Efficacy and cost-effectiveness of a clinic-based counseling intervention tested in an ethnically diverse sample of pregnant smokers. Health beliefs and health care behaviour in pregnancy. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. Efficacy of telephone counseling for pregnant smokers: a randomized controlled trial. A smoking cessation program at a public antenatal clinic. A randomized controlled trial of smoking cessation intervention in pregnancy in an academic clinic. Telephone support for pregnant women: outcome in late pregnancy. Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down. Impact of health education during pregnancy on behavior and utilization of health resources. Latin American Network for Perinatal and Reproductive Research. Reducing smoking during pregnancy and postpartum: physician's advice supported by individual counseling. Comparison of three antismoking interventions among pregnant women in an urban setting: a randomized trial. Case studies of three pregnant smokers and their use of nicotine replacement therapy. Smoking relapse prevention methods for pregnant women: a formative evaluation. A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: effects on patient outcomes. Smoking relapse prevention counseling during prenatal and early postnatal care. A randomized evaluation of smoking cessation interventions for pregnant women at a WIC clinic. Prevention of relapse in women who quit smoking during pregnancy. A preliminary study of the use of peer support in smoking cessation programs for pregnant adolescents. Modeling smoking cessation: exploring the use of a videotape to help pregnant women quit smoking. Cotinine-assisted intervention in pregnancy to reduce smoking and low birthweight delivery. Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care? Nicotine patches for pregnant smokers: a randomized controlled study. The influence of observing carbon monoxide level on cigarette smoking by public prenatal patients. A pilot study to establish a randomized trial methodology to test the efficacy of a behavioural intervention. A community health center smoking-cessation intervention for pregnant and postpartum women. The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough? An evaluation of videotaped vignettes for smoking cessation and relapse prevention during pregnancy: the very important pregnant smokers (VIPS) program. Training midwives to help pregnant women stop smoking. Relapse prevention among women who stop smoking early in pregnancy: a randomized clinical trial of a self-help intervention. Randomised controlled trial of anti-smoking advice in pregnancy. Individualized smoking cessation counseling during prenatal and early postnatal care. Efficacy and effectiveness of the smoking cessation program for pregnant women. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: significant other supporter (SOS) program. A cluster randomised controlled trial of smoking cessation in pregnant women comparing interventions based on the transtheoretical (stages of change) model to standard care. Is smoking an indication for prenatal ultrasonography? RADIUS Study Group. Quit for keeps: tailored smoking cessation guides for pregnancy and beyond. A randomized controlled trial of a smoking cessation intervention during pregnancy. A trial of health education aimed to reduce cigarette smoking among pregnant women. A clinical trial of change in maternal smoking and its effect on birth weight. One-to-one: a motivational intervention for resistant pregnant smokers. Integrating smoking cessation into routine public prenatal care: the Smoking Cessation in Pregnancy project. The effects of smoking cessation counseling by midwives on Dutch pregnant women and their partners. Nicotine replacement and behavioral therapy for smoking cessation in pregnancy. Randomized controlled trial of a midwife-delivered brief smoking cessation intervention in pregnancy. Evaluation of a motivational smoking cessation intervention for women in public health clinics. Feedback from a point-of-care test for nicotine intake to reduce smoking during pregnancy. Multimodal intervention raises smoking cessation rate during pregnancy. Evaluation of antenatal smoking cessation programs for pregnant women. Stages of change in smoking during pregnancy in low-income women. Proactive telephone peer support to help pregnant women stop smoking. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Evaluation of a smoking cessation intervention for pregnant women in an urban prenatal clinic. A randomised controlled trial of individual counselling of smokers in pregnancy. The effectiveness of smoking cessation methods for smokers in public health maternity clinics: a randomized trial. A randomized trial of a serialized self-help smoking cessation program for pregnant women in an HMO. The effects of peer counseling on smoking cessation and reduction. Effect of anti-smoking health education on infant size at birth: a randomized controlled trial. Health education for pregnant smokers: its behavioral impact and cost benefit. A pilot study on voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Self help smoking cessation in pregnancy: cluster randomised controlled trial. Smoking cessation in pregnancy. Mode of intervention and effect. Smoking cessation in pregnancy: the effect of hypnosis in a randomized study. Smoking cessation in pregnancy. Intervention among heavy smokers. Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care.
Rates of cigarette smoking are higher among women who receive obstetric care through publicly funded prenatal clinics. This study compared smoking outcomes for pregnant women (n=105) who were randomized to receive either usual care (standard cessation advice from the health care provider) or an intervention conducted in the prenatal clinic consisting of 1.5 h of counseling plus telephone follow-up delivered by a masters prepared mental health counselor.
                Subjects were 105 low income, predominantly Hispanic, pregnant patients in an urban prenatal clinic. Smoking outcomes were assessed at end of pregnancy and 6 months post-partum.
                At follow-up, 28.3% and 9.4% of participants in the experimental intervention and 9.6% and 3.8% of patients in usual care were abstinent at end of pregnancy (p=.015) and 6 months post-partum, respectively (p=.251). Cost of the intervention was $56 per patient and cost to produce a non-smoker at end of pregnancy was $299.
                This model for intervention was cost-effective and was associated with significantly lower smoking rates at end of pregnancy.
                If these findings are replicated, prenatal clinics could offer the option for intensive smoking cessation treatment by training mental health counselors to deliver one extended smoking cessation counseling session. Primiparae were randomly assigned to two conditions of routine ultrasound examination at their first antenatal clinic visit: (a) high feedback ultrasound where the monitor screen was visible and the patient was shown the foetal size, shape and movement (N = 67); (b) low feedback ultrasound where the screen was not seen and specific verbal feedback was denied (N = 62). Women were interviewed at 16 weeks gestation. Those receiving high feedback were more likely to report that they had acted on health advice given at the first antenatal visit to reduce their smoking and drinking. We evaluated a comprehensive program of prenatal and postpartum nurse home visitation. The program was designed to prevent a wide range of health and developmental problems in children born to primiparous women who were either teenagers, unmarried, or of low socioeconomic status. During pregnancy, women who were visited by nurses, compared with women randomly assigned to comparison groups, became aware of more community services; attended childbirth classes more frequently; made more extensive use of the nutritional supplementation program for women, infants, and children; made greater dietary improvements; reported that their babies' fathers became more interested in their pregnancies; were accompanied to the hospital by a support person during labor more frequently; reported talking more frequently to family members, friends, and service providers about their pregnancies and personal problems; and had fewer kidney infections. Positive effects of the program on birth weight and length of gestation were present for the offspring of young adolescents (less than 17 years of age) and smokers. In contrast to their comparison-group counterparts, young adolescents who were visited by nurses gave birth to newborns who were an average of 395 g heavier, and women who smoked and were visited by nurses exhibited a 75% reduction in the incidence of preterm delivery. (P less than or equal to .05 for all findings.) Reducing tobacco use in pregnancy is a public health priority. Brief smoking counseling during prenatal care is effective but generates modest cessation rates. Telephone counseling is an effective smoking cessation method that could offer pregnant women convenient access to more intensive smoking cessation counseling.
                The efficacy of proactive pregnancy-tailored telephone counseling for smoking cessation was compared with a "best-practice" brief-counseling control in a randomized controlled trial of 442 pregnant smokers referred by prenatal providers and a managed care plan. Trained counselors using cognitive-behavioral and motivational interviewing methods called intervention subjects throughout pregnancy and for 2 months postpartum (mean = 5 calls, mean total contact = 68 minutes). Controls received one 5-minute counseling call.
