematic review. This review was overseen by an advisory board of Aboriginal Elders, researchers, and clinicians. A search of eight databases (PubMed, MEDLINE, PsycInfo, CINAHL, Embase, Emcare, Dissertations and Theses and Indigenous Health InfoNet) and grey literature was conducted. All studies were screened, extracted, and appraised for quality by two reviewers and results were categorised, and narratively summarised.

RESULTS

Ten studies were included within this review. Their findings were summarised into four categories: safeguarding baby, traditional practices of birthing and grieving, bereavement photography and post-mortem examination. The results indicate a diversity of perceptions, knowledge and beliefs primarily around smoking cessation and bereavement practices after stillbirth. However, there was a paucity of research available.

CONCLUSIONS

Further research is needed to understand the perceptions, knowledge and beliefs about stillbirth among First Nations Peoples. Without research within this area, interventions to prevent stillbirth and support bereaved parents and their communities after stillbirth may face barriers to implementation.

Indigenous Women's Experiences of Smoking and Quitting Smoking in Pregnancy: A Phenomenological Study

BACKGROUND

Maternal smoking during pregnancy (MSDP) is an important public health concern because of potential adverse health effects to the woman, fetus, and child after birth. Prevalence rates are high among groups with socioeconomic disadvantage, including Indigenous women.

PURPOSE

This study was conducted to understand experiences of MSDP for Indigenous women.

METHODS

The study was conducted using phenomenology. Data were collected through interviews with 15 pregnant and postnatal Indigenous women who had smoked during pregnancy. The data were analyzed for themes using phenomenological methods.

RESULTS

The women's narratives revealed four experiences: quitting smoking during pregnancy to protect the unborn baby from harm; quitting smoking during pregnancy because of personal adverse health effects; cutting down smoking during pregnancy and feeling remorse for not quitting; and keeping on smoking during pregnancy and not planning to try to quit. The women's experiences also indicated several impediments to quitting smoking.

CONCLUSIONS

There is need for health care policy to ensure adequate smoking cessation services and support for Indigenous women who smoke in pregnancy. Health care professionals should provide individualized interventions that take into account the challenges to quitting that pregnant women experience and that are in accordance with clinical practice guidelines for MSDP.

Smoking Cessation Messages for Pregnant Aboriginal and Torres Strait Islander Women: A Rapid Review of Peer-Reviewed Literature and Assessment of Research Translation of Media Content

This review summarized literature about knowledge, attitudes, and beliefs of Aboriginal and Torres Strait Islander women from Australia who smoke during pregnancy, then examined the extent that existing health promotion materials and media messages aligned with evidence on smoking cessation for pregnant Aboriginal and Torres Strait Islander women. Knowledge, attitudes, and beliefs of pregnant Aboriginal women who smoke tobacco were identified in the literature. Health promotion campaigns were retrieved from a grey literature search with keywords and social and professional networks. Key themes from peer-reviewed papers were compared against the content of health promotion campaigns using the Aboriginal Social and Emotional Wellbeing Model, the Behavior Change Wheel and thematic analysis. Eleven empirical studies and 17 campaigns were included. Empirical studies highlighted women sought holistic care that incorporated nicotine replacement therapy, engaged with their family and community and the potential for education about smoking cessation to empower a woman. Health promotion campaigns had a strong focus on 'engagement with family and community', 'knowledge of risks of smoking,' 'giving up vs cutting down' and 'culture in language and arts'. There were similarities and variances in the key themes in the research evidence and promotion materials. Topics highly aligned included risks from smoking and quitting related issues.

Socioecological Mapping of Barriers and Enablers to Smoking Cessation in Indigenous Australian Women During Pregnancy and Postpartum: A Systematic Review

BACKGROUND

With a high prevalence of smoking during pregnancy and limited Indigenous-specific evidence for treatment, we used socioecological mapping to identify multilevel barriers and enablers to smoking cessation related to Indigenous Australian pregnant and postpartum women.

METHODS

Nine electronic databases were searched. Original studies except interventions and trials, published in English, up to February 29, 2020 were included. Studies were appraised using the QualSyst tool. Evidence was narratively synthesized. The review protocol was registered with PROSPERO (CRD42019135543).

RESULTS

A total of 15 studies (10 quantitative, 5 qualitative) were included, covering 1306 women, 3 partners/family members, 234 health professionals (HP), and 2755 patient records. Complex and overlapping barriers were identified at individual, family, community, societal, and system levels. Socioeconomic disadvantages, inequality, and pervasive racism as legacies of colonization, combined with personal, family, and community circumstances intensified individual experiences of stress, which may be heightened during pregnancy. Inadequate smoking cessation care (SCC), inconsistent antitobacco messages, and ineffectual HP interventions underscore a need for service enhancement and further evidence to develop culturally relevant messages. High motivation of pregnant women to quit, resilience, and supports available in the family and community are strengths that warrant attention in future interventions.

CONCLUSIONS

SCC without ameliorating the social disadvantages and the disparities in health determinants between Indigenous and non-Indigenous Australian women may limit the effectiveness of SCC. A comprehensive approach is required that includes policy changes for addressing external stressors the women experience, engagement of family and community, and better training of HP and provision of free pharmacotherapy.

