Comparison of CO breath testing and women's self-reporting of smoking behaviour for identifying smoking during pregnancy

Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial

INTRODUCTION

Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services.

METHODS AND ANALYSIS

A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.

Tobacco treatment incorporating contingency management, nicotine replacement therapy, and behavioral counseling for pregnant women who use substances: a feasibility trial

Introduction

Most pregnant women with substance use problems smoke, and few will quit during their pregnancy. Tobacco treatment is often overlooked, with the focus usually placed on other substance use. Additionally, few targeted effective treatments for this group exist. To address this, the feasibility of an intensive tobacco treatment incorporating contingency management (CM) that featured non-face-to-face delivery was examined.

Methods

A single-arm pre-post design feasibility trial was conducted in three antenatal services that support women who use substances in metropolitan Australia. Participants were over the age of 15, had <33-week gestation, and smoked tobacco daily. They received financial incentives for daily carbon monoxide-verified smoking abstinence or reduction through an internet-based CM programme, nicotine replacement therapy (NRT) posted to women and partners or household members who smoked and telephone-delivered behavioral counseling from study enrolment to birth.

Results

Of the 101 referrals, 46 women (46%) consented. The mean (SD) age was 31(±6) years, and the gestation period was 22(±6) weeks. Nineteen (41%) of those enrolled were retained for 12-week postpartum. Of 46 women, 32 (70%) utilized CM; 32 (70%) used NRT for ≥2 weeks; 23 (50%) attended ≥1 counseling session; and 15 (22%) received NRT for partners/household members. Fifteen (33%) were verified abstinent from tobacco at delivery after a median (IQR) period of abstinence of 65(36-128) days. All non-smokers at birth utilized NRT and financial incentives, and 9/15 (60%) utilized counseling. Four (9%) were abstinent at 12-week postpartum. Median cigarettes smoked/day reduced from baseline to delivery (10(6-20) to 1(0-6) p =< 0.001). Women who quit smoking had more education (72% vs. 33% p =< 0.02), completed more CO samples (median (IQR) 101(59-157) vs. 2(0-20) p =< 0.001), and received more incentives (median (IQR) $909($225-$1980) vs. $34($3-$64) p =< 0.001). Intervention acceptability was rated favorably by participants (9 items rated 0-10 with scores >5 considered favorable).

Discussion

This study demonstrated the feasibility and acceptability of a consumer-informed, non-face-to-face intensive tobacco treatment, highlighting the potential of remotely delivered technology-based CM to reduce the health impact of tobacco smoking in high-priority populations. The intervention demonstrates scale-up potential. Future studies should extend treatment into the postpartum period, utilizing new technologies to enhance CM delivery and improve counseling provision and partner support.

Clinical trial registration

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374196, ACTRN1261800056224.

Evaluation of the MoMba Live Long Remote Smoking Detection System During and After Pregnancy: Development and Usability Study

Background

The smoking relapse rate during the first 12 months after pregnancy is around 80% in the United States. Delivering remote smoking cessation interventions to women in the postpartum period can reduce the burden associated with frequent office visits and can enable remote communication and support. Developing reliable, remote, smoking measuring instruments is a crucial step in achieving this vision.

Objective

The study presents the evaluation of the MoMba Live Long system, a smartphone-based breath carbon monoxide (CO) meter and a custom iOS smartphone app. We report on how our smoking detection system worked in a controlled office environment and in an out-of-office environment to examine its potential to deliver a remote contingency management intervention.

Methods

In-office breath tests were completed using both the MoMba Live Long system and a commercial monitor, the piCO⁺ Smokerlyzer. In addition, each participant provided a urine test for smoking status validation through cotinine. We used in-office test data to verify the validity of the MoMba Live Long smoking detection system. We also collected out-of-office tests to assess how the system worked remotely and enabled user verification. Pregnant adult women in their second or third trimester participated in the study for a period of 12 weeks. This study was carried out in the United States.

Results

Analyses of in-office tests included 143 breath tests contributed from 10 participants. CO readings between the MoMba Live Long system and the piCO⁺ were highly correlated (r=.94). In addition, the MoMba Live Long system accurately distinguished smokers from nonsmokers with a sensitivity of 0.91 and a specificity of 0.94 when the piCO⁺ was used as a gold standard, and a sensitivity of 0.81 and specificity of 1.0 when cotinine in urine was used to confirm smoking status. All participants indicated that the system was easy to use.