                Cotinine-validated 7-day tobacco abstinence rates in intervention and control groups were 10.0% and 7.5% at end of pregnancy (odds ratio [OR] 1.37, 95% confidence interval [CI] 0.69-2.70; number needed to treat = 40) and 6.7% versus 7.1% at 3 months postpartum (OR 0.93, 95% CI 0.44-1.99). The intervention increased end-of-pregnancy cessation rates among 201 light smokers (< 10 cigarettes/day at study enrollment) (intervention 19.1% versus control 8.4%; OR 2.58, 95% CI 1.1-6.1; number needed to treat = 9.3) and among 193 smokers who attempted to quit in pregnancy before enrollment (intervention 18.1% versus control 6.8%; OR 3.02, CI 1.15-7.94; number needed to treat = 8.8); 63% of the sample (n = 267) was in one of these subgroups.
                Proactive pregnancy-tailored telephone counseling did not outperform a brief "best practice" intervention among pregnant smokers. The intervention had efficacy in light smokers and in women who had attempted cessation earlier in pregnancy. Future studies should confirm whether telephone counseling benefits these groups of pregnant smokers.
                ClinicalTrials.gov, #NCT00181909.
                I. A randomized trial evaluated the impact of smoking cessation interventions on point prevalence and consecutive quit rates at an Australian public prenatal clinic.
                Self-reports and urine cotinine tests confirmed patients' smoking status at the midpoint and end of pregnancy and 6 weeks postpartum.
                At all points, validated abstinence rates were significantly higher in the experimental group than in the control group. The rate of failed biochemical validation was significantly higher in the control group than in the experimental group.
                Prenatal clinic staff can significantly increase quit rates by using cognitive-behavioral strategies. Brief advice appears to be ineffective. To evaluate the effectiveness of a physician-based intervention to promote smoking cessation during pregnancy, we conducted this randomized controlled trial in the resident-staffed prenatal clinics at the University of North Carolina Women's Hospital . Two hundred fifty prenatal patients who smoked were enrolled at their first visit and randomly assigned to the intervention or the usual-care group. Resident physicians provided self-help materials to intervention subjects and used a script to set goals with them at each prenatal visit. Subjects who set quit dates were contacted by volunteer cessation counselors. To verify smoking status, subjects provided a self-report and breath carbon monoxide (CO) sample at each visit. Controls were similarly assessed at enrollment and at three additional predetermined intervals. Twenty percent of intervention subjects and 10% of controls reported cessation, which was verified by CO level (P = .052). Fifty-one percent of subjects reduced their consumption by half or more, compared with 30% of controls (P = .002). The intervention is effective in promoting smoking cessation and reduction. In addition, this technique is inexpensive, readily accepted by staff, and efficient. The aim of the study was to test the psychosocial benefits of a telephone support program for pregnant women.
                Randomised controlled trial. The study sample were women recruited from an antenatal clinic and general practice surgeries who were less than 20 weeks gestation and either single or in a relationship where the partner was unemployed. Women in the intervention group received weekly telephone calls throughout their pregnancy. All women were interviewed initially and at 34 weeks gestation. There were 66 women in the control group and 65 women in the intervention group.
                The intervention and control groups did not differ significantly on the psychosocial measures at baseline. Comparisons at 34 weeks were made by analysis of covariance using the baseline scores. The intervention group at 34 weeks had lower stress scores than the control group (means 16.5 vs 18.4, p = 0.02), lower trait anxiety (means 35.2 vs 39.4, p = 0.04) and less depressed mood (means 6.6 vs 8.1, p = 0.02). Self esteem was higher for the intervention group (means 34.9 vs 32.5, p = 0.008). The intervention failed to alter smoking but the intervention women did report more use of community resources (p = 0.02) and were less likely to skip meals (p = 0.03).
                A low cost health promotion program of telephone support during pregnancy can significantly improve a woman's psychosocial status during pregnancy. To determine whether motivational interviewing--a behavioural therapy for addictions-provided at home by specially trained midwives helps pregnant smokers to quit.
                Randomised controlled non-blinded trial analysed by intention to treat.
                Clinics attached to two maternity hospitals in Glasgow.
                762/1684 pregnant women who were regular smokers at antenatal booking: 351 in intervention group and 411 in control group.
                All women received standard health promotion information. Women in the intervention group were offered motivational interviewing at home. All interviews were recorded.
                Self reported smoking cessation verified by plasma or salivary cotinine concentration.
                17/351 (4.8%) women in the intervention group stopped smoking (according to self report and serum cotinine concentration < 13.7 ng/ml) compared with 19/411(4.6%) in the control group. Fifteen (4.2%) women in the intervention group cut down (self report and cotinine concentration less than half that at booking) compared with 26 (6.3%) in the control group. Fewer women in the intervention group reported smoking more (18 (5.1%) v 44 (10.7%); relative risk 0.48, 95% confidence interval 0.28 to 0.81). Birth weight did not differ significantly (mean 3078 g v 3048 g).
                Good quality motivational interviewing did not significantly increase smoking cessation among pregnant women. Our purpose was to assess whether an intervention in the education of the mother and the support person involves a change in health-related behavior and use of health facilities.
                A randomized, controlled trial was conducted in four cities of Latin America on pregnant women at risk. Half of them (n = 1115) received a home intervention of four to six visits dealing with psychosocial support and education about health-related habits, alarm signs, hospital facilities, antismoking and antialcohol programs, and a reinforcement of adequate health services utilization for the pregnant woman and a support person. The control group (n = 1120) received routine prenatal care.
                The distribution of risk factors and demographic, obstetric, and psychologic characteristics at baseline was similar in both groups. Women in the intervention group showed a statistically significant better knowledge of seven of the nine alarm signs considered and of two of the three labor-onset signs required. No differences between groups were observed in improvement on diet, cigarette and alcohol consumption, maternal physical strain, lactation at 40 days postpartum, and utilization of health facilities.
                An intervention of psychosocial support and health education during pregnancy failed to show any benefit on perinatal outcome, health-related behavior, or utilization of health facilities. Physicians' advice to help pregnant women quit smoking during prenatal care has had mixed results. Training and prompting physicians to provide consistent advice and referral to on-site support might improve cessation rates.
                Pregnant women who smoked were randomly assigned to receive structured advice from their physician and referral to individual behavior change counseling during prenatal care or to receive brief advice to stop smoking and a quit smoking booklet at their first visit. Smoking status was measured by self-report, exhaled carbon monoxide, and urinary cotinine.
                Compared with usual care, greater proportions of intervention group women reported not smoking at the 36th-week visit (14% vs 10%) and at 1 year postpartum (18% vs 11%), but these differences were not significant. However, significantly greater proportions of intervention group women reported either not smoking or reducing their cigarette consumption by 50% or more at their second visit (43% vs 29%, P = 0.02), at their 36th-week visit (40% vs 25%, P < 0.01), and at 1 year postpartum (26% vs 14%, P = 0.02).