IMPLICATIONS

To systematically address barriers to smoking cessation at multiple levels, initiatives to ameliorate social disadvantages and discrepancies in social determinants of health between Indigenous and non-Indigenous Australians are required to be taken in tandem with SCC. Initiatives may include making relevant policy changes and allocating more resources for education, employment, housing, and community development. Enhancement of knowledge, skills, and confidence of HP regarding the provision of high-quality SCC for Indigenous women and their families is warranted. Future interventions may build on high motivation, resilience, and strengths of individual women, and incorporate support strategies engaging family and community.

Knowledge, Attitude and Smoking Patterns Among Pregnant Women: A Jordanian Perspective

Background:

Smoking during pregnancy is one of the main modifiable factors associated with perinatal morbidity and mortality and maternal complications. Literature is scant regarding smoking habits of pregnant women in Jordan.

Objectives:

To investigate smoking patterns and attitudes of Jordanian pregnant women towards smoking.

Methods:

A cross-sectional survey of patterns and attitudes towards smoking among 436 mothers attending healthcare facilities in the Governorate of Irbid, Jordan, between August and September 2019.

Results:

Out of 436 pregnant women in the Governorate of Irbid, Jordan, 13 (2.9%) quit smoking once pregnancy was conformed, and 77 (17.6%) continued to smoke.

Pregnant non-smokers believed that hookah and electronic cigarettes are as bad to health as cigarettes, while smokers believed that hookah and electronic cigarettes are less hazardous than cigarettes (5.19% versus 21.99%, p = 0.001, and 6.49% versus 19.37%, p = 0.009, respectively).

Non-smokers were significantly more aware regarding the hazards of smoking on perinatal outcomes, such as abortion (31.94% versus 10.39%, p = 0.001), placental abruption (31.94% versus 10.39%, p = 0.001), intrauterine growth restriction and fetal malformations (36.65% versus 14.29%, p = 0.007), fetal death (30.89% versus 6.49, p < 0.001), neonatal pulmonary diseases (44.50% versus 24.68%, p = 0.024), neonatal asthma (47.12% versus 28.57%, p = 0.038), and ear diseases (42.41% versus 20.8%, p = 0.012).

Conclusion:

There is a high prevalence of smokers among pregnant women in Jordan. The level of awareness regarding long-term consequences of tobacco use remains low. Educational programs should include information about the hazards of all forms of smoking. Pregnancy provides a good opportunity for promoting smoking cessation.

An ecological model of drug and alcohol use and related harms among Aboriginal and Torres Strait Islander Australians: A systematic review of the literature

Globally, Indigenous populations experience a disproportionately higher burden of disease related to substance use. Effective prevention of harm related to substance use is a key strategy for improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples in Australia. To inform preventative approaches, this review synthesised the evidence of risk and protective factors of substance use and related harms among Aboriginal and Torres Strait Islander peoples. Eight peer-reviewed and two grey literature databases were systematically searched for quantitative or qualitative studies assessing factors associated with substance use and related harms among Aboriginal and Torres Strait Islander peoples, published between 1 January 1990 and 30 April 2018. Study quality was assessed using validated instruments. Risk or odds ratios were extracted or calculated and factors were summarised in an ecological model into individual, relationship, community, societal or culturally-distinct levels. Thirty-eight relevant studies were identified and reviewed. Individual-level risk factors for substance use were identified including low socio-economic status, high psychological distress, poly drug use and being male. Relationship-level factors were peer pressure and partner/family substance use; protective factors were supportive environments and positive role models. Community-level risk factors included availability of substances. Culturally-distinct factors included cultural connection as a protective factor, but cultural obligations around sharing was a risk factor. Societal risk factors included intergenerational trauma caused by government policies. These findings highlight the importance of tailored preventative approaches for Aboriginal and Torres Strait Islander communities that address identified risk factors and promote protective factors across all ecological levels.

Barriers and facilitators to smoking cessation within pregnant Aboriginal and/or Torres Strait Islander women: An integrative review

OBJECTIVE

To synthesise primary research regarding the facilitators and barriers to smoking cessation amongst Aboriginal and/or Torres Strait Islander women during pregnancy.

DESIGN

An integrative review.

REVIEW METHODS

A systematic search of peer-reviewed literature from five databases published from January 2008 to April 2018. Articles were reviewed using the approach outlined by Whittemore and Knafl, with the identified themes collated and synthesised according to study characteristics and barriers and facilitators of smoking cessation.

FINDINGS

Of the 310 papers retrieved, nine studies were included within the review (five quantitative and four qualitative). The quality of the studies were ascertained via Joanna Briggs Institute checklists for cross sectional analysis, randomized controlled trials, and qualitative research. The overall quality of the research was deemed acceptable. Two facilitators to smoking cessation within the studied population were identified: 'support to quit' and 'information and advice', while four barriers to smoking cessation within pregnant Aboriginal and/or Torres Strait Islander women were identified: 'smoking prevalence', 'high daily stress', 'ambivalence regarding adverse effects of smoking', and 'attitudes, knowledge and training of the healthcare professional'.

