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The Kaiser Permanente prenatal smoking cessation trial: when more isn't better, what is enough?
  1. Daniel H Ershoffa,
  2. Virginia P Quinna,
  3. Neal R Boydb,
  4. Julie Sterna,
  5. Margaret Gregorya,
  6. David Wirtschaftera
  1. aKaiser Permanente Southern California Group, Pasadena, California, USA, bFox Chase Comprehensive Cancer Center
  1. Dr VP Quinn, Southern California Permanente Medical Group, Department of Research and Evaluation, Walnut Center 911, Pasadena, CA 91188, USA;Virgina.P.Quinn{at}

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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 counselling from prenatal care providers and a self help booklet could be improved by adding more resource intensive cognitive behavioural programs.


Randomised clinical trial.


A large group model manage care organisation.


Three hundred and ninety English speaking women 18 years of age or older who self reported to be active smokers at their initial prenatal appointment.


Participants were randomised 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 computerised telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counselling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking related usual care advice from prenatal providers.

Main outcome measure

Biochemically confirmed abstinence measured by concentration of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy.


Twenty per cent 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 education 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 computerised telephone cessation program nor systematic provision of motivational counselling 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.


First published as an abstract to an article inAm J Prev Med1999;17:161–8.