                Physician training on how to gain a pregnant smoker's commitment to change her smoking behavior, an office prompt system, and individualized smoking behavior change counseling show promise in reducing smoking during pregnancy and postpartum, but practical methods to assist pregnant smokers between regular prenatal visits, as they attempt to quit, need to be developed. This study examined smoking cessation and cigarette reduction of indigent inner city pregnant women (n = 193) who completed one of three interventions: a special video program based on their perceptions of the effects of smoking during pregnancy, the American Lung Association's "Freedom From Smoking For You and Your Baby" program, or the usual physician's advice. Six percent of the women quit smoking, and 43% reduced the number of cigarettes they smoked. There were no significant differences among the three groups for either the number who quit smoking or who reduced the number of cigarettes smoked. To examine the barriers encountered by pregnant women who attempt to stop smoking by highlighting three women who used nicotine patches.
                A randomised-controlled trial of nicotine-replacement therapy (NRT) in the form of patches to test its acceptability for pregnant women. Ethics approval was granted despite NRT being contraindicated in Australia for pregnant women and having a low safety rating (category D) (Australian Drug Evaluation Committee, 1999). Salivary cotinine levels were used to assess nicotine exposure and provide some indicator of NRT safety. All participants were given pregnancy-specific cessation counselling, and the 20 women in the treatment arm were offered nicotine patches (15 mg/16 hr), with the option of weaning to lower strength patches if desired.
                The Women's and Children's Hospital, Adelaide, a public tertiary teaching hospital in South Australia, with almost 4000 births annually.
                40 'high-risk' pregnant smokers who expressed interest in stopping smoking.
                As has been found in the general population, 'quit' rates with NRT use were low. Only three of the participants in this study, who became abstinent with patch use during pregnancy, were still abstinent at birth. The circumstances of two of these women, and a third woman who used patches to 'control' her smoking despite researcher advice, are detailed here. Only one of the two women 'abstinent at delivery' was still abstinent 3 months after birth, the last contact point of the study.
                Although health providers intuitively regard pregnancy as an appropriate time for women to stop smoking, the stressors during pregnancy seem to militate against cessation. This study does not indicate that use of NRT will provide an easier solution. It may be more fruitful to institute a concerted lifestyle approach with both the woman and her partner (or significant household members), and continue this support and education postnatally if cessation has not been achieved. Health professionals should also support better-targeted public health campaigns and tobacco-control initiatives generally, because, undoubtedly, the social environment is a major determinant of initiation and continuation of smoking. nan To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics.
                Group randomised trial.
                22 antenatal clinics in New South Wales, Australia.
                Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail-out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail-out plus feedback, training, and ongoing support with midwife facilitator.
                Independent cross sectional surveys of women on a second or subsequent visit undertaken pre-dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO).
                5849 women pre-dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post-dissemination (2302 SD, 2843 ID).
                There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post-dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID).
                Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control. Our objective was to examine the efficacy of the added effect of individualized smoking relapse prevention counseling on obstetricians' and nurse midwives' usual advice during prenatal care. One hundred and seventy-five pregnant women who were smoking early in their pregnancy, but had quit by first prenatal visit, were randomly assigned to receive the usual advice from their obstetrician or nurse midwife, or usual advice plus individual relapse prevention counseling. Smoking status was measured by self-report, by urinary cotinine/creatinine ratio at the 36-week visit, and by self-report at long-term postpartum follow-up. We found that a smaller percentage of women in the intervention group (8.8%) reported smoking at the thirty-sixth-week visit than those in the usual care group (16.9%), a nonsignificant difference. No significant difference in relapse rates during pregnancy was observed based on urinary cotinine/creatinine ratios, but these rates, 29.5% and 27.9% respectively, were substantially higher than those based on self-report. The average number of days abstinent reported by women in the intervention group was significantly longer than that in the usual care group, 199 days versus 166 days respectively (P < .01). Logistic regression analysis indicated that longest time abstaining before first visit, level of belief in smoking's harm to the fetus, and motivation to smoke were independently related to the probability of relapsing to smoking by the 36-week visit. Long-term relapse rates were not significantly different: intervention group, 50.9%, usual care group, 50.0%.(ABSTRACT TRUNCATED AT 250 WORDS) Pregnant smokers attending a local health department WIC clinic were randomly assigned to one of two self-help smoking cessation programs or usual care. The multiple component program resulted in larger quit rates than usual care during the last month of pregnancy (11 percent vs 3 percent) and postpartum (7 percent vs 0 percent). Achieving quit rates in WIC similar to those in studies conducted at prenatal care settings, suggests that smoking cessation programs for low-income pregnant WIC clients are feasible. This study is an evaluation of relapse prevention interventions for smokers who quit during pregnancy.
                Pregnant smokers at 2 managed care organizations were randomized to receive a self-help booklet only, prepartum relapse prevention, or prepartum and postpartum relapse prevention. Follow-up surveys were conducted at 28 weeks of pregnancy and at 8 weeks, 6 months, and 12 months postpartum.
                The pre/post intervention delayed but did not prevent postpartum relapse to smoking. Prevalent abstinence was significantly greater for the pre/post intervention group than for the other groups at 8 weeks (booklet group, 30%; prepartum group, 35%; pre/post group, 39%; P = .02 [different superscripts denote differences at P < .05]) and at 6 months (booklet group, 26%, prepartum group, 24%; pre/post group, 33%; P = .04) postpartum. A nonsignificant reduction in relapse among the pre/post group contributed to differences in prevalent abstinence. There was no difference between the groups in prevalent abstinence at 12 months postpartum.
                Relapse prevention interventions may need to be increased in duration and potency to prevent post-partum relapse. This article describes preliminary findings of an experimental, randomized, three-group, controlled design examining the effectiveness of a smoking cessation intervention for pregnant teens. The three groups are: Teen FreshStart with a buddy program (TFSB), a Teen FreshStart program (TFS) without peer support, and the Usual Care (UC) control group. Forty-six subjects completed the post-intervention assessment of smoking status. The TFSB group consistently achieved greater smoking cessation across all measures when compared to the subjects in the other two groups. These results indicate that the use of peer support may be an effective adjunct in smoking cessation programs for pregnant adolescents. This exploratory study examined the acceptability and efficacy of a videotape modeling smoking cessation as an adjunct to smoking cessation advice delivered during prenatal care. In a randomized controlled trial involving 60 women, we compared the delivery of brief smoking cessation advice and a tipsheet to the same advice and tipsheet plus provision of the videotape. Outcomes included opinions about content and acceptability of the videotape, and smoking behavior change during pregnancy. The most highly endorsed features of the videotape were seeing other women quitting smoking (77%), dealing with stress and bad feelings (69%), talking about what to do with urges to smoke (69%), and discussing ways to get support from families and friends (54%). The reported quit rate in the last month of pregnancy, validated by exhaled carbon monoxide levels, and including women lost to follow-up as smokers, was 19.2% in the intervention group and 0% in the comparison group (p = .02). This study suggests that the use of videotapes modeling smoking behavior change may increase the effectiveness of the assistance in quitting smoking that is generally available in obstetric and family practices or public maternity clinics. To investigate the feasibility and impact of integrating a cotinine-assisted smoking intervention programme with an existing antenatal maternal serum alpha-fetoprotein (AFP) screening service for open neural tube defects.
                A multisite randomized controlled trial.
                139 physician offices and clinic sites in Maine providing antenatal care.
                2848 pregnant women who smoked 10 or more cigarettes daily, enrolled at between 15 and 20 weeks gestation, from a population base of approximately 18,000 pregnancies.