CONCLUSIONS

Social and familial influences and daily stress have a strong impact on whether a woman feels she can quit smoking during pregnancy. However, in this study, information and advice regarding potential adverse effects of smoking on the foetus, or lack thereof, from health professionals either facilitated cessation of smoking in pregnancy or was a barrier to quitting. Likewise, a lack of awareness from midwives and doctors on smoking cessation strategies, such as nicotine replacement therapy, was a barrier for women.

IMPLICATIONS FOR PRACTICE

The findings indicate that education regarding the adverse effects of smoking in pregnancy, as well as strategies on smoking cessation from midwives, doctors, and Aboriginal Health Workers within the antenatal period may have a positive effect on current smoking rates among pregnant Aboriginal and/or Torres Strait Islander women. Involving the partner/support person and family of the woman in this education may have a greater impact on smoking cessation rates through the woman gaining social and familial support in her decision to quit. Thus, healthcare workers require additional professional development to provide information and knowledge within a culturally competent manner. Successful smoking cessation programs for Aboriginal and Torres Strait Islander women during pregnancy could have measurable impacts on mortality rates for Indigenous infants and significantly contribute to 'Closing the Gap'.

Wula (Voices) of Aboriginal women on barriers to accepting smoking cessation support during pregnancy: Findings from a qualitative study

AIM

To gather Aboriginal women's stories of smoking and becoming pregnant to identify the barriers in accepting smoking cessation support during pregnancy.

METHODS

Qualitative data were collected through use of yarning methodology between August 2015 and January 2016 by an Aboriginal Researcher with experience in social and community services. A short on-line survey was used to collect quantitative data. Interviews only recorded the therapeutic yarning process, which ranged from 9 to 45min duration, averaging 30min. Audio-recorded interviews were transcribed and independently coded. A general inductive analysis was used to determine emergent themes.

RESULTS

Twenty Aboriginal women between 17-38 years of age, who were pregnant or recently given birth, living in the Hunter New England (HNE) area took part. Eleven women were still smoking; nine had quit. Most were highly aware of the implications of smoking for their babies. Major themes identified for accepting support were: ambivalence towards a need for support, health professional advice, reduction in smoking, and attitudes to Nicotine Replacement Therapy (NRT). Women reported being advised to cut down, rather than to quit; reducing consumption may be a barrier to accepting NRT. Women recommended enhanced clinical support and Aboriginal community engagement in cessation care.

DISCUSSION/CONCLUSIONS

Aboriginal women in the HNE area reported quitting or reducing their cigarette intake during pregnancy. Health Professionals working with Aboriginal women during pregnancy should give consistent messages to quit smoking completely, and offer increased, ongoing and extensive smoking cessation support to Aboriginal mothers. Clinical practices could partner with Aboriginal communities to support the delivery of smoking cessation services.

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

OBJECTIVE

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

DESIGN

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

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

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

KEY CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women

BACKGROUND

Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians. We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally competent approach, developed collaboratively with AMS.

METHOD

The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.'s "Behaviour Change Wheel" guide.

RESULTS

Targets identified for health provider behaviour change included the following: capability (psychological capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation (optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring consultations using a flipchart and prompts. Education and training were selected as the main intervention functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints, bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded with videos to improve patients' capability, opportunity and motivation.

CONCLUSIONS

The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services in how to implement culturally competent evidence-based practice including counselling and nicotine replacement therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at systemic, provider, community and individual levels. This process was therefore important for defining the design and intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.

Prevention and Treatment of Smoking and Tobacco Use During Pregnancy in Selected Indigenous Communities in High-Income Countries of the United States, Canada, Australia, and New Zealand: An Evidence-Based Review

Tobacco smoking during pregnancy is the most important modifiable risk factor for adverse pregnancy outcomes and long-term health complications for mother and baby. Tobacco use during pregnancy has decreased in high-income countries but not in Indigenous women in Australia, New Zealand, the United States, and Canada. This evidence-based review focuses on tobacco use among Indigenous pregnant women in high-income countries that share a history of European colonization. Indigenous women are more likely to use tobacco because of socioeconomic disadvantage, social norms, and poor access to culturally appropriate tobacco cessation support. Complications arising from tobacco smoking during pregnancy, such as low birth weight, prematurity, perinatal death, and sudden infant death syndrome, are much higher in Indigenous populations. Effective approaches to cessation in pregnant nonindigenous women involves behavioral counseling, with or without nicotine replacement therapy (NRT). Higher nicotine metabolism during pregnancy and poor adherence may affect therapeutic levels of NRT. Only two randomized trials were conducted among Indigenous women: neither found a statistically significant difference in cessation rates between the treatment and comparison arms. Considerations should be given to (1) whole life course approaches to reduce tobacco use in Indigenous women, (2) prohibiting tobacco promotion and reducing access to alcohol for minors to prevent smoking initiation in Indigenous youth, and (3) training health-care professionals in culturally appropriate smoking cessation care to improve access to services. It is critical to ensure acceptability and feasibility of study designs, consult with the relevant Indigenous communities, and preempt implementation challenges. Research is needed into the effect of reducing or stopping smoking during pregnancy when using NRT on subsequent maternal and infant outcomes.

