Smoking cessation in pregnancy: psychosocial interventions and patient-focused perspectives

Figures & data

Table 1 Prevalence of smoking during pregnancy

Authors	Publication year	Country	Prevalence of smoking during pregnancy	Sample size	Survey year
Murphy et al^Citation12	2013	Ireland	12.1%	907	2010–2011
Miyazaki et al^Citation9	2013	Japan (female nurses)	7.8%	49,927	2001–2007
Tong et al^Citation4	2013	US	15.2%	10,485	2003
Krstev et al^Citation13	2012	Serbia	37.2%	2,668	2008
Ystrom et al^Citation14	2012	Norway	8.9%	835	2008
Maxson et al^Citation15	2012	US	17.6%	1,518	2004–2008
Li et al^Citation16	2012	Australia	13.5%	294,814	2010
Hayashi et al^Citation17	2011	Japan	5.8%	180,855	2001–2005
Al-Sahab et al^Citation18	2010	Canada	10.5%	6,421	2005–2006
Kabir et al^Citation19	2009	Ireland	20.6%	7,648	2005
		Ireland	23.4%	7,593	2003
Pickett et al^Citation20	2009	UK	23.0%	18,225	2000–2001
Bachir and Chaaya^Citation21	2008	Lebanon	25.7%	538	1997–1998
Bloch et al^Citation22	2008	Argentina	10.3%	796	2004–2005
		Uruguay	18.3%	716
		Brazil	6.1%	749
		Ecuador	0.8%	746
		Guatemala	0.8%	752
Ostrea et al^Citation23	2008	Philippines	1.3%	316	–
		Thailand	0.9%	106	–
		Singapore	11.5%	61	–
Schneider et al^Citation24	2008	Germany	13.0%	647,392	2005

Table 2 Clinical trials focused on psychosocial intervention conducted among pregnant women in 2004–2014