Conclusions

Relatively inexpensive portable and internet-connected CO monitors can enable remote smoking status detection in a wide variety of nonclinical settings with reliable and valid measures comparable to a commercially available CO monitor.

Trial Registration

ClinicalTrials.gov NCT02237898; https://clinicaltrials.gov/ct2/show/NCT02237898

Electronic cigarettes and obstetric outcomes: a prospective observational study

OBJECTIVE

To compare the obstetric outcomes and socio-demographic factors in electronic cigarette (EC) users with cigarette smokers and non-smokers in pregnancy.

DESIGN

Prospective observational cohort study.

SETTING

A large urban maternity hospital delivering almost 8500 infants per year.

POPULATION

Pregnant women attending for antenatal care.

METHODS

Electronic cigarette users at time of booking history were prospectively identified. Maternal and neonatal outcomes were compared with those of pregnant smokers and non-smokers. Multiple logistic regression analysis was performed to estimate the association between the explanatory variables and birthweight.

MAIN OUTCOMES MEASURES

Infant birthweight, gestation at delivery, incidence of low birthweight.

RESULTS

A total of 218 women with exclusive EC use and 195 women with dual use of both cigarettes and EC, had a live birth during the study period. EC users were of higher socio-economic status than smokers. Infants born to EC users had a mean birthweight of 3470 g (± 555 g), which was similar to that of non-smokers (3471 ± 504 g, P = 0.97) and significantly greater than that of smokers (3166 ± 502 g, P < 0.001). The mean birth centile of EC users was similar to non-smokers (51st centile versus 47th centile, P = 0.28) and significantly greater than that of smokers (27th centile, P < 0.001). Dual users had a mean birthweight and birth centile similar to that of smokers.

CONCLUSION

The birthweight of infants born to EC users is similar to that of non-smokers, and significantly greater than cigarette smokers. Dual users of both cigarettes and EC have a birthweight similar to that of smokers.

TWEETABLE EXTRACT

Birthweight of infants born to electronic cigarette users appears to be similar to that of non-smokers.

The Incentives to Quit tobacco in Pregnancy (IQuiP) protocol: piloting a financial incentive-based smoking treatment for women attending substance use in pregnancy antenatal services

INTRODUCTION

While tobacco smoking prevalence is falling in many western societies, it remains elevated among high-priority cohorts. Rates up to 95% have been reported in women whose pregnancy is complicated by other substance use. In this group, the potential for poor pregnancy outcomes and adverse physical and neurobiological fetal development are elevated by tobacco smoking. Unfortunately, few targeted and effective tobacco dependence treatments exist to assist cessation in this population. The study will trial an evidence-based, multicomponent tobacco smoking treatment tailored to pregnant women who use other substances. The intervention comprises financial incentives for biochemically verified abstinence, psychotherapy delivered by drug and alcohol counsellors, and nicotine replacement therapy. It will be piloted at three government-based, primary healthcare facilities in New South Wales (NSW) and Victoria, Australia. The study will assess the feasibility and acceptability of the treatment when integrated into routine antenatal care offered by substance use in pregnancy antenatal services.

METHODS AND ANALYSIS

The study will use a single-arm design with pre-post comparisons. One hundred clients will be recruited from antenatal clinics with a substance use in pregnancy service. Women must be <33 weeks' gestation, ≥16 years old and a current tobacco smoker. The primary outcomes are feasibility, assessed by recruitment and retention and the acceptability of addressing smoking among this population. Secondary outcomes include changes in smoking behaviours, the comparison of adverse maternal outcomes and neonatal characteristics to those of a historical control group, and a cost-consequence analysis of the intervention implementation.

ETHICS AND DISSEMINATION

Protocol approval was granted by Hunter New England Human Research Ethics Committee (Reference 17/04/12/4.05), with additional ethical approval sought from the Aboriginal Health and Medical Research Council of NSW (Reference 1249/17). Findings will be disseminated via academic conferences, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trial Registry (Ref: ACTRN12618000576224).

The conversation matters: a qualitative study exploring the implementation of alcohol screening and brief interventions in antenatal care in Scotland

Background

Alcohol screening and brief intervention (SBI) in antenatal care is internationally recommended to prevent harm caused by alcohol exposure during pregnancy. There is, however, limited understanding of how SBI is implemented within antenatal care; particularly the approach taken by midwives. This study aimed to explore the implementation of a national antenatal SBI programme in Scotland.