Exploring an adapted Risk Behaviour Diagnosis Scale among Indigenous Australian women who had experiences of smoking during pregnancy: a cross-sectional survey in regional New South Wales, Australia

OBJECTIVES

Explore Aboriginal women's responses to an adapted Risk Behaviour Diagnosis (RBD) Scale about smoking in pregnancy.

METHODS AND DESIGN

An Aboriginal researcher interviewed women and completed a cross-sectional survey including 20 Likert scales.

SETTING

Aboriginal Community Controlled Health Services, community groups and playgroups and Aboriginal Maternity Services in regional New South Wales, Australia.

PARTICIPANTS

Aboriginal women (n=20) who were pregnant or gave birth in the preceding 18 months; included if they had experiences of smoking or quitting during pregnancy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes: RBD constructs of perceived threat and perceived efficacy, dichotomised into high versus low. Women who had quit smoking, answered retrospectively.

SECONDARY OUTCOME MEASURES

smoking status, intentions to quit smoking (danger control), protection responses (to babies/others) and fear control responses (denial/refutation). Scales were assessed for internal consistency. A chart plotted responses from low to high efficacy and low to high threat.

RESULTS

RBD Scales had moderate-to-good consistency (0.67-0.89 Cronbach's alpha). Nine women had quit and 11 were smoking; 6 currently pregnant and 14 recently pregnant. Mean efficacy level 3.9 (SD=0.7); mean threat 4.3 (SD=0.7). On inspection, a scatter plot revealed a cluster of 12 women in the high efficacy-high threat quadrant-of these 11 had quit or had a high intention of quitting. Conversely, a group with low threat-low efficacy (5 women) were all smokers and had high fear control responses: of these, 4 had low protection responses. Pregnant women had a non-significant trend for higher threat and lower efficacy, than those previously pregnant.

CONCLUSION

Findings were consistent with a previously validated RBD Scale showing Aboriginal smokers with high efficacy-high threat had greater intentions to quit smoking. The RBD Scale could have diagnostic potential to tailor health messages. Longitudinal research required with a larger sample to explore associations with the RBD Scale and quitting.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

Supporting Aboriginal Women to Quit Smoking: Antenatal and Postnatal Care Providers' Confidence, Attitudes, and Practices

INTRODUCTION

Tobacco use during pregnancy is substantially higher among Aboriginal women compared to non-Aboriginal women in Australia. However, no studies have investigated the amount or type of smoking cessation care that staff from Aboriginal antenatal and postnatal services provide to clients who smoke or staff confidence to do so. This study examined Aboriginal antenatal and postnatal staff confidence, perceived role and delivery of smoking cessation care to Aboriginal women and characteristics associated with provision of such care.

METHODS

Staff from 11 Aboriginal Maternal and Infant Health Services and eight Aboriginal Child and Family Health services in the Hunter New England Local Health District in Australia completed a cross-sectional self-reported survey (n = 67, response rate = 97.1%).

RESULTS

Most staff reported they assessed clients' smoking status most or all of the time (92.2%). However, only a minority reported they offered a quitline referral (42.2%), provided follow-up support (28.6%) or provided nicotine replacement therapy (4.7%) to most or all clients who smoked. Few staff felt confident in motivating clients to quit smoking (19.7%) and advising clients about using nicotine replacement therapy (15.6%). Staff confident with talking to clients about how smoking affected their health had significantly higher odds of offering a quitline referral [OR = 4.9 (1.7-14.5)] and quitting assistance [OR = 3.9 (1.3-11.6)] to clients who smoke.

CONCLUSIONS

Antenatal and postnatal staff delivery of smoking cessation care to pregnant Aboriginal women or mothers with young Aboriginal children could be improved. Programs that support Aboriginal antenatal and postnatal providers to deliver smoking cessation care to clients are needed.

IMPLICATIONS

Aboriginal antenatal and postnatal service staff have multiple opportunities to assist Aboriginal women to quit smoking during pregnancy and postpartum. However, staff confidence and practices of offering various forms of smoking cessation support to pregnant Aboriginal women is unexplored. This is the first study to examine the amount and type of smoking cessation support Aboriginal antenatal and postnatal service staff provide to Aboriginal women, staff confidence and their perceived role in delivering smoking cessation care. This information is valuable for developing strategies that assist antenatal and postnatal staff to improve their delivery of smoking cessation care to Aboriginal women.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Sociodemographic correlates of smoking in pregnancy and antenatal-care attendance in Indigenous and non-Indigenous women in South Australia

Smoking in pregnancy is a key health issue in Australia, particularly among Indigenous women. However, few studies have examined the sociodemographic factors associated with smoking in pregnancy or the predictors of antenatal-care attendance among Indigenous and non-Indigenous Australian women who smoke. Data from the South Australian perinatal statistics collection of all births from 2000-2010 (n=197538) were analysed separately by Indigenous status to determine the sociodemographic factors associated with smoking in pregnancy and antenatal-care attendance by women who smoke. For Indigenous and non-Indigenous women, smoking in pregnancy was significantly independently associated with socioeconomic disadvantage, residing in regional or remote areas, increased parity, unemployment, being a public patient and attending fewer antenatal care visits. Smoking in pregnancy was associated with younger age and not being partnered only for non-Indigenous women. For Indigenous and non-Indigenous pregnant women who smoked, antenatal-care attendance was lower among women who were of younger age, higher parity, unemployed and not partnered. Differences in attendance within sociodemographic factors were greater for Indigenous women. Therefore, while sociodemographic correlates of smoking in pregnancy and antenatal-care attendance are largely similar for Indigenous and non-Indigenous women, tailored cessation and antenatal-care programs that reflect the differences in sociodemographic groups most at risk may be beneficial.