Authors	Publication year	Country	Intervention programs	Effect on smoking status	Additional findings
Herbec et al^Citation33	2014	UK	Intervention (n=99): internet-based smoking cessation intervention for pregnant smokers (MumsQuit), an interactive, personalized, structured quit plan; control (n=101): non- personalized website that provided brief standard advice	Continuous 4-week abstinence assessed at 8 weeks post-baseline – 28.3% in MumsQuit, 20.8% in control, OR (MumsQuit/control) =1.5, CI =0.8–2.9	Women in intervention group logged in more often, viewed more pages, and spent more time browsing the website. MumsQuit is a helpful form for pregnant women who seek cessation support online
Pollak et al^Citation34	2013	US	Intervention (n=15): SMS via cell phone, SGR; control (n=16): SMS	Seven-day point prevalence abstinence at end of pregnancy – intervention: 13.4%, control: 7.5%	The pilot study suggested that the support messages were effective. The SGR arm was more effective than message only
Wilkinson et al^Citation35	2012	Australia	Intervention (n=87): attend a 1-hour “Healthy Start to Pregnancy” workshop; control (n=181): usual care	Percentage of women smoking before (pre) and during pregnancy – intervention: 18.0% (pre), 16.3%; control: 18.1% (pre), 17.0%	Women who attended the workshop increased their consumption of fruit and vegetables, met fruit guidelines, had a higher diet quality score, and clinically relevant increases in physical activity. There was not a significant difference for smoking between groups
Eades et al^Citation36	2012	Australia	Intervention: tailored advice and support to quit smoking using evidence-based communication skills, engaging the woman’s partner and other adults in supporting the quit attempts; control: advice to quit smoking and further support and advice by general practitioners at scheduled antenatal visits	Smoking rate at 36 weeks – intervention: 89%, control: 95%, risk ratio (intervention/control) =0.93, CI =0.86–1.08	There was no significant intervention effect
Naughton et al^Citation37	2012	UK	Intervention (n=102): tailored self-help smoking cessation intervention (MiQuit), text message via personal mobile phone; control (n=105): nontailored self-help leaflet	Self-reported 7-day point prevalence at 3-month follow-up – intervention: 22.9%, control: 19.6%, OR (intervention/control) =1.22, CI =0.62–2.41	Delivering tailored smoking cessation support via leaflet and text message is feasible and acceptable. MiQuit had positive effects on self- efficacy, harm beliefs, determination to quit, and setting a quit date
Ondersma et al^Citation38	2012	US	A computer delivered 5 A’s-based brief intervention (CD-5As) and a computer- assisted, simplified, and low-intensity contingency management (CM-Lite): a sample was assigned to four groups: CD-5As (n=26), CM-Lite (n=28), CD-5As + CM-Lite (n=30), treatment as usual (n=26)	Percent of abstinence as measured by cotinine – CD-5As: 43.5% (OR =10.1, CI =1.4–75.0), CM-Lite: 13.6% (OR =0.6, CI =0.1–4.2), CD-5As + CM-Lite: 15.4% (OR =0.7, CI =0.1–4.0), treatment as usual (control): 17.4%	CD-5As was successful in smoking cessation. CM-Lite did not affect smoking
El-Mohandes et al^Citation39	2011	US	Intervention (n=262): cognitive behavioral therapy with ten sessions; control (n=238): usual care	There was no significant interventional effect on smoking behavior during pregnancy	The intervention had a significant protective effect against smoking in the postpartum period
Windsor et al^Citation40	2011	US	Intervention (n=544): brief routine advice to quit, video, a pregnant woman’s guide to quit smoking, counseling; control (n=549): brief routine advice to quit, comparison (n=96): pre-trial group	Cessation rate – intervention: 12.0%, control: 10.0%, comparison: 4.2% (ns)	Significant reduction* rate was higher in the experimental group than in the control group
Manfredi et al^Citation41	2011	US	Twelve clinics were randomized to three dissemination strategies: Group 1: core dissemination; Group 2: core dissemination + telephone counseling access; Group 3: core dissemination + telephone counseling access + outreach visits	Implementation outcomes were post- dissemination improvements over baseline in the percent of smokers reporting to receipt/exposure provider advice, self-help booklet, videos, posters, and an adjunct intervention	Compared with baseline, more smokers in the post-dissemination received a self-help booklet and complete an adjunct intervention
Washio et al^Citation42	2011	US	Intervention (n=80): vouchers exchangeable for retail items contingent on biochemically verified abstinence; control (n=74): vouchers independent of smoking status	Seven-day point prevalence smoking abstinence at end of pregnancy – intervention: 36%, control: 8%, OR (intervention/control) =7.3, CI =2.7–19.5	Smoking abstinence at the end of pregnancy was significantly greater in the incentive group than the control group. Maternal weight gain did not differ significantly between treatment conditions