                The women were individually allocated at random to intervention or control groups within each centre at the time the serum sample was received for AFP measurement. The intervention group received an interpreted measurement of the serum cotinine, reported through the physician to the woman, along with a self-help smoking cessation booklet and a repeat serum cotinine measurement one month later, again interpreted and reported through the physician to the woman. Women in the control group received the usual anti-smoking advice provided by the antenatal care site and were not told of the study.
                Birthweight, physician cooperation with study protocol (as measured by effectiveness in obtaining repeat serum samples for cotinine measurements).
                Pregnancy outcome data were available for 97% of the study population, including birthweight for 2700 singleton viable pregnancies. The smoking intervention programme led to a significant 66 g increase in mean birthweight (P = 0.03; 95% CI+9 to +123 g) and to a 30% reduction in the rate of low birthweight in pregnancies managed by the 70 physicians who secured the highest rate of obtaining repeat serum samples for cotinine measurements in their intervention group. Among the remaining 69 physicians, intervention had no detectable effect on birthweight.
                A cotinine-assisted smoking intervention programme managed from a central location as an adjunct to a maternal serum AFP screening service can, with the cooperation of physicians responsible for antenatal care, lead to a significant and cost-effective reduction in the number of low birthweight babies. This programme is inexpensive, requires little extra effort, and does not need specially trained personnel. To test the hypothesis that appropriate interventions delivered by midwives within usual primary maternity care, can assist women to stop or reduce the amount they smoke and facilitate longer duration of breast feeding.
                In a cluster randomised trial of smoking education and breast-feeding interventions in the lower North Island, New Zealand, midwives were stratified by locality and randomly allocated into a control group and three intervention groups. The control group provided usual care. Midwives in the intervention groups delivered either a programme of education and support for smoking cessation or reduction, a programme of education and support for breast feeding or both programmes. Sixty-one midwives recruited a total of 297 women.
                Structured programmes provided by midwives.
                Women receiving only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and 36 weeks gestation. Women receiving both the smoking cessation and breast-feeding education and support programmes were significantly more likely than women in the control group to have changed their smoking behaviour at 36 weeks gestation. There was no difference in rates of cessation or reduction between the groups in the postnatal period. There was no difference in rates of full breast feeding between the control and intervention groups for women who planned to breast feed.
                Education and support by midwives, as part of primary midwifery, can facilitate smoking cessation and reduction during pregnancy. To assess the effect of nicotine patches on continine-validated smoking cessation in pregnant women and the effect of nicotine on birth weight and preterm delivery.
                Pregnant women who smoked ten or more cigarettes after the first trimester (N = 250) were randomly assigned to receive nicotine patches (n = 124) or placebo patches (n = 126). Women randomized to nicotine were treated with 15-mg patches (16 hours/day) for 8 weeks, and 10-mg patches (16 hours/day) for 3 weeks.
                Overall, 26% stopped smoking and 14% were nonsmokers 1 year after delivery. There was no difference between nicotine and placebo groups. At the end of the intervention, the mean value of cotinine in saliva in women assigned to nicotine was 120 ng/mL and placebo 153 ng/mL (mean difference -33; 95% CI -72, 6 ng/mL). Mean birth weight difference was 186 g (95% CI 35, 336 g) higher in the nicotine than placebo group, and there was an insignificantly lower rate of low birth weight (under 2500 g) in the former group. There was no difference in the rate of preterm delivery between the two groups.
                Nicotine patches had no influence on smoking cessation during pregnancy, although they might increase birth weight in comparison with placebo. From theories that suggest behavior is influenced by direct observation of personal and immediate consequences of the behavior, we hypothesized that public prenatal patients would reduce their smoking if they observed the level of carbon monoxide in their own alveolar air. An experimental design was used that involved 170 subjects, multiple measures of smoking, and data collection before the intervention and six weeks later. It was concluded that the intervention had either a small or no influence on cigarette smoking. How can pregnant women be helped to stop smoking? This was a pilot study of midwife home-based motivational interviewing. Clients were 100 consecutive self-reported smokers booking at clinics in Glasgow from March to May 1997. Smoking guidance is routinely given at booking. In addition, intervention clients received a median of four home-based motivational interviewing sessions from one specially trained midwife. All sessions (n = 171) were audio-taped and interviews (n = 49) from 13 randomly selected clients were transcribed for content analysis. Three 'experts' assessed intervention quality using a recognized rating scale. Cotinine measurement on routine blood samples confirmed self-reported smoking change from late pregnancy telephone interview. Postnatal telephone questionnaire measured client satisfaction. Focus groups of routine midwives explored acceptability, problems and disruption of normal care. Fisher exact, chi 2 and Mann-Whitney tests compared enrolment characteristics. Two-sample t-tests assessed outcome between groups. Motivational interviewing was satisfactory in more than 75% of transcribed interviews. In this pilot study, self-reported smoking at booking (100 of 100 available) corroborated by cotinine (93 of 100) compared with late pregnancy self-reports (intervention 47 of 48; control 49 of 49) and cotinine (intervention 46 of 48; control 47 of 49) showed no significant difference between groups. Tools have been developed to answer the question: 'Can proactive opportunistic home-based motivational interviewing help pregnant smokers reduce their habit?'. To evaluate the effect of a provider counseling and office systems intervention in obstetric, pediatric, and Special Supplemental Nutrition Program for Women, Infants and Children (WIC) clinics on smoking and relapse rates in pregnant and postpartum women.
                Five community health centers were randomized to special intervention (SI) or usual care (UC). Subjects (n =601) were current smokers or had quit with pregnancy. Prenatal and postpartum interviews assessed smoking status and related factors. Data were collected between May 1997 and November 2000.
                There was a statistically significant difference in 30-day abstinence rates between SI (26%) and UC (12%) conditions at the end of pregnancy among women who had not quit spontaneously with pregnancy (odds ratio [OR]=2.57, p =0.05). This effect remained at 1 month postpartum but was lost at 3- and 6-month postpartum follow-ups.
                Brief interventions delivered by healthcare providers during routine prenatal care increased smoking abstinence during pregnancy among women who did not quit spontaneously. Interventions extended into postpartum care did not affect relapse and smoking rates postdelivery. The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs.
                Randomized Clinical Trial.
                A large-group-model managed care organization.
                390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment.
                Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers.
                Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy.
                Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups.
                Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers. nan This study hypothesized that midwives with fuller training in smoking cessation and intervention techniques would be more successful Than those without such training at enabling pregnant women to give up smoking. Twenty-six midwives were divided equally between a control and treatment group. after one year, the results showed quit rates of 9% in the treatment group and 0% in the control group. Reported relapse rates were 4% and occurred within one month postpartum. The treatment group reported reducing smoking by 13.1 cigarettes a day compared with 16 in the control group. the intervention therefore helped to cut the number of cigarettes smoked. Studies have demonstrated the effectiveness of smoking cessation interventions targeted at women who are smoking during pregnancy. In contrast, there is limited information about the experience of smokers who have stopped before entering prenatal care--"spontaneous quitters." These women constitute the majority of women who stop smoking sometime during pregnancy, although evidence suggests that as many as one third relapse prior to delivery. We report the results of a population-based randomized clinical trial that tested the effectiveness of a relapse prevention program for spontaneous quitters. The intervention consisted predominantly of printed materials received through the mail. The population (n = 171) of spontaneous quitters was an ethnically diverse group of women enrolled in a large health maintenance organization. Biochemical confirmation of continuous abstinence through delivery revealed that 16% of the women in the experimental self-help program relapsed compared with 20% of usual care controls (NS). Analysis confirmed that the program was equally ineffective among all subgroups including women at highest risk for relapse. Given the negative outcomes associated with self-help materials and clinic-based counseling reported in this and other trials, alternative intervention strategies need to be developed and tested for this significant group of prepregnancy smokers. In a randomised controlled trial intensive individual anti-smoking advice given in parallel with hospital antenatal care did not influence the outcome of pregnancy. The belief that retardation of fetal growth caused by maternal smoking occurs in late pregnancy is not well based, and the advice may not have been given in time to be effective. Other possible interpretations of the results, that maternal smoking is merely an index of some other factor that retards growth or that those counselled did not reduce their smoking sufficiently to influence outcome, cannot be excluded. We examined the efficacy of individualized smoking cessation counseling added to obstetricians' and nurse-midwives' advice.
                In a mixed private and publicly supported prenatal clinic 600 pregnant women who smoked were randomly assigned to receive the usual advice from their obstetrician or nurse-midwife or the usual advice plus individualized smoking cessation counseling. Smoking status was measured by self-report and urinary cotinine/creatinine ratios at 36 weeks and by self-report during long-term postpartum follow-up.
                Quitting rates during pregnancy were not increased by adding individualized smoking cessation counseling to usual care. At the long-term follow-up, reported quitting rates were significantly greater among intervention group women cared for in the publicly supported clinic than among those receiving the usual care, 14.5% versus 2.5%, p < 0.01.
                Although adding individual smoking cessation counseling did not increase quitting rates during pregnancy, it should be considered for women in public maternity clinics because of its potential long-term effectiveness. The aim of randomized trial was to evaluate the effectiveness of anti-smoking counseling in the population of pregnant women from the maternity centers in Lódź, central Poland.
                One hundred and forty nine current smokers and 56 spontaneous quitters were randomized into the smoking cessation intervention and 144 current smokers and 37 spontaneous quitters were included in the control group. The intervention program covered four midwife visits during pregnancy and one after delivery. The control units received standard written information about the health risk from maternal smoking to the fetus.
                The chance of quitting smoking by the women was significantly higher in the intervention group than in the control group (OR = 2.5; 95% CI 1.8-3.7). The difference in the mean infant birthweight between the quitters and non-quitters was 203.8 g (p = 0.01) in the intervention group and 198.2 g in the control group (p = 0.08). After controlling for socio-demographic characteristics that could affect the birthweight, the differences remained significant in the intervention group - 182.8 g (p = 0.02), whereas in the control group it was 92.4 g (p = 0.4).
                The midwife-assisted smoking cessation intervention seems to be an effective tool to help pregnant smokers make a decision to quit smoking. nan To evaluate the effectiveness in helping pregnant women stop smoking of two interventions (Pro-Change for a healthy pregnancy) based on the transtheoretical model of behaviour change (TTM) compared to current standard care.
                Cluster randomised trial.
                Antenatal clinics in West Midlands, UK general practices.
                918 pregnant smokers
                100 general practices were randomised into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM based self help manuals), and C (TTM based self help manuals plus sessions with an interactive computer program giving individualised smoking cessation advice).
                Biochemically confirmed smoking cessation for 10 weeks previously, and point prevalence abstinence, both measured at 30 weeks of pregnancy and 10 days after delivery.
                There were small differences between the TTM arms. Combining the two arms, the odds ratios at 30 weeks were 2.09 (95% confidence interval (CI) 0.90 to 4.85) for 10 week sustained abstinence and 2.92 (95% CI 1.42 to 6.03) for point prevalence abstinence relative to controls. At 10 days after delivery, the odds ratios were 2.81 (95% CI 1.11 to 7.13) and 1.85 (95% CI 1.00 to 3.41) for 10 week and point prevalence abstinence respectively.
                While there is a small borderline significant increase in quitting in the combined intervention arms compared with the controls, the effect of the intervention is small. At 30 weeks gestation and at 10 days postnatal, only about 3% of the intervention groups achieved sustained cessation, with numbers needed to treat of 67 (30 weeks of gestation) and 53 (10 weeks postnatal) for one additional woman to achieve sustained confirmed cessation. Given also that the intervention was resource intensive, it is of doubtful benefit. To evaluate whether ultrasound screening during pregnancy decreases the frequency of smoking in women who present with a history of smoking.
                The Routine Antenatal Diagnostic Imaging with Ultrasound Study was a multicenter, randomized clinical trial of ultrasound screening during pregnancy. We obtained information on smoking habits during pregnancy from birth certificate records for the subset of women who were delivered of a neonate in Missouri hospitals, and determined the effect of ultrasound screening on smoking habits during pregnancy.
                The study was conducted in multiple practices in six states.
                Women who registered for prenatal care at participating practices.
                Women in the screened group were routinely scheduled for ultrasound screening at 16 to 22 weeks' gestation and at 31 to 35 weeks' gestation. Those in the control group received ultrasound screening only for medical indications, as determined by their physicians.
                Smoking habits were measured by the number of cigarettes smoked per day.
                There was no difference in the rates of smoking cessation between the screened group and the control group. For those who continued smoking, the mean number of cigarettes smoked per day, as reported at the time of delivery, was slightly higher in the screened group.
                Ultrasound screening does not reduce the frequency of smoking during pregnancy. nan This study was a randomized controlled trial of a smoking cessation intervention for pregnant smokers. Women who reported smoking at their first antenatal visit and satisfied the inclusion criteria were asked to participate in the trial. Analysis was restricted to 393 evaluable women in the control group (received usual antenatal care) and 339 women to the study group (received usual antenatal care plus the intervention). The primary hypotheses were that the intervention would result in a higher proportion of quitters and that the mean birth-weight of babies born to women receiving the intervention would be greater than that of babies born to women in the control group. The outcome measures were smoking status based on self-report combined with a urinary cotinine level of <115 ng/mL, and birth-weight. There was no significant difference in quit rate between women receiving the intervention and women in the control group (11.9% versus 9.8% p=0.41). Babies born to women receiving the intervention were on average 84 g heavier than babies born to controls (p=0.04). The factors that contribute to the lack of a significant increase in smoking cessation in the intervention group and the possible explanation for the changes in birth-weight are discussed. Three hundred and forty-six women who reported smoking one or more cigarettes per day prior to the 20th week of gestation were recruited into a trial of health educational counselling to stop or reduce cigarette smoking. Counselling was begun at the first prenatal visit and then continued subsequently in the home. Among the 319 women included in analysis, at first follow-up visit those who received counselling smoked 1.7 fewer cigarettes a day than control women (P less than 0.05) and 10.4% had stopped smoking, compared to 5.4% in the control group (NS). Similar but not significant differences were noted at the end of pregnancy. Study effects were limited to the 284 women smoking five or more cigarettes a day at booking. This report refers primarily to them. At first follow-up visit the proportion of such women in the counselled group who ceased smoking (9.3%) was significantly greater than in the control group (2.6%; P less than 0.05). The magnitude of this difference persisted through late pregnancy (11.8% vs. 4.3%; NS) and delivery (10.6% vs. 4.7%; NS). The differences between counselled women and controls in numbers of cigarettes reported smoked at first and last prenatal follow-up visits (2.4 and 2.1) and at delivery (2.0) were all statistically significant. While there was no effect of counselling on either serum thiocyanate or end expiratory carbon monoxide, the counselled group gained slightly more weight than controls during the study (0.47 vs. 0.44 kg per week among controls; NS), and their infants had modestly higher birthweight (44 g; NS). These clinical trial results are the first, to our knowledge, from a prospective, randomized, and controlled experiment demonstrating that a reduction of smoking during pregnancy improves the birth weight of the infant. Nine hundred thirty-five pregnant smokers were randomly assigned to treatment and control groups; the former received smoking intervention. At the eighth month of pregnancy, differences between the two groups in salivary thiocyanate level and reported smoking were statistically significant. For single, live births, the treatment group infants had a mean birth weight that was 92 g heavier and were 0.6 cm greater in length than the control group infants. The decrement in weight related to smoking cannot be fully explained by gestational age. The findings suggest that some fetal growth retardation can be overcome by the provision of antismoking assistance to pregnant women. 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. In 1986, the state health departments of Colorado, Maryland, and Missouri conducted a federally-funded demonstration project to increase smoking cessation among pregnant women receiving prenatal care and services from the Women, Infants, and Children (WIC) program in public clinics.