Getting over the shock: taking action on Indigenous maternal smoking

Smoking rates are slow to decline among pregnant Indigenous women. One in two pregnant Indigenous Australian women is a tobacco smoker compared with one in eight in the non-Indigenous population. The National Close the Gap strategy ambitiously aims to reduce Indigenous smoking prevalence to half by 2018, but this goal is unlikely to be achieved. Evidence is growing to better inform targeted strategies for Indigenous pregnant women based on national and international studies. It is proposed to be an appropriate time to refine translational approaches for anti-tobacco messages and cessation support in this population, rather than waiting for further empirical research before making these essential changes. Systemic barriers to Indigenous pregnant women receiving equitable primary health care have been identified, are remediable, and urgently require addressing. These barriers include: (1) lack of subsidised access to suitable oral forms of nicotine replacement therapy; (2) lack of clinician training in the complex area of management of maternal Indigenous smoking; and (3) lack of targeted health promotion programs addressing the psychosocial challenges that Indigenous women face. In the interim, translational strategies to target tobacco control and cessation in pregnant Indigenous women need to be based on current evidence.

Smoking among Aboriginal adults in Sydney, Australia

Issue addressed Tobacco consumption contributes to health disparities among Aboriginal Australians who experience a greater burden of smoking-related death and diseases. This paper reports findings from a baseline survey on factors associated with smoking, cessation behaviours and attitudes towards smoke-free homes among the Aboriginal population in inner and south-western Sydney. Methods A baseline survey was conducted in inner and south-western Sydney from October 2010 to July 2011. The survey applied both interviewer-administered and self-administered data collection methods. Multiple logistic regression was performed to determine the factors associated with smoking. Results Six hundred and sixty-three participants completed the survey. The majority were female (67.5%), below the age of 50 (66.6%) and more than half were employed (54.7%). Almost half were current smokers (48.4%) with the majority intending to quit in the next 6 months (79.0%) and living in a smoke-free home (70.4%). Those aged 30-39 years (AOR 3.28; 95% CI: 2.06-5.23) and the unemployed (AOR 1.67; 95% CI: 1.11-2.51) had higher odds for current smoking. Participants who had a more positive attitude towards smoke-free homes were less likely to smoke (AOR 0.79; 95% CI: 0.74-.85). Conclusions A high proportion of participants were current smokers among whom intention to quit was high. Age, work status and attitudes towards smoke-free home were factors associated with smoking. So what? The findings address the scarcity of local evidence crucial for promoting cessation among Aboriginal tobacco smokers. Targeted promotions for socio-demographic subgroups and of attitudes towards smoke-free homes could be meaningful strategies for future smoking-cessation initiatives.

Provision of antenatal smoking cessation support: a survey with pregnant Aboriginal and Torres Strait Islander women

INTRODUCTION

Guidelines recommend assessment of smoking status, with advice and support for smoking cessation, as a routine and integral part of antenatal care. Approximately 50% of pregnant Australian Aboriginal and Torres Strait Islander women smoke through pregnancy, 3 times the rate of other pregnant Australian women. This study describes smoking cessation assessment and support reported by pregnant Aboriginal and Torres Strait Islander women.

METHODS

Surveys of 261 pregnant Aboriginal and Torres Strait Islander women in New South Wales and the Northern Territory, Australia assessed women's reports of assessment, advice and support for smoking cessation from antenatal providers.

RESULTS

The majority of women (90%, 95% CI = 85, 93) reported being asked their smoking status; 81% (95% CI = 73, 87) of smokers reported being advised to stop smoking and 62% (95% CI = 53, 71) of smokers reported being offered support to quit.

CONCLUSIONS

Despite most pregnant women who smoke reporting advice and support to quit, the persisting high prevalence of smoking suggests that this support is insufficient to overcome the many factors pushing women to smoke. Improving the support provided to women will require empowering the antenatal providers with adequate skills, appropriate resources and effective interventions. Current guidelines are based on research from non-Indigenous populations, as there are no published effective interventions for Indigenous pregnant women. Trials of interventions designed specifically for pregnant Aboriginal and Torres Strait Islander women are urgently needed, as are approaches aimed at reducing uptake of smoking.

Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people

OBJECTIVES

To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting.

DESIGN, SETTING AND PARTICIPANTS

The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013.

MAIN OUTCOME MEASURES

Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit.

RESULTS

Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not.

CONCLUSION

Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.