Tsoh et al^Citation43	2010	US	Intervention (n=23): 15-minute Video Doctor sessions and provider cueing; control (n=19): usual care	The 30-day abstinence rate at 2 months post-baseline – intervention: 26.1%, control: 10.5% (P=0.201)	The intervention is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction
Cinciripini et al^Citation44	2010	US	CBASP group (n=128): smoking cessation counseling and depression-focused intervention; HW group (n=129): smoking cessation counseling and HW program	Percent of continuous abstinence (no smoking on any day) at 3 months after end of treatment – CBASP: 23.4%, HW: 21.0%, OR (CBASP/HW) =1.2, CI =0.6–2.1	Pregnant women with high level of depressive symptoms may benefit from a depression- focused treatment
Hennrikus et al^Citation45	2010	US	For all subjects, the single counseling session and information were provided. Intervention (n=54): supporters received monthly contacts from a counselor; control (n=28): supporters were not contacted	Percent of quits at end of pregnancy – intervention: 13.0%, control: 3.6% (ns)	Intervention group subjects reported that their supporters had provided support behaviors more frequently and were more committed to helping them to quit
Patten et al^Citation46	2010	US	Intervention (n=17): counseling, telephone calls, video, and cessation guide; control (n=18): counseling and written materials	The participation rate was 12% of eligible women. The study retention rates were 71% in intervention and 94% in control groups	The program was not feasible or acceptable among Alaska Native pregnant women. Alternative approaches are needed
Ruger et al^Citation47	2009	US	Intervention (n=156): delivered MI, whose components were tailored to each client’s stage; control (n=146): standard prenatal care at the clinic site (UC)	Main outcome is cost-effectiveness	The total cost of MI was $311.8 per participant, and the total cost of UC was $4.82 per participant
Stotts et al^Citation48	2009	US	A sample was assigned to three groups: BP based on the 5 A (n=120); BP and US feedback (BP + US) (n=120); MI-based counseling and US feedback (MI + US) (n=120)	Percent abstinent at end of pregnancy (ns) – BP: 10.8%, BP + US: 14.2%, MI + US: 18.3%	Intervention effects were found conditional upon level of baseline smoking. Light smokers quit at significantly higher rates particularly in the MI + US group. Heavy smokers were unaffected by the intervention
Bullock et al^Citation49	2009	US	Baby BEEP groups received weekly calls and beeper access to the nurse (social support). A sample was assigned to four groups: social support + booklets (n=170), social support (n=175), booklets (n=179), control (n=171)	Percent abstinent in late pregnancy (ns) – social support + booklets: 17.0%, social support: 22.0%, booklets: 19.2%, control: 17.2%	The percentage of early and middle quitters (by 32 weeks of gestation) were 19.2% in social support + booklets group, 21.3% in social support group, 20.2% in booklets group, and 15.7% in control group
Katz et al^Citation50	2008	US	Cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence were the four risks targeted. Individualized counseling provided an integrated and tailored approach to the multiple risks reported by each woman	Forty-eight percent of women had smoking risk. Sixty-one percent of women reported a single risk, and 39% had multiple risks. Most intervention women had a positive view of their relationship with the counselor, and found the session content helpful	Multiple risk behavioral interventions can be implemented in a prenatal care setting
Ruger et al^Citation51	2008	US	Intervention (n=156): delivered MI, whose components were tailored to each client’s stage of readiness; control (n=146): standard prenatal care at the clinic site (UC)	Main outcome is cost-effectiveness	For smoking cessation, MI costs more but provided no additional benefit compared to UC. For prevention relapse, MI is relatively cost-effective
Parker et al^Citation52	2007	US	A smoker’s guide, monetary incentive lottery program, a motivational telephone counseling intervention (MI); no MI calls (n=52), one call (n=92), two calls (n=49), three calls (n=165)	Quit rate by number of calls received – no calls: 9.6%, one call: 13.0%, two calls: 16.3%, three calls: 23.0%, OR (three calls received/others) =1.84, CI =1.04–3.27	Telephone counseling is acceptable to low- income pregnant smokers. Feasibility and cost-effectiveness were suggested. This report focuses on the women randomly assigned to one intervention group
Park et al^Citation53	2007	US	Four hundred and forty-two pregnant smokers were recruited from two sources; the health plan and CBP. Intervention: telephone-delivered smoking counseling based on the motivational stage; control: modified best practice intervention	Smoking cessation at end of pregnancy in intervention group – the health plan: 16%, CBP: 18%	Smoking cessation outcomes did not differ by two disparate recruitment sources