                Low-intensity interventions were designed to be integrated into routine prenatal care. Clinics were randomly assigned to intervention or control status; pregnant smokers filled out questionnaires and gave urine specimens at enrollment, in the eighth month of pregnancy, and postpartum. Urine cotinine concentrations were determined at CDC by enzyme-linked immunosorbent assay and were used to verify self-reported smoking status.
                At the eighth month of pregnancy, self-reported quitting was higher for intervention clinics than control clinics in all three states. However, the cotinine-verified quit rates were not significantly different.
                Biochemical verification of self-reported quitting is essential to the evaluation of smoking cessation interventions. Achieving changes in smoking behavior in pregnant women with low-intensity interventions is difficult. Smoking during pregnancy is an important problem in the Netherlands. We tested the effectiveness of a health counseling method by midwives using a RCT.
                Four provinces with 42 practices including 118 midwives were randomly assigned to the experimental or control condition. Midwives in the experimental group provided brief health counseling, self-help materials on smoking cessation during pregnancy and early postpartum, and a partner booklet. Controls received routine care. The main outcome measures were 7-day abstinence, continuous abstinence, and partner smoking at 6 weeks post-intervention (T1) and 6 weeks postpartum (T2).
                Multi-level analysis revealed significant differences between both conditions at T1 and T2 using intention-to-treat analysis. Nineteen percent of the experimental group reported 7-day abstinence compared to 7% of the control group at T1, and 21 and 12%, respectively, at T2. For continuous abstinence these percentages were 12% in the experimental group and 3% in the control group. The partner intervention was not successful.
                The intervention resulted in significant effects on smoking behavior for pregnant women, but not for partner smoking.
                The program realized short-term effects. An important precondition is that midwives need a proper training. This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation.
                An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum.
                Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth.
                The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy. To evaluate the efficacy of a brief smoking cessation intervention with pregnant women practicable routinely by midwives.
                Midwives were randomized to deliver the experimental intervention or usual care. The 10-15-minute intervention was based on brief counselling, written materials, arrangements for continuing self-help support and feedback on expired-air carbon monoxide levels. The intervention was tailored to the women's needs: those who did not want to stop smoking received a brief motivational intervention, those who wanted to stop received an intervention designed to assist them and those that had stopped recently (recent ex-smokers) received a relapse prevention intervention.
                Booking interviews with pregnant women in nine hospital and community trusts.
                A total of 1120 pregnant women in the third month of pregnancy (249 recent ex-smokers and 871 current smokers).
                Three indicators of biochemically validated abstinence were collected. Continuous abstinence for at least 3 months prior to delivery, point prevalence abstinence immediately post-delivery, and continuous abstinence from 3 months pre-delivery to 6 months post-delivery.
                Only a small proportion of the women who would have been eligible to take part in the trial were actually recruited by 178 recruiting midwives, with lack of time being cited as the main barrier. The intervention and usual care groups differed in post-delivery point prevalence abstinence rates for recent ex-smokers (65% vs. 53%, p < 0.05, one-tailed), but not in other outcome measures. Overall, 54% of "recent ex-smokers" at booking and 7% of "current smokers" at booking had been abstinent for at least 3 months at the time of delivery, and 23% and 3%, respectively, were still abstinent by the time the child was 6 months old (i.e. 12 months post-intervention). Smoking status at follow-up was predicted by dependence indexed by time to first cigarette in the morning.
                A brief "one-off" smoking cessation intervention by midwives does not seem to be a practicable or effective method of helping pregnant smokers to stop. Other options such as tailored self-help materials and telephone counselling and other specialist treatments should be examined. Current smoking cessation rates in pregnancy are very low. A multicomponent motivational smoking cessation intervention was evaluated in 33 prenatal, family planning, and pediatric services in 12 public health clinics. Clinic-based intervention components were implemented by clinic personnel as part of routine medical visits.
                The evaluation design included pre- and postintervention measurements of multiple study outcomes in a baseline (all clinics prior to the start of the intervention) and an experimental period (matchedpair random assignment of clinics to intervention or control conditions). Subjects were 683 (baseline) and 1,064 (experimental) smokers with measurements of smoking outcomes at both times. Mixed-effects regressions analyzed individual outcomes clustered within clinics and services.
                Control and intervention clinics had similar outcomes in the baseline period. In the experiment, outcomes improved in the intervention but not in the control clinics. Compared to controls, smokers exposed to the intervention were more likely to have quit (14.5 versus 7.7%) or take actions toward quitting and had higher mean action, stage of readiness, and motivation to quit scores. These positive effects persisted when clustering within clinics and services was controlled.
                This intervention, implemented by clinic personnel as part of routine medical visits, was effective under these natural conditions across different types of clinic service. Smoking is the most important modifiable risk factor for adverse pregnancy outcome in the UK. New tools are needed to improve smoking cessation advice. The aim was to investigate a point-of-care urine test for smoking, to provide feedback to women, to improve awareness about the effects of smoking during pregnancy and to relate the test results to pregnancy outcome.
                A cross-sectional randomized controlled trial involving 856 pregnant women. All intervention patients were interviewed at their initial visit and tested for smoking. The test provided visual and numerical feedback. Smokers were followed up and retested at subsequent visits. The control group received anti-smoking counselling as part of routine care, but their smoking was monitored using the test. Both groups were interviewed and retested at 36 weeks' gestation.
                Self-reported cigarette consumption fell significantly (P < 0.001) in the intervention group, with 16.2% giving up and 33.3% significantly reducing their cigarette consumption. There was a significant fall in test results from 'booking' to 36 weeks' gestation (P < 0.0001). In the control group, only 8% reported stopping and 23% reducing their cigarette consumption. Combined smoking test results at 36 weeks correlated significantly with birth weight (P = 0.006) and body length (P = 0.011).
                Point-of-care testing and feedback coupled with counselling can significantly reduce smoking during pregnancy and increase birthweight. The aim was to study the effect of a multimodal smoking cessation intervention regimen on a number of pregnant smokers.