Methods

Qualitative interviews were conducted with antenatal SBI implementation leaders (N = 8) in eight Scottish health boards. Interviews were analysed thematically and using the ‘practical, robust implementation and sustainability model’ (PRISM) to understand differences in implementation across health boards and perceived setting-specific barriers and challenges.

Results

In several health boards, where reported maternal alcohol use was lower than expected, implementation leaders sought to optimize enquires about women’s alcohol use to facilitate honest disclosure. Strategies focused on having positive conversations, exploring pre-pregnancy drinking habits, and building a trusting relationship between pregnant women and midwives. Women’s responses were encouraging and disclosure rates appeared improved, though with some unexpected variation over time. Adapting the intervention to the local context was also considered important.

Conclusions

This is the first study to explore implementation leaders’ experiences of antenatal SBI delivery and identify possible changes in disclosure rates arising from the approach taken. In contrast with current antenatal alcohol screening recommendations, a conversational approach was advocated to enhance the accuracy and honesty of reporting. This may enable provision of support to more women to prevent Fetal Alcohol Spectrum Disorders (FASD) and will therefore be of international interest.

Assessment of the validity of self-reported smoking status among schoolchildren in Sousse, Tunisia

INTRODUCTION

Tobacco use, which begins in adolescence and childhood and continues in later life, is the major avoidable risk for non-communicable diseases and death in the world. Self-reports have frequently been used to estimate smoking prevalence and health consequences. This study explores the validity of self-reports of smoking behavior among schoolchildren in Tunisia.

MATERIALS AND METHODS

This study was conducted in March 2014 among a sample of 147 schoolchildren randomly selected. Data concerning the smoking habit were collected by a questionnaire designed for the purposes of this work. Then, exhaled CO, a biochemical marker of smoke exposure, was measured using piCO+ Smokerlyzer® breath CO monitor among participants. Sensitivity and specificity of self-reports were calculated.

RESULTS

The prevalence of reported smoking was 9.5% with 16.7% and 1.7% respectively among boys and girls. Their mean age was 14.5±1.28 years old. When considering 4 ppm as the cut-off level of breath CO, sensitivity and specificity of self-reports were 100% and 93.7%, respectively. But at a breath CO cut-off of 3 ppm, self-reporting was 62.5% sensitive and 93.5% specific.

CONCLUSION

According to our findings, we suggest that self-reports can be considered as a good tool to be used with a reasonable confidence to assess the smoking status.

Representativeness of the participants in the smoking Cessation in Pregnancy Incentives Trial (CPIT): a cross-sectional study

Background

The limited representativeness of trial samples may restrict external validity. The aim of this study was to ascertain the representativeness of the population enrolled in the Cessation in Pregnancy Incentives Trial (CPIT), a therapeutic exploratory study to examine the effectiveness of financial incentives for smoking cessation during pregnancy.

Methods

CPIT participants (n = 492) were compared with all self-reported smokers at maternity booking who did not participate in the trial (n = 1982). Both groups were drawn from the National Health Service (NHS) Greater Glasgow and Clyde area over a 1-year trial enrolment period. Variables used for comparison were age, area-based deprivation index, body mass index, gestation, and carbon monoxide (CO) breath test level. Chi-square and Mann-Whitney U tests were used to compare groups.

Results

From January to December 2012, 2474/13,945 (17.7 %) women, who booked for maternity care, self-reported as current smokers (at least one cigarette in the last week). Seven hundred and fifty-two were ineligible for trial participation because of a CO breath test level of less than 7 parts per million (ppm) used as a biochemical cut-off to corroborate self-report of current smoking. At telephone consent 301 could not be contacted, 11 had miscarried, 16 did not give consent and 3 opted out after randomisation, leaving 492 participants for analysis. There were no differences in demographic or clinical characteristics between trial participants, and self-reported smokers not enrolled in the trial in terms of CO breath test (as a measure of smoking level for those with a CO level of 7 ppm or higher), material deprivation (using an area-based measure), maternal age and maternal body mass index. Gestation at booking was statistically significantly lower for participants.