Dornelas et al^Citation54	2006	US	Intervention (n=53): counseling intervention delivered by mental health counselors, with planned telephone calls; control (n=52): usual care by health care provider	Abstinence rates at end of pregnancy – intervention: 28.3%, control: 9.6% (P=0.015)	This model for intervention was cost-effective and was associated with significantly lower smoking rates at end of pregnancy
Rigotti et al^Citation55	2006	US	Intervention (n=220): telephone-delivered smoking counseling based on the motivational stage; control (n=222): brief smoking counseling	Seven-day tobacco abstinence rate at end of pregnancy – intervention: 10.0%, control: 7.5%, OR =1.37, CI =0.69–2.70	The intervention increased end-of-pregnancy tobacco abstinence among light smokers (intervention 19.1% vs control 8.4%, OR =2.58, CI =1.1–6.1), and among women who attempted to quit in pregnancy before enrollment
Higgins et al^Citation56	2006	US	Intervention (n=66): voucher-based incentives delivered contingent on biochemically verified abstinence; control (n=63): incentives independent of smoking status	Percent of smoking at end of pregnancy – 79% in intervention, 92% in control among women smoked in the initial 2 weeks	Smoking in the initial 2 weeks predicted smoking at the end of pregnancy assessment independent of treatment condition
Aveyard et al^Citation57	2006	UK	Intervention programs are based on the TTM. Arm A: controls. Standard smoking cessation advice (n=289); Arm B: self-help manuals based on TTM (n=305); Arm C: self- help manuals plus computer program based on TTM (n=324)	Point prevalence of quitting at 30 weeks of gestation among women in preparation stage – intervention (B and C): 22.4%, control: 9.1%, OR (B and C/A) =2.88 (P=0.09)	Women in the TTM-based intervention were more likely to make positive movements in stage. The effect of intervention was not great on women in precontemplation and contemplation stages (prevalence of quit was 6.4% in control, 4.7% in intervention, not significant)
Campbell et al^Citation58	2006	Australia	Group-randomized trial: SD: an SD condition which received a mail-out of program resources; ID: an ID which included SD condition plus feedback, training, ongoing support with midwife facilitator	The cessation proportion in the post- dissemination – SD: 6.4%, ID: 10.5%	There were no significant differences between the groups on change
Ayadi et al^Citation59	2006	US	5 A’s smoking cessation counseling intervention across three disparate settings: 1) a clinical trial, 2) a national pregnant smokers telephone quit line, 3) a rural managed care organization	Main outcome is cost-effectiveness	The costs of the 5 A’s vary depending on the intensity and nature of the intervention, but in this study, the analysis shows a narrow range across the three disparate settings
de Vries et al^Citation60	2006	the Netherlands	Intervention (n=141): counseling, a video, self-help guide, booklet; control (n=177): routine care	Percent of 7-day abstinence 6 weeks after intervention – intervention: 19%, control: 7%	Multilevel analysis revealed significant differences between both conditions. The intervention resulted in significant effects on smoking behavior for pregnant women but not for partner smoking
Ma et al^Citation61	2005	US	Intervention: SI based on national clinical practice guidelines tailored to the woman’s stage of change; control: usual care	Abstinence at delivery (SI/usual care): OR =3.36, CI =1.17–9.62	Women in the SI condition were more likely to quit during pregnancy. Factors associated at baseline were later week of pregnancy at baseline, quitting spontaneously, while women who lived with a smoker were less likely to quit
Tappin et al^Citation62	2005	UK	Intervention (n=351): MI at home by midwives; control (n=411): standard health promotion information	Percent of quitting of women – intervention: 4.8%, control: 4.6%, relative risk (intervention/control) =1.05, CI =0.55–1.98	Intervention did not significantly increase smoking cessation. Birth weight did not differ significantly
Aveyard et al^Citation63	2005	UK	Intervention programs are based on the TTM. Arm A: controls. Standard smoking cessation advice; Arm B: self-help manuals based on TTM; Arm C: self-help manuals plus computer program based on TTM	Main outcome is perceived stress of pregnant women	Intensive advice to stop smoking was not associated with increases in stress

Notes:

* A baseline saliva cotinine had to be ≥50 ng/mL and follow-up to be ≤50% lower than the baseline.

Abbreviations: OR, odds ratio; CI, 95% confidence interval; SMS, short message service; SGR, scheduled gradual reduction; ns, not significant; CBASP, cognitive behavioral analysis system of psychotherapy; HW, health and wellness; MI, motivational interviewing; BP, best practices counseling; US, ultrasound; CBP, community-based practices; TTM, transtheoretical model; SD, simple dissemination; ID, incentive dissemination; SI, special intervention; BEEP, a pocket pager.

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