                A prospective intervention study was designed where participants were allocated to intervention or control based on their birth date. The study included 647 pregnant smokers. The intervention group (n = 327) received initial individual smoking cessation counseling supplemented by an invitation to join, individually or in a group, a smoking cessation program with nicotine replacement therapy as a voluntary option. Intervention was designed as an integral part of the midwives' prenatal care. All pregnant smokers in the usual care group (n = 320) received standard counseling from a midwife. Outcome was self-reported smoking cessation in the 37th week of pregnancy and the reported cessation was validated by cotinine saliva concentration.
                Self-reported cessation rates during pregnancy were significantly higher in the intervention group (14%) than in the group receiving usual care (5.0%) (p < 0.0001) (Fisher's exact test). Cotinine-validated cessation rates during pregnancy were significantly higher among the former (7%) than the latter (2%) (p = 0.003). The adjusted odds ratio (OR) for smoking cessation was 4.20 (95% CI 2.13-8.03). Logistic regression analysis showed a significant positive association of smoking cessation with low caffeine consumption in pregnancy, many years in school, no exposure to passive smoking outside the home, and previous attempts to stop smoking.
                A multimodal intervention regimen with initial individual counseling supplemented by an invitation to join a smoking cessation program with nicotine replacement therapy as a voluntary option markedly increased cessation rates during pregnancy. Smoking during pregnancy has been linked to health problems, including the risk of low birthweight, preterm labour, spontaneous abortion and perinatal death. Two trials to investigate the efficacy of self-help materials were undertaken. During the first trial, a self-help booklet developed overseas was evaluated through a randomised controlled design to determine the effects of the booklet alone, compared with the booklet with midwife counselling for the women. We recruited 217 women into the study and followed them up at 20 weeks' gestation to ascertain smoking cessation and to measure process variables. Smoking cessation rates were lower than expected, and process measures indicated that materials were not being used. A second trial was commenced after a comprehensive review of the materials with focus groups of pregnant women and one-to-one interviews of nurses and doctors. Trial 2 was based new materials, and used a magazine-style (smoking cessation) booklet designed by the focus groups. A total of 119 women were randomly allocated into the new-materials group or a usual-care group. The materials were well received, relevant and pertinent, and were used by the women. Smoking cessation rates at 20 weeks' gestation were biochemically validated and indicated that 9 per cent in the intervention group and none in the usual-care group had stopped smoking. The use of overseas programs needs to be approached with caution. This study examined the effects of a smoking cessation intervention on stages of change in 349 low-income, pregnant women. At first prenatal visit, women were randomized into experimental or usual care condition and classified by stage of change: precontemplation, contemplation, preparation, or action. For each stage of change at the first prenatal visit, the stage distributions of the experimental and usual care groups were compared at the second and 36-week prenatal visits. Kruskal-Wallis tests revealed significant differences at the second visit in the stage distributions by condition for subjects who were initially in precontemplation or in preparation. In each case, a greater proportion of experimental than usual care subjects advanced through the stages. The shift was not maintained at the 36-week visit. nan This study examined whether voucher-based reinforcement therapy (VBRT) contingent upon smoking abstinence during pregnancy is an effective method for decreasing maternal smoking during pregnancy and improving fetal growth.
                A two-condition, parallel-groups, randomized controlled trial was conducted in a university-based research clinic. A total of 82 smokers entering prenatal care participated in the trial.
                Participants were assigned randomly to either contingent or non-contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non-contingent condition, vouchers were earned independent of smoking status.
                Smoking outcomes were evaluated using urine-toxicology testing and self-report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester.
                Contingent vouchers significantly increased point-prevalence abstinence at the end-of-pregnancy (41% versus 10%) and at the 12-week postpartum assessment (24% versus 3%). Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight, femur length and abdominal circumference in the contingent compared to the non-contingent conditions.
                These results provide further evidence that VBRT has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health. A smoking cessation and relapse prevention intervention was tested in an urban, prenatal clinic serving predominantly low-income, African-American women. At their first prenatal visit, 391 smokers were randomly assigned to an experimental (E) group to receive usual clinic information plus a prenatal and postpartum intervention or to a control (C) group to receive only usual clinic information. The intervention consisted of individual skills instruction and counseling by a peer health counselor on the use of a self-help cessation guide and routine clinic reinforcement. Among the E group (n = 193), 6.2% were cotinine-confirmed quitters at third trimester and among the C group (n = 198) the quit rate was 5.6%. Quitters were light smokers at entry into prenatal care. Many had tried to quit smoking at least once prior to pregnancy. nan Little insight is available in the literature on how best to assist the pregnant smoker in public health maternity clinics to quit during pregnancy. A randomized pretest/posttest experiment was used to evaluate the effectiveness of two different self-help cessation methods. Three hundred and nine pregnant women from three public health maternity clinics were assigned randomly to one of three groups with one-third assigned to each: a control group; a group receiving the American Lung Association's Freedom From Smoking Manual; and those receiving A Pregnant Woman's Self-Help Guide to Quit Smoking. Using a saliva thiocyanate (SCN) and behavioral report at mid-pregnancy and end of pregnancy to confirm cessation or reduction, 2 per cent in the control group quit and 7 per cent reduced their SCN levels substantially. Of the women assigned to the ALA method, 6 per cent quit and 14 per cent reduced their SCN levels substantially. Of the women who used the Guide, 14 per cent quit and 17 per cent reduced their SCN levels substantially. Results of this trial indicate that health education methods tailored to the pregnant smoker are more effective in changing smoking behavior than the standard clinic information and advice to quit and/or the use of smoking cessation methods not tailored to the needs of the pregnant smoker. We report the results of a population-based randomized clinical trial that tested the effectiveness of a prenatal self-help smoking cessation program. The intervention consisted predominantly of printed materials received through the mail. The population (n = 242) consisted of a socioeconomically and ethnically diverse group of pregnant women enrolled in a large health maintenance organization (HMO) who reported they were smoking at the time of their first prenatal visit. Biochemical confirmation of continuous abstinence achieved prior to the 20th completed week of pregnancy and lasting through delivery revealed 22.2 per cent of the women in the eight-week serialized program quit versus 8.6 per cent of controls with usual care. The adjusted odds ratio was 2.80 (95 per cent CI = 1.17, 6.69). We conclude that a low-cost prenatal self-help intervention can significantly affect the public health problem of smoking during pregnancy and its associated risks for maternal and child health. To evaluate a peer counseling intervention for pregnant smokers.
                One hundred forty-two pregnant, predominantly Hispanic women were assigned to a peer-led smoking cessation program or to usual care.
                Compared with usual care, peer counseling reduced smoking (-9.1 versus -4.5 cigarettes daily, P =.03), but did not affect absolute quit rates (24% versus 21%) at 36 weeks' gestation. Infant birth weight negatively correlated with cigarettes smoked per day (r = -0.29, P <.01) and expired carbon monoxide (r = -0.39, (P <.001) at delivery. Birth weight for infants born to women who quit smoking averaged 7.2 lb versus 6.8 and 6.3 lb for mothers smoking one to six and more than six cigarettes per day at delivery (P <.01).