Conclusions

To ensure that all trial participants were smokers, biochemical validation excluded self-reported smokers with a CO level of less than 7 ppm from taking part in the trial, which excluded 30 % of self-reported smokers who were ‘lighter’ smokers. The efficacy of financial incentives would not have been likely to decrease if ‘lighter’ smokers had been included in the trial population. Trial participants were slightly earlier in their pregnancy at maternity booking, but this difference would not clinically affect the provision of financial incentives if provided routinely. Overall, the trial population was representative of all self-reported smokers with regard to available routinely collected data. Appropriate comparison of trial and target populations, with detailed reporting of exclusion criteria would contribute to the understanding of the wider applicability of trial results.

Trial registration

Current Controlled Trials ISRCTN87508788. Registered/Assigned on 1 September 2011.

The Modified Reasons for Smoking Scale: factorial structure, validity and reliability in pregnant smokers

RATIONALE, AIMS AND OBJECTIVES

Smoking during pregnancy can cause several maternal and neonatal health risks, yet a considerable number of pregnant women continue to smoke. The objectives of this study were to test the factorial structure, validity and reliability of the Dutch version of the Modified Reasons for Smoking Scale (MRSS) in a sample of smoking pregnant women and to understand reasons for continued smoking during pregnancy.

METHODS

A longitudinal design was performed. Data of 97 pregnant smokers were collected during prenatal consultation. Structural equation modelling was performed to assess the construct validity of the MRSS: an exploratory factor analysis was conducted, followed by a confirmatory factor analysis.Test-retest reliability (<16 weeks and 32-34 weeks pregnancy) and internal consistency were assessed using the intraclass correlation coefficient and the Cronbach's alpha, respectively. To verify concurrent validity, Mann-Whitney U-tests were performed examining associations between the MRSS subscales and nicotine dependence, daily consumption, depressive symptoms and intention to quit.

RESULTS

We found a factorial structure for the MRSS of 11 items within five subscales in order of importance: tension reduction, addiction, pleasure, habit and social function. Results for internal consistency and test-retest reliability were good to acceptable. There were significant associations of nicotine dependence with tension reduction and addiction and of daily consumption with addiction and habit.

CONCLUSIONS

Validity and reliability of the MRSS were shown in a sample of pregnant smokers. Tension reduction was the most important reason for continued smoking, followed by pleasure and addiction. Although the score for nicotine dependence was low, addiction was an important reason for continued smoking during pregnancy; therefore, nicotine replacement therapy could be considered. Half of the respondents experienced depressive symptoms. Hence, it is important to identify those women who need more specialized care, which can include not only smoking cessation counselling but also treatment for depression.

'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support

Background

In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object.

Methods

To assess the impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before–after’ service development evaluation. In the 6-month ‘before’ period, there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In the 6-month ‘after’ period, additional ‘opt-out’ referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.

Results

Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation).

Conclusions

In a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.

The Collection and Analysis of Carbon Monoxide Levels as an Indirect Measure of Smoke Exposure in Pregnant Adolescents at a Multidisciplinary Teen Obstetrics Clinic

STUDY OBJECTIVE

In this study we aimed to collect and analyze CO levels as an indirect measure of smoke exposure in pregnant adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Participants included pregnant adolescents who received antenatal care over 18 months (2012-2013) at the Multidisciplinary Teen Obstetrics Clinic at a tertiary-care hospital in Southeastern Ontario.

INTERVENTIONS

The CO breath test is a noninvasive method that is used to assess smoke exposure, in which nonsmokers have levels of 0-6 ppm, and levels of 7-10, 11-20 and more than 20 ppm are consistent with light, typical, and heavy smokers, respectively. Expired CO, smoking status, cigarette number, and home secondhand smoke exposure were documented at 3 clinic visits.

MAIN OUTCOME MEASURES

To determine mean CO levels as a measure of smoke exposure and prevalence of secondhand smoke exposure.

RESULTS

The mean age of participants was 17.6 years. CO means (ppm) across 3 visits were 6.0, 5.9, and 4.8. Sixty-two percent of patients were self-reported nonsmokers, 38% were self-reported smokers (n = 93). CO means (standard error of the mean) were consistently different for nonsmokers vs smokers at visits 1 to 3, respectively: 2.9 (0.79) vs 9.7 (1.8); 3.0 (0.71) vs 12.9 (2.2), and 2.4 (0.71) vs 8.8 (1.5; P < .01, t test; n = 91). Of patient's highest CO (COmax), 62%, 9%, 15%, and 12% had levels of 6 or less, 7-10, 11-20, and greater than 20, respectively. Eighty-four percent of pregnant adolescents had home secondhand smoke exposure, which included 40% of nonsmokers and 100% of smokers (n = 57). Although most nonsmokers had a COmax of 6 or fewer ppm, 56% of smokers had COmax greater than 10 ppm (P < .05, χ(2)).