Predictors of intentions to quit smoking in Aboriginal tobacco smokers of reproductive age in regional New South Wales (NSW), Australia: quantitative and qualitative findings of a cross-sectional survey

OBJECTIVES

To assess the predictors of intentions to quit smoking in a community sample of Aboriginal smokers of reproductive age, in whom smoking prevalence is slow to decline.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey involved 121 Aboriginal smokers, aged 18-45 years from January to May 2014, interviewed at community events on the Mid-North Coast NSW. Qualitative and quantitative data were collected on smoking and quitting attitudes, behaviours and home smoking rules. Perceived efficacy for quitting, and perceived threat from smoking, were uniquely assessed with a validated Risk Behaviour Diagnosis (RBD) Scale.

MAIN OUTCOME MEASURES

Logistic regression explored the impact of perceived efficacy, perceived threat and consulting previously with a doctor or health professional (HP) on self-reported intentions to quit smoking, controlling for potential confounders, that is, protection responses and fear control responses, home smoking rules, gender and age. Participants' comments regarding smoking and quitting were investigated via inductive analysis, with the assistance of Aboriginal researchers.

RESULTS

Two-thirds of smokers intended to quit within 3 months. Perceived efficacy (OR=4.8; 95% CI 1.78 to 12.93) and consulting previously with a doctor/HP about quitting (OR=3.82; 95% CI 1.43 to 10.2) were significant predictors of intentions to quit. 'Smoking is not doing harm right now' was inversely associated with quit intentions (OR=0.25; 95% CI 0.08 to 0.8). Among those who reported making a quit attempt, after consulting with a doctor/HP, 40% (22/60) rated the professional support received as low (0-2/10). Qualitative themes were: the negatives of smoking (ie, disgust, regret, dependence and stigma), health effects and awareness, quitting, denial, 'smoking helps me cope' and social aspects of smoking.

CONCLUSIONS

Perceived efficacy and consulting with a doctor/HP about quitting may be important predictors of intentions to quit smoking in Aboriginal smokers of reproductive age. Professional support was generally perceived to be low; thus, it could be improved for these Aboriginal smokers. Aboriginal participants expressed strong sentiments about smoking and quitting.

Supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking: views of antenatal care providers and pregnant indigenous women

To assess support for 12 potential smoking cessation strategies among pregnant Australian Indigenous women and their antenatal care providers. Cross-sectional surveys of staff and women in antenatal services providing care for Indigenous women in the Northern Territory and New South Wales, Australia. Respondents were asked to indicate the extent to which each of a list of possible strategies would be helpful in supporting pregnant Indigenous women to quit smoking. Current smokers (n = 121) were less positive about the potential effectiveness of most of the 12 strategies than the providers (n = 127). For example, family support was considered helpful by 64 % of smokers and 91 % of providers; between 56 and 62 % of smokers considered advice and support from midwives, doctors or Aboriginal Health Workers likely to be helpful, compared to 85-90 % of providers. Rewards for quitting were considered helpful by 63 % of smokers and 56 % of providers, with smokers rating them more highly and providers rating them lower, than most other strategies. Quitline was least popular for both. This study is the first to explore views of pregnant Australian Indigenous women and their antenatal care providers on strategies to support smoking cessation. It has identified strategies which are acceptable to both providers and Indigenous women, and therefore have potential for implementation in routine care. Further research to explore their feasibility in real world settings, uptake by pregnant women and actual impact on smoking outcomes is urgently needed given the high prevalence of smoking among pregnant Indigenous women.

The impact of Aboriginal status, cigarette smoking and smoking cessation on perinatal outcomes in South Australia

OBJECTIVE

To assess the impact of Aboriginal status, active cigarette smoking and smoking cessation during pregnancy on perinatal outcomes.

DESIGN

Retrospective cohort study from 1 January 1999 to 31 December 2008.

SETTING

All singleton births in South Australia.

PARTICIPANTS

Population-based birth records of pregnancies to Aboriginal women (n = 4245) and non-Aboriginal women (n = 167 746).

MAIN OUTCOME MEASURES

Adjusted odds ratios (aORs) and 95% CIs for adverse maternal and neonatal outcomes according to Aboriginal status and maternal smoking in pregnancy.

RESULTS

Active cigarette smoking during pregnancy was associated with an increased risk of adverse perinatal outcomes, including premature labour (Aboriginal, 1-10 cigarettes per day: aOR, 1.69; 95% CI, 1.28-2.23; non-Aboriginal, 1-10 cigarettes per day: aOR, 1.46; 95% CI, 1.34-1.58), preterm birth (Aboriginal, 1-10 cigarettes per day: aOR, 1.40; 95% CI, 1.14-1.73; non-Aboriginal, 1-10 cigarettes per day: aOR, 1.48; 95% CI, 1.39-1.57), intrauterine growth restriction (Aboriginal, 1-10 cigarettes per day: aOR, 2.33; 95% CI, 1.77-3.08; non-Aboriginal, 1-10 cigarettes per day: aOR, 2.65; 95% CI, 2.48-2.83) and small for gestational age (Aboriginal, 1-10 cigarettes per day: aOR, 2.49; 95% CI, 2.06-3.00; non-Aboriginal, 1-10 cigarettes per day: aOR, 2.29; 95% CI, 2.20-2.40). For both Aboriginal and non-Aboriginal women who smoked 11 or more cigarettes per day the aOR for these outcomes increased. Smoking cessation in the first trimester reduced these risks to levels comparable with non-smokers. The risk of each adverse outcome was greater in Aboriginal than non-Aboriginal women for all smoking categories; however, interactions between Aboriginal status and smoking were not significant, indicating an equal contribution of smoking to poor outcomes in both populations.