                Peer counseling reduced the number of cigarettes smoked daily but did not increase cigarette abstinence rates. Infant birth weight increases with both smoking cessation and smoking reduction, suggesting that peer counseling intervention programs may improve newborn health despite their failure to affect smoking cessation. The effects of anti-smoking health education during pregnancy on smoking behaviour and the subsequent infant's size at birth were investigated in a controlled trial. It was found that the planned educational intervention was incompletely carried out and was given more effectively to primigravidae in whom subsequent reduction of smoking was more evident. The effects of educative intervention on size at birth were therefore analysed for first and later pregnancies separately. The differences in birthweight and length between the intervention and control groups were concentrated almost entirely among the first born infants who were 68 g heavier and 0.75 cm longer in the intervention group than the first born infants in the control group. A randomized trial (the Birmingham Trial II) was conducted to evaluate the behavioral impact of health education methods among 814 female smokers at four public health maternity clinics.
                Four hundred patients were randomly assigned to an Experimental (E) Group, and 414 were assigned to a Control (C) Group. Self-reports and saliva cotinine tests confirmed smoking status at the first visit, at midpregnancy, and at end of pregnancy.
                The E Group exhibited a 14.3% quit rate and the C Group an 8.5% quit rate. A Historical Comparison (C) Group exhibited a 3.0% quit rate. Black E and C Group patients had higher quit rates than White E and C Group patients. A cost-benefit analysis found cost-to-benefit ratios of $1:$6.72 (low estimate) and $1:$17.18 (high estimate) and an estimated savings of $247,296 (low estimate) and $699,240 (high estimate).
                Health education methods are efficacious and cost beneficial for pregnant smokers in public health maternity clinics. We report results from a pilot study examining the use of vouchers redeemable for retail items as incentives for smoking cessation during pregnancy and postpartum. Of 100 study-eligible women who were still smoking upon entering prenatal care, 58 were recruited from university-based and community obstetric practices to participate in a smoking cessation study. Participants were assigned to either contingent or noncontingent voucher conditions. Vouchers were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence. In the noncontingent condition, vouchers were earned independent of smoking status. Abstinence monitoring and associated voucher delivery was conducted daily during the initial 5 days of the cessation effort, gradually decreased to every other week antepartum, increased to once weekly during the initial 4 weeks postpartum, and then decreased again to every other week for the remaining 8 weeks of the postpartum intervention period. Contingent vouchers increased 7-day point-prevalence abstinence at the end-of-pregnancy (37% vs. 9%) and 12-week postpartum (33% vs. 0%) assessments. That effect was sustained through the 24-week postpartum assessment (27% vs. 0%), which was 12 weeks after discontinuation of the voucher program. Total mean voucher earnings across antepartum and postpartum were 397 US dollars (SD=414 US dollars) and 313 US dollars (SD=142 dollars) in the contingent and noncontingent conditions, respectively. The magnitude of these treatment effects exceed levels typically observed with pregnant and recently postpartum smokers, and the maintenance of effects through 24 weeks postpartum extends the duration beyond those reported previously. To evaluate the effectiveness of a self help approach to smoking cessation in pregnancy.
                Pragmatic cluster randomised controlled trial with community midwife as the unit of randomisation.
                Three NHS hospital trusts in England.
                1527 women who smoked at the start of pregnancy.
                A series of five self help booklets comprising a step by step programme to increase motivation for quitting smoking and to teach strategies for cessation and relapse prevention. The first booklet was given to the women by a midwife at the earliest opportunity in antenatal care, together with a booklet for partners, family members, and friends. The remaining four booklets were mailed directly to the women.
                The primary outcome was smoking cessation validated by cotinine measurement at the end of the second trimester of pregnancy. Other outcomes were self reported smoking status and cigarette consumption among daily smokers. Qualitative data exploring the acceptability of the intervention and the way that smoking cessation advice was delivered in both trial arms were also collected.
                Smoking cessation rates were low: the cotinine validated rates were 18.8% (113/600) in the intervention group and 20.7% (144/695) in the normal care group (difference 1.9%, 95% confidence intervals -3.5% to 7.3%). Self reported quit rates were higher. In the intervention group, 156 (25.6%) women reported not smoking for at least seven days, compared with 207 (29.1%) in the normal care group. In both groups, median self reported daily cigarette consumption among daily smokers was 10 cigarettes per day. Pregnant women and midwives approved of the intervention, but the way in which it was delivered varied considerably. For the primary smoking outcome, the degree of clustering at the midwife level was non-trivial (intracluster correlation coefficient 0.031).
                The self help intervention was acceptable but ineffective when implemented during routine antenatal care. More intensive and complex interventions, appropriately targeted and tailored, need to be developed and evaluated. Validated smoking cessation rates among pregnant women are substantially lower than the self reported rates on which current smoking policy is based. Three groups (n = 50 each) of pregnant smokers wanting to quit the habit were assigned to three different intervention programs around their 18th week in pregnancy. Group 1 participated in a smoking cessation program offering several self-help methods; group 2 attended a doctor's information meeting at the hospital; and group 3 received a pamphlet on the deleterious effects of smoking in pregnancy. For Group 4, the control group, there was no intervention. In all three intervention groups, more than one-third reduced their smoking to almost half, while 38% quit altogether in group 1, compared with less than 10% in groups 2 and 3. Twelve months later, 16%, 6% and 8% respectively, remained abstinent in the three groups. In groups 2 and 3, abstinence proved to be of the same magnitude as in the control group. We conclude that smoking in pregnancy, being one of the few amenable to risk factors affecting the perinatal death statistics, demands an active smoking cessation program during pregnancy led by specially trained health professionals. At Buskerud Central Hospital in Norway, a county hospital with 2000 deliveries per year, an intervention study, using hypnosis, aimed at smoking cessation and reduction among pregnant women still smoking around 18th week of pregnancy was carried out during the period 1992-1993. Two sessions (each lasting 45 minutes) using conventional induction into a superficial nonsomnabulistic stage of trance were performed. A tape was played, encouraging the pregnant woman's wish to quit smoking and her capacity to do so. Relaxation techniques together with self-hypnotic methods were introduced to combat craving. Changes in smoking pattern were investigated at delivery time. No significant effect on smoking cessation or smoking reduction was obtained (p > 0.05). We recorded a 10% quit rate in both intervention group and control group, and 42% and 31% reduced their smoking in the intervention group and control group, respectively. To investigate the effects of a low cost multicomponent intervention program among pregnant heavy smokers.
                A randomized controlled experimental trial.
                The National Hospital, Oslo, Norway.
                104 pregnant women smoking 10 cigarettes or more daily at the time of routine ultrasound screening around the 18th week of pregnancy.
                Around the 18th week of gestation the women received information about the dangers of smoking in pregnancy together with a self-help manual. The manual was developed especially for pregnant women to aid smoking cessation during a 10 day program. A control ultrasound was performed around the 32nd week of pregnancy. Two encouraging reminders were mailed to them before and after the control ultrasound.
                Changes in smoking pattern were investigated at delivery time. Smoking cessation, reduction, increase and no change in smoking consumption was registered.
                20% stopped smoking and 65% reduced their smoking in the intervention group compared to 4% and 38% respectively in the control group. 11% in the intervention group did not change their smoking habit and 4% increased their consumption compared to 36% and 22% respectively in the control group. The differences were highly significant.
                This low cost multiple intervention model seems more effective than other intervention models investigated in Norway. The resources invested are probably within the limits of the common pregnancy health care. The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers.
                After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy.
                A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%).
                The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.