CONCLUSION

Emphasis on smoking cessation is imperative in pregnant adolescents and should particularly target partners and families, because secondhand smoke exposure was very prevalent.

Environmental Tobacco Smoke Exposure in Pregnancy is Associated With Earlier Delivery and Reduced Birth Weight

The association between maternal smoking and preterm birth (PTB) has been known for more than 50 years but the effect of passive smoking is controversial. This retrospective cohort study in Bristol, United Kingdom, examines the effect of environmental tobacco smoke exposure (ETSE) on gestational age at delivery, birth weight, PTB, and being small-for-gestational age (SGA). Environmental tobacco smoke exposure was defined by either self-report or exhaled carbon monoxide (eCO) levels, and exposed women were compared with unexposed controls. Two models were used: The first included all women with adjustment for maternal smoking, and the second considered nonsmokers alone. Both models were further adjusted for maternal age, body mass index, parity, ethnicity, employment status, socioeconomic position, asthma, preeclampsia, and offspring sex. Logistic regression and likelihood ratio tests were used to test for any association between exposure and the binary outcomes (PTB and SGA), while linear regression and F tests were used to test for associations between exposure and the continuous outcomes. There were 13 359 deliveries in 2012 to 2014, with complete data for 5066 and 4793 women in the self-reported and eCO-measured exposure groups, respectively. Self-reported exposure was associated with earlier delivery (-0.19 weeks; 95% confidence interval [CI]: -0.32 to -0.05) and reduced birth weight (-56 g, 95% CI: -97 to -16 g) but no increase in the risk of PTB or SGA. There was no evidence for an association between eCO-measured exposure and any of the outcome measures. This information is important when advising women and their families and adds further support to continued public health efforts to reduce exposure to tobacco smoke.

Optimal Carbon Monoxide Criteria to Confirm Smoking Status Among Postpartum Women

INTRODUCTION

Although expired-air carbon monoxide (CO) is a well characterized biomarker of cigarette smoking, limited research has assessed whether the standard clinical CO cutoffs need to be altered for postpartum women and whether these cutoffs remain constant across the postpartum year. Accordingly, the present study evaluated the effectiveness of using CO as a method to confirm smoking status relative to salivary cotinine among postpartum women and assessed optimal CO criteria to confirm smoking status across the postpartum year. Differences in optimal CO criteria to confirm smoking status also were examined between black and white postpartum women.

METHODS

Women (N = 208) for the present study had quit smoking for their current pregnancy and were enrolled in a larger postpartum relapse prevention intervention. Smoking status was assessed at 12, 24, and 52 weeks postpartum using both expired-air CO and salivary cotinine.

RESULTS

Receiver-operating characteristic analyses indicated that CO provided moderately high diagnostic accuracy to distinguish between women who were and were not smoking when using salivary cotinine as the reference criterion to confirm smoking status. CO cutoffs of 2 and 3 parts per million (ppm) had the highest overall efficiency and combined sensitivity and specificity across the postpartum year. Results were consistent for black and white women.

CONCLUSIONS

These findings indicate that optimal CO criteria to confirm smoking status remains stable throughout the postpartum year and support a need to utilize CO cutoffs much lower than the standard clinical CO criterion of 8 ppm to confirm abstinence among postpartum women.

IMPLICATIONS

Findings from the present study confirm the value of CO as a biomarker of smoking status among postpartum women. Results indicate that CO cutoffs of 2 and 3 ppm were optimal for confirming smoking status across the entire postpartum year in both black and white women. These findings offer a replication and extension of previous work and indicate that optimal CO criteria to confirm smoking status remain stable throughout the postpartum period and further support a need to utilize CO cutoffs much lower than the standard clinical criterion of 8 ppm to confirm smoking status among postpartum women.