CONCLUSIONS

Smoking cessation or reduction during pregnancy would significantly improve outcomes in both Aboriginal and non-Aboriginal women. This should be made a clear priority to improve pregnancy outcomes for all women.

Validation of risk assessment scales and predictors of intentions to quit smoking in Australian Aboriginal and Torres Strait Islander peoples: a cross-sectional survey protocol

INTRODUCTION

Tobacco smoking is a very significant behavioural risk factor for the health of Australian Aboriginal and Torres Strait Islanders, and is embedded as a social norm. With a focus on women of childbearing age, and men of similar age, this project aims to determine how Aboriginal and Torres Strait Islander smokers assess smoking risks and how these assessments contribute to their intentions to quit. The findings from this pragmatic study should contribute to developing culturally targeted interventions.

METHODS AND ANALYSIS

A cross-sectional study using quantitative and qualitative data. A total of 120 Aboriginal and Torres Strait Islander community members aged 18-45 years will be recruited at community events and through an Aboriginal Community Controlled Health Service (ACCHS). Participants will be interviewed using a tablet computer or paper survey. The survey instrument uses modified risk behaviour scales, that is, the Risk Behaviour Diagnosis (RBD) scale and the Smoking Risk Assessment Target (SRAT) (adapted from the Risk Acceptance Ladder) to determine whether attitudes of Aboriginal and Torres Strait Islander smokers to health risk messages are predictors of intentions to quit smoking. The questionnaire will be assessed for face and content validity with a panel of Indigenous community members. The internal consistency of the RBD subscales and their patterns of correlation will be explored. Multivariate analyses will examine predictors of intentions to quit. This will include demographics such as age, gender, nicotine dependence, household smoking rules and perceived threat from smoking and efficacy for quitting. The two risk-assessment scales will be examined to see whether participant responses are correlated.

ETHICS AND DISSEMINATION

The Aboriginal Health & Medical Research Council Ethics Committee and university ethics committees approved the study. The results will be published in a peer-reviewed journal and a community report will be disseminated by the ACCHS, and at community forums.

NOTE ABOUT TERMINOLOGY

We use the term Aboriginal and Torres Strait Islander peoples, except where previous research has reported findings from only one group for example, Aboriginal people. Indigenous is used here to refer to Indigenous peoples in the international context, and issues, policies or systems, for example, Indigenous health, Indigenous tobacco control.

Tobacco, alcohol and cannabis use during pregnancy: clustering of risks

BACKGROUND

Antenatal substance use poses significant risks to the unborn child. We examined use of tobacco, alcohol and cannabis among pregnant Aboriginal and Torres Strait Islander women; and compared characteristics of women by the number of substances reported.

METHODS

A cross-sectional survey with 257 pregnant Indigenous women attending antenatal services in two states of Australia. Women self-reported tobacco, alcohol and cannabis use (current use, ever use, changes during pregnancy); age of initiation of each substance; demographic and obstetric characteristics.

RESULTS

Nearly half the women (120; 47% (95%CI:40%, 53%) reported no current substance use; 119 reported current tobacco (46%; 95%CI:40%, 53%), 53 (21%; 95%CI:16%, 26%) current alcohol and 38 (15%; 95%CI:11%, 20%) current cannabis use. Among 148 women smoking tobacco at the beginning of pregnancy, 29 (20%; 95%CI:14%, 27%) reported quitting; with 80 of 133 (60%; 95%CI:51%, 69%) women quitting alcohol and 25 of 63 (40%; 95%CI:28%, 53%) women quitting cannabis. Among 137 women reporting current substance use, 77 (56%; 95%CI:47%, 65%) reported one and 60 (44%; 95%CI:35%, 53%) reported two or three. Women using any one substance were significantly more likely to also use others. Factors independently associated with current use of multiple substances were years of schooling and age of initiating tobacco.

CONCLUSIONS

While many women discontinue substance use when becoming pregnant, there is clustering of risk among a small group of disadvantaged women. Programmes should address risks holistically within the social realities of women's lives rather than focusing on individual tobacco smoking. Preventing uptake of substance use is critical.

"Nobody smokes in the house if there's a new baby in it": Aboriginal perspectives on tobacco smoking in pregnancy and in the household in regional NSW Australia

BACKGROUND

Smoking prevalence in Aboriginal and Torres Strait Islander pregnant women is quadruple that of non-Indigenous counterparts, impacting on the health of babies and children.

AIMS

To explore attitudes and experiences related to prenatal tobacco smoking by Aboriginal women and household smoking, and to provide recommendations for culturally appropriate interventions.

METHODS

We conducted five focus groups with clients and family members of a regional NSW Aboriginal maternity service (n=18). Committees, including Aboriginal representatives, oversaw the study. We analysed transcripts with the constant comparative method and developed key categories.

