Patricia Dolan-Mullen

One-to-one. A motivational intervention for resistant pregnant smokers

The purpose of this prospective, randomized controlled study was to determine the efficacy of an intensified, late pregnancy, smoking cessation intervention for resistant pregnant smokers (n = 269). Participants received 3-5 min of counseling plus a self-help booklet at their first prenatal visit and seven booklets mailed weekly thereafter; at 28 weeks, all had been smoking in the past 28 days. The experimental group received a stage of change-based, personalized feedback letter and two telephone counseling calls using Motivational Interviewing (MI) strategies. The control group received care as usual. The 34th week cotinine data demonstrated no overall difference between groups. However, an implementation analysis suggested that 43% of women who received the full intervention (E2) were classified as not smoking compared to 34% of the control group. At 6 weeks postpartum, 27.1% of the E2 group reported being abstinent or light smokers vs. 14.6% of the controls. No differences were detected at 3 and 6 months postpartum. Results lend preliminary but very modest support for this intervention with resistant pregnant smokers. Improvements in the intervention and implementation issues are discussed.

A meta-analysis of randomized trials of prenatal smoking cessation interventions+

OBJECTIVE Our purpose was to assess the effect of prenatal smoking interventions on rates of smoking cessation and low birth weight. STUDY DESIGN We used a meta-analysis model to compare and summarize smoking cessation and low birth weight outcomes with the risk ratio used as a common metric. We located 11 randomized, controlled trials with objective validation of smoking status; four of these studies also measured rates of low birth weight. RESULTS Risk ratios for smoking cessation ranged from 0.9 to 7.1. The combined risk ratio for the homogeneous group of 10 studies was 1.50 (95% confidence interval 1.22 to 1.86) after the outlier study with a risk ratio of 7.1 was excluded. This was a 50% increase in smoking cessation. Low birth weight risk ratios of 0.6 for two studies that achieved a 50% increase in cessation suggested that the incidence of low birth weight was decreased. CONCLUSION Prenatal smoking cessation interventions increase rates of smoking cessation during pregnancy, and there is evidence that they reduce the incidence of low birth weight.

The process of pregnancy smoking cessation: Implications for interventions

OBJECTIVE There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy. DATA SOURCES Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period. DATA SYNTHESIS An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention. CONCLUSIONS Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.

Recommended cessation counselling for pregnant women who smoke: a review of the evidence

OBJECTIVE To review the evidence base underlying recommended cessation counselling for pregnant women who smoke, as it applies to the steps identified in the Agency for Healthcare Research and Qualitys publication,Treating tobacco use and dependence: a clinical practice guideline. DATA SOURCES Secondary analysis of literature reviews and meta-analyses. DATA SYNTHESIS A brief cessation counselling session of 5–15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials, significantly increases rates of cessation among pregnant smokers. This low intensity intervention achieves a modest but clinically significant effect on cessation rates, with an average risk ratio of 1.7 (95% confidence interval 1.3 to 2.2). There are five components of the recommended method—“ask, advise, assess, assist, and arrange”. CONCLUSIONS We recommend these evidence based procedures be adopted by all prenatal care providers. The use of this evidence based intervention is feasible in most office or clinic settings offering prenatal care and can be implemented without inhibiting other important aspects of prenatal care or disrupting patient flow. If implemented widely, this approach has the potential to achieve an important reduction in a number of adverse maternal, infant, and pregnancy outcomes and to reduce associated, excess health care costs.

Effects of an intensive depression-focused intervention for smoking cessation in pregnancy.

OBJECTIVE The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. METHOD Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies-Depression Scale (Radloff, 1977). RESULTS At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. CONCLUSIONS The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.

The use of pharmacotherapies for smoking cessation during pregnancy

A workshop entitled “The use of pharmacotherapies for smoking cessation during pregnancy”, sponsored by the National Institute of Child Health and Human Development (NICHD) and the Robert Wood Johnson Foundation (RWJF), was held in Rockville, Maryland, on 19 May 1999. The goals of the workshop were: (1) to determine the current state of knowledge related to the use of pharmacotherapies for smoking cessation during pregnancy; and (2) to outline a research agenda to determine the effectiveness and safety of these pharmacotherapies. Attending the workshop were many of the academic experts working in this area in the USA and representatives from NICHD, RWJF, the National Cancer Institute (NCI), the National Institute of Drug Abuse (NIDA), the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), the American College of Obstetrics and Gynecology (ACOG), the Society for Research on Nicotine and Tobacco (SRNT), and several pharmaceutical companies. In the USA, of the four million women who deliver babies each year, approximately 0.8–1 million smoke during their pregnancies. Smoking has a substantial adverse impact on pregnancy outcomes including growth retardation, preterm birth, perinatal mortality, sudden infant death syndrome (SIDS), and childhood behavioural problems. In developed countries, more than a third of all cases of growth retardation is caused by maternal smoking, and the more a woman smokes, the larger the effect on fetal growth. Stopping smoking is one of the major preventive measures likely to have a substantial impact on improving pregnancy outcome. Smoking most likely achieves its negative impact on pregnancy outcome through a number of mechanisms. These include the following: (1) nicotine is a toxin at the cellular level and also may act through its vasoconstrictive properties; (2) carbon monoxide—a major byproduct of cigarette smoking—binds to haemoglobin, resulting in a functional maternal anaemia; (3) carbon monoxide also …