Provision of smoking cessation support for pregnant women in England: results from an online survey of NHS Stop Smoking Services for Pregnant Women

BACKGROUND

Smoking during pregnancy is a major public health concern and an NHS priority. In 2010, 26% of UK women smoked immediately before or during their pregnancy and 12% smoked continuously. Smoking cessation support is provided through free at the point of use Stop Smoking Services for Pregnant women (SSSP). However, to date, little is known of how these services provide support across England. The aim of this study was to describe the key elements of support provided through English SSSP.

METHODS

SSSP managers were invited to participate in this survey by email. Data were then collected via an online questionnaire; one survey was completed for each SSSP. Up to four reminder emails were sent over a two month period.

RESULTS

86% (121 of 141) of services completed the survey. Responding services were, on average, larger than non-responding services in terms of the number of pregnant women setting quit dates and successfully quitting (p < 0.01). In line with the 2010 NICE guidelines, Stop Smoking in Pregnancy and following Childbirth, one in five SSSP identified pregnant smokers using carbon monoxide (CO) testing and refer via an opt-out pathway. All services offered nicotine replacement therapy (NRT) to pregnant women and 87% of services also offered dual therapy NRT, i.e. combination of a patch and short acting NRT product.. The 2010 NICE guidelines note that services should be flexible and client-centred. Consistent with this, SSSP offer pregnant women a range of support types (median 4) including couple/family, group (open or closed) or one-to-one. These are available in a number of locations (median 5), including in community venues, clinics and women's homes.

CONCLUSIONS

English Stop Smoking Services offer behavioural support and pharmacotherapy to pregnant women motivated to quit smoking. Interventions provided are generally evidence-based and delivered in a variety of both social and health care settings.

Give It Up For Baby: outcomes and factors influencing uptake of a pilot smoking cessation incentive scheme for pregnant women

Background

The use of incentives to promote smoking cessation is a promising technique for increasing the effectiveness of interventions. This study evaluated the smoking cessation outcomes and factors associated with success for pregnant smokers who registered with a pilot incentivised smoking cessation scheme in a Scottish health board area (NHS Tayside).

Methods

All pregnant smokers who engaged with the scheme between March 2007 and December 2009 were included in the outcome evaluation which used routinely collected data. Data utilised included: the Scottish National Smoking Cessation Dataset; weekly and periodic carbon monoxide (CO) breath tests; status of smoking cessation quit attempts; and amount of incentive paid. Process evaluation incorporated in-depth interviews with a cross-sectional sample of service users, stratified according to level of engagement.

Results

Quit rates for those registering with Give It Up For Baby were 54% at 4 weeks, 32% at 12 weeks and 17% at 3 months post partum (all data validated by CO breath test). Among the population of women identified as smoking at first booking over a one year period, 20.1% engaged with Give It Up For Baby, with 7.8% of pregnant smokers quit at 4 weeks. Pregnant smokers from more affluent areas were more successful with their quit attempt. The process evaluation indicates financial incentives can encourage attendance at routine advisory sessions where they are seen to form part of a wider reward structure, but work less well with those on lowest incomes who demonstrate high reliance on the financial reward.

Conclusions

Uptake of Give It Up For Baby by the target population was higher than for all other health board areas offering specialist or equivalent cessation services in Scotland. Quit successes also compared favorably with other specialist interventions, adding to evidence of the benefits of incentives in this setting. The process evaluation helped to explain variations in retention and quit rates achieved by the scheme.

This study describes a series of positive outcomes achieved through the use of incentives to promote smoking cessation amongst pregnant smokers.

Implementation of routine biochemical validation and an 'opt out' referral pathway for smoking cessation in pregnancy

AIMS

To introduce an 'opt out' referral pathway for smoking cessation in pregnancy and to compare different methods for identifying pregnant smokers in maternity care.

DESIGN

Pilot study that analysed routine data from maternity and smoking cessation services with biochemical validation of smoking status.

SETTING

Dudley and South Birmingham, England.

PARTICIPANTS

A total of 3712 women who entered the referral pathway-1498 in Dudley and 2214 in South Birmingham.

MEASUREMENTS

Routine monitoring data on smoking at maternity booking, referral to smoking cessation services, number of women who set quit dates set and short-term (4-week) self-report smoking status. Comparison of self-report, carbon monoxide (CO)-validated and urinary cotinine-validated smoking status for a subsample (n = 1492) of women at maternity booking.