FINDINGS

Categories included: social and family influences, knowing and experiencing the health effects of smoking, responses to health messages, cravings and stress, giving up and cutting down, managing smoke-free homes and cars, and community recommendations. Smoking in pregnancy and passive smoking were acknowledged as harmful for babies and children. Anti-tobacco messages and cessation advice appeared more salient when concordant with women's lived experience. Reduced cigarette consumption was reported in pregnancy. Despite smoking in the home, families were engaged in the management of environmental tobacco smoke to reduce harm to babies and children. Abstinence was difficult to initiate or maintain with the widespread use of tobacco in the social and family realm.

CONCLUSION

Anti-tobacco messages and interventions should relate to Aboriginal women's experiences, improve understanding of the quitting process, support efficacy, and capitalise on the positive changes occurring in smoke-free home management. Focus group participants recommended individual, group and family approaches, and access to cessation services and nicotine replacement therapy for Aboriginal pregnant women who smoke.

Psychosocial interventions for supporting women to stop smoking in pregnancy

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.

Socio-demographic and lifestyle-related characteristics associated with self-reported any, daily and occasional smoking during pregnancy

Smoking during pregnancy is a risk factor for various adverse birth outcomes. In order to develop effective interventions, insight is needed into the characteristics associated with pregnant women who smoke. Unknown is whether these characteristics differ for women who smoke daily and women who smoke occasionally. Our study sample, drawn from the DELIVER study (Sept 2009-March 2011), consisted of 6107 pregnant women in primary care in the Netherlands who were up to 34 weeks pregnant. The associations of thirteen socio-demographic or lifestyle-related characteristics with 'any smoking', 'daily smoking' and 'occasional smoking' during pregnancy were tested using multiple binary logistic regression with general estimating equations (GEE). Characteristics most strongly associated with any smoking were low education (OR 10.3; 95% confidence interval (CI) 7.0-15.4), being of Turkish ethnicity (OR 3.9; 95%CI 2.3-6.7) and having no partner (OR 3.7; 95%CI 2.3-6.0). Women of Dutch ethnicity were three times more likely to smoke than those from Dutch-speaking Caribbean countries and non-religious women were much more likely to smoke than religious women. Low education was markedly more strongly associated with daily smoking than with occasional smoking (OR 20.3; 95%CI 13.2-31.3 versus OR 6.0; 95%CI 3.4-10.5). Daily smokers were more likely to be associated with other unfavorable lifestyle-related characteristics, such as not taking folic acid, being underweight, and having had an unplanned pregnancy. There is still much potential for health gain with respect to smoking during pregnancy in the Netherlands. Daily and occasional smokers appear to differ in characteristics, and therefore possibly require different interventions.

How will we close the gap in smoking rates for pregnant Indigenous women?

Aboriginal and Torres Strait Islander women are more than three times more likely to smoke during pregnancy than non-Indigenous women, greatly increasing the risk of poor birth outcomes. Our systematic review found that there is currently no evidence for interventions that are effective in supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking, which impedes development and implementation of evidence-informed policy and practice. There is an urgent need for methodologically rigorous studies to test innovative approaches to addressing this problem.

Knowledge, attitudes and other factors associated with assessment of tobacco smoking among pregnant Aboriginal women by health care providers: a cross-sectional survey

BACKGROUND

As with many Indigenous peoples, smoking rates among Aboriginal Australians are considerably higher than those of the non-Indigenous population. Approximately 50% of Indigenous women smoke during pregnancy, a time when women are more motivated to quit. Antenatal care providers are potentially important change agents for reducing the harms associated with smoking, yet little is known about their knowledge, attitudes or skills, or the factors associated with providing smoking cessation advice.

METHODS

This paper aimed to explore the knowledge and attitudes of health care providers caring for pregnant Australian Aboriginal women with regard to smoking risks and cessation; and to identify factors associated with self-reported assessment of smoking. A cross-sectional survey was undertaken with 127 staff providing antenatal care to Aboriginal women from two jurisdictions: the Northern Territory and New South Wales, Australia. Measures included respondents' estimate of the prevalence of smoking among pregnant women; optimal and actual assessment of smoking status; knowledge of risks associated with antenatal smoking; knowledge of smoking cessation; attitudes to providing cessation advice to pregnant women; and perceived barriers and motivators for cessation for pregnant women.

RESULTS

The median provider estimate of the smoking prevalence was 69% (95%CI: 60,70). The majority of respondents considered assessment of smoking status to be integral to antenatal care and a professional responsibility. Most (79%) indicated that they assess smoking status in 100% of clients. Knowledge of risks was generally good, but knowledge of cessation was poor. Factors independently associated with assessing smoking status among all women were: employer service type (p = 0.025); cessation knowledge score (p = 0.011); and disagreeing with the statement that giving advice is not worth it given the low level of success (p = 0.011).

CONCLUSIONS

Addressing knowledge of smoking risks and cessation counselling is a priority and should improve both confidence and ability, and increase the frequency and effectiveness of counselling. The health system must provide supports to providers through appropriate policy and resourcing, to enable them to address this issue.