Weight gain associated with prenatal smoking cessation in white, non- Hispanic women

OBJECTIVE Our purpose was to assess the effect of prenatal smoking cessation on maternal weight gain and infant birth weight in women who smoked at least five cigarettes per week. STUDY DESIGN This prospective study followed up a sample of white, non-Hispanic pregnant smokers enrolled in three multispecialty clinics. By use of t tests, women quitting smoking before 28 weeks and continuing smokers were compared on total weight gain, Institute of Medicine weight gain categories, and infant birth weight. RESULTS Quitters gained 36.6 pounds (SD 14.5) and smokers 28.9 pounds (SD 11.7) (p < 0.001). The relative risk of quitters gaining less than the Institute of Medicine minimum was 0.47 (95% confidence interval 0.27 to 0.81). Quitters also gained more than Institute of Medicine standards (relative risk 1.74, 95% confidence interval 1.21 to 2.51), and they were 3.1 times as likely to be delivered of infants weighing > 4000 gm (95% confidence interval 1.18 to 7.97). The four low-birth-weight babies were born to smokers with low weight pain. CONCLUSION In this population smoking cessation is associated with a lower risk of gaining too little by Institute of Medicine standards and also with higher risk of gaining more than the Institute of Medicine standard and having infants weighing > 4000 gm. The clinical significance of these effects needs to be determined in further studies.

Predictors of intentions to stop smoking early in prenatal care

OBJECTIVE To determine baseline variables associated with low intentions of stopping smoking early in pregnancy. DESIGN Cross sectional survey. PARTICIPANTS Pregnant smokers pooled across seven Smoke-Free Families trials (n = 1314). RESULTS 36% of pregnant smokers had low intentions of stopping smoking within the next 30 days. In contrast to pregnant smokers with higher intentions of quitting, pregnant smokers with low intentions were less confident in their ability to quit, less likely to have private health insurance, and less likely to agree that smoking harms the unborn child. They were more likely to smoke heavily, more likely to have fewer years of education, and more likely to have friends and family members who smoke. CONCLUSIONS Three options to smoking cessation assistance are proposed for pregnant smokers with low intentions of quitting: targeting, triage, and tailoring. Further research is needed to determine which approach is most appropriate.

The role of prepartum motivation in the maintenance of postpartum smoking abstinence

OBJECTIVE Motivation plays an important role in a variety of behaviors, including smoking cessation, and is integral to theory and treatment of smoking. For many women, pregnancy offers a motivational shift that helps them stop smoking and maintain abstinence during pregnancy. However, womens motivation to maintain smoking abstinence postpartum is not well-understood and may play a role in high postpartum relapse rates. The current study utilized multiple measures of prepartum motivation to maintain smoking abstinence to predict postpartum smoking abstinence. METHODS As part of a randomized clinical trial on postpartum smoking relapse prevention, pregnant women who quit smoking during pregnancy reported their motivation to continue smoking abstinence at a prepartum baseline session. Biochemically verified continued smoking abstinence was assessed at 8 and 26 weeks postpartum. RESULTS Direct relationships among multiple measures of motivation were significant, and ranged in strength from weak to moderate. All motivation measures individually predicted continuous smoking abstinence, after controlling for treatment group, demographics, and prequit tobacco use. When tested simultaneously, a global motivation measure and parenthood motives for quitting remained significant predictors of abstinence. Backward selection modeling procedures resulted in a reduced model of prepartum predictors of postpartum abstinence including global motivation, parenthood motives, and stage of change. CONCLUSIONS Global motivation for smoking abstinence and parenthood motives for quitting are particularly important motivational constructs for pregnant womens continued smoking abstinence.

Enhanced prenatal case management for low income smokers

Smoking during pregnancy is highly prevalent in populations of white, low socioeconomic status women who are more addicted to nicotine than most other groups within their social class. Qualitative and quantitative assessments conducted by this research team suggested that eVective pregnancy smoking interventions should be oVered in the context of high risk counselling that also addressed sources of stress, depression, negative family support, and the various problems associated with poverty. 1‐3 Because many of these women are in early stages of change for smoking cessation, they need an approach focused on motivation and decision making rather than advice or quitting guides. Motivational interviewing is an approach that addresses the motivational enhancement needs of these women, meets them at their stage of change, and therefore seemed particularly appropriate for these women. 4 This project proposed using the existing prenatal high risk case management delivery system for motivational enhancement based smoking cessation counselling. The case manager’s role is to give support and marshal resources to address emotional and environmental stressors for high risk pregnancies, a role supported by Medicaid in most states. In addition, we believed that the interaction style and counselling skills of case managers in the cooperating clinic network were compatible with the demands of an individualised, comprehensive, motivational approach to pregnancy smoking cessation.