FINDINGS

In Dudley 27% of women who entered the opt out referral pathway were identified as smokers following CO testing. Of those referred to the smoking cessation services, 19% reported stopping smoking at 4-week follow-up. In South Birmingham 17% were smokers at booking, with 5% of those referred recorded as non-smokers at 4 weeks. The number of women quitting did not increase during the study when compared with the previous year, despite higher referral rates in both areas. An optimum cut-off CO measurement of 4 parts per million (p.p.m.) was identified for sensitivity and specificity.

CONCLUSION

The introduction of an opt out referral pathway between maternity and stop smoking services resulted in more women being referred for support to quit but not higher numbers of quitters, suggesting that automatic referral may include women who are not motivated to stop and who may not engage with services. Routine carbon monoxide monitoring introduced as part of a referral pathway should involve a cut-off of 4 p.p.m. to identify smoking in pregnancy.

[The correlation between smoking, environmental tobacco smoke and preterm birth]

The rate of preterm births is very high in Hungary; it was 8.9% of the total livebirths in 2010. Preterm birth (<37 weeks) has a considerable health impact, because it is responsible for 85% of infant mortality and morbidity as well as for numerous chronic diseses in the long-term. Many maternal and fetal diseases can be identified in the background, but in a number of cases, preterm labor begins unexpectedly, without any prodrome. Presumably, the socioeconomic background and the presence of harmful lifestyle factors are related to preterm birth in these cases. Tobacco smoking is the most frequent harmful health behavior. At national level, the rate of smoking during pregnancy was 14.4% in the last 13 years, but in some counties, this proportion mounted to 25%. In these counties, the prevalence of preterm births also exceeds the national average. This summary highlights the factors related to disadvantaged socio-economic status that can be responsible for the higher number of preterm birth cases.

Smoking cessation during pregnancy: the influence of partners, family and friends on quitters and non-quitters

This research compared pregnant quitters' and non-quitters' accounts of how partners, family and friends influenced their smoking cessation attempts. Qualitative secondary data analysis was carried out on a purposive sample of motivational interview transcripts undertaken by research midwives with pregnant women as part of SmokeChange, a smoking cessation intervention. Interviews with all quitters in the intervention group (n = 12) were analysed comparatively with interviews from a matched sample of non-quitters (n = 12).The discourses of both revealed similarity in how their partners, family and friends influenced their cessation efforts: salient others were simultaneously perceived by both groups of women as providing drivers and barriers to quit attempts; close associates who smoked were often perceived to be as supportive as those who did not. However, women who quit smoking during pregnancy talked more about receiving active praise/encouragement than those who did not. While close associates play an important role in women's attempts to stop smoking during pregnancy, the support they provide varies; further research is needed to develop a better understanding of how key relationships help or hinder cessation during pregnancy.

Using breath carbon monoxide to validate self-reported tobacco smoking in remote Australian Indigenous communities

Background

This paper examines the specificity and sensitivity of a breath carbon monoxide (BCO) test and optimum BCO cutoff level for validating self-reported tobacco smoking in Indigenous Australians in Arnhem Land, Northern Territory (NT).

Methods

In a sample of 400 people (≥16 years) interviewed about tobacco use in three communities, both self-reported smoking and BCO data were recorded for 309 study participants. Of these, 249 reported smoking tobacco within the preceding 24 hours, and 60 reported they had never smoked or had not smoked tobacco for ≥6 months. The sample was opportunistically recruited using quotas to reflect age and gender balances in the communities where the combined Indigenous populations comprised 1,104 males and 1,215 females (≥16 years). Local Indigenous research workers assisted researchers in interviewing participants and facilitating BCO tests using a portable hand-held analyzer.

Results

A BCO cutoff of ≥7 parts per million (ppm) provided good agreement between self-report and BCO (96.0% sensitivity, 93.3% specificity). An alternative cutoff of ≥5 ppm increased sensitivity from 96.0% to 99.6% with no change in specificity (93.3%). With data for two self-reported nonsmokers who also reported that they smoked cannabis removed from the analysis, specificity increased to 96.6%.

Conclusion

In these disadvantaged Indigenous populations, where data describing smoking are few, testing for BCO provides a practical, noninvasive, and immediate method to validate self-reported smoking. In further studies of tobacco smoking in these populations, cannabis use should be considered where self-reported nonsmokers show high BCO.

'Breathe': the stop smoking service for pregnant women in Glasgow

OBJECTIVE

to develop a pragmatic service for pregnant smokers.

DESIGN

identification and referral of pregnant smokers to specialist services using self-report gathered on routine pregnancy booking questionnaire augmented by a carbon monoxide breath test. Engagement by specialist smoking cessation midwives using telephone contact with the offer of clinic-based counselling for women who want help. Telephone support and pharmacy provision of nicotine replacement therapy for women who decide to quit.

SETTING

three maternity units serving Glasgow in the West of Scotland.

PARTICIPANTS

a relatively deprived population of 12,000 pregnant women each year in Glasgow.

INTERVENTIONS

at maternity booking, women with either a carbon monoxide breath test result >7 parts per million or self-reporting to be a current smoker during the routine pregnancy booking questionnaire were identified as smokers. All smokers were referred on to the specially trained midwives who provided an opt-out smoking cessation intervention. This involved motivational interviewing to engage pregnant smokers during telephone contact. Women considering quitting were invited for a follow-up face-to-face meeting in a clinic setting. Women who set a quit date were offered withdrawal oriented therapy augmented by pharmacy-based nicotine replacement therapy.

FINDINGS

booking midwives found it difficult to approach all pregnant women to talk about smoking. This was not made easier by the service requirement that all pregnant women should provide a carbon monoxide breath test at maternity booking. In one hospital, auxiliary nurses performed the carbon monoxide breath test and 2879 of 3219 (89%) women booking for antenatal care provided a sample, allowing most smokers to be identified. In another hospital where the carbon monoxide test was administered by midwives, only 1968 of 5570 (35%) women provided a carbon monoxide breath test sample; 61% of pregnant smokers were not identified and referred to specialist services. Of the 1936 pregnant smokers referred from all three hospitals, 386 (20%) attended a face-to-face appointment with specialist smoking cessation midwives, 370 (19%) set a quit date and 117 (6%) had quit 4 weeks after their quit date.

IMPLICATIONS FOR PRACTICE

this service development provides a pragmatic approach to identify nearly all pregnant smokers at maternity booking, and an opt-out model to refer them to specialist smoking cessation services. Further research is required to establish if extra auxiliary staff in maternity booking clinics can optimise the identification and referral of pregnant smokers to specialist smoking cessation services. This telephone- and clinic-based specialist service engaged 20% of referred pregnant smokers to attend a face-to-face appointment with a specialist smoking cessation midwife. Further research is required to assess if home-based support would engage a greater proportion of pregnant smokers, or if an incentive scheme would achieve the same aim. In total, 117 of 370 (32%) women who set a quit date had quit smoking 4 weeks later, which compares fairly well with a figure of 40% for pregnant smokers in the English smoking treatment services.

Fetal growth restriction triggered by polycyclic aromatic hydrocarbons is associated with altered placental vasculature and AhR-dependent changes in cell death

Maternal cigarette smoking is considered an important risk factor associated with fetal intrauterine growth restriction (IUGR). Polycyclic aromatic hydrocarbons (PAHs) are well-known constituents of cigarette smoke, and the effects of acute exposure to these chemicals at different gestational stages have been well established in a variety of laboratory animals. In addition, many PAHs are known ligands of the aryl hydrocarbon receptor (AhR), a cellular xenobiotic sensor responsible for activating the metabolic machinery. In this study, we have applied a chronic, low-dose regimen of PAH exposure to C57Bl/6 female mice before conception. This treatment caused IUGR in day 15.5 post coitum (d15.5) fetuses and yielded abnormalities in the placental vasculature, resulting in significantly reduced arterial surface area and volume of the fetal arterial vasculature of the placenta. However, examination of the small vasculature within the placental labyrinth of PAH-exposed dams revealed extensive branching and enlargement of these vessels, indicating a possible compensatory mechanism. These alterations in vascularization were accompanied by reduced placental cell death rates, increased expression levels of antiapoptotic Xiap, and decreased expression of proapoptotic Bax, cleaved poly(ADP-ribose) polymerase-1, and active caspase-3. AhR-deficient fetuses were rescued from PAH-induced growth restriction and exhibited no changes in the labyrinthine cell death rate. The results of this investigation suggest that chronic exposure to PAHs is a contributing factor to the development of IUGR in human smokers and that the AhR pathway is involved.