Smoking relapse prevention during pregnancy: A trial of coordinated advice from physicians and individual counseling

doi:10.1016/S0749-3797(98)00029-4

American Journal of Preventive Medicine

Volume 15, Issue 1, July 1998, Pages 25-31

https://doi.org/10.1016/S0749-3797(98)00029-4 Get rights and content

Abstract

Introduction: Our objective was to examine the efficacy of physicians’ advice and referral to individual counseling in preventing relapse to smoking among women who were smokers early in pregnancy, but quit prior to their first prenatal visit.

Design: A randomized controlled trial of prompted physician’s advice and individual relapse prevention counseling during pregnancy compared to usual physician advice. Smoking status was assessed by self-report, exhaled carbon monoxide, and urinary cotinine during pregnancy and by self-report 1 year postpartum.

Results: There were no significant differences in relapse rates between the intervention and usual-care groups during pregnancy, nor at 1 year postpartum. Relapse rates were 23% in both groups at the 36-week visit, and 32% and 22%, respectively, 1 year postpartum. Younger age, higher motivation to resume smoking, and higher levels of exhaled carbon monoxide at the first prenatal visit were predictive of relapse to smoking during pregnancy. With the conservative assumption that all those lost to follow-up relapsed, the combined 1-year postpartum relapse rate, 51%, was 17 percentage points lower than we observed in an earlier relapse prevention trial, and 15 percentage points lower than that observed nationally a decade earlier.

Conclusion: Prompting physicians to provide supportive advice combined with referral to individual relapse prevention counseling did not reduce smoking relapse rates during pregnancy, or postpartum. However, the level of attention paid to smoking by physicians in both intervention and usual-care groups during pregnancy may have contributed to the relatively low relapse rates seen 1-year postpartum.

Introduction

About 25% of women smokers stop smoking when they become pregnant.1, 2, 3 Most of these women remain abstinent during the remainder of their pregnancy, but 15%–30% relapse during this time.4, 5, 6, 7, 8 Four controlled trials of the efficacy of different interventions designed to prevent relapse to smoking during prenatal care have shown no effect in reducing relapse rates during pregnancy.5, 6, 7, 8 Two of these trials examined the efficacy of different pregnancy-specific self-help materials,5, 6 while the other two examined the efficacy of individual relapse prevention counseling and other supportive materials.7, 8

Although women are seen regularly for prenatal care during the course of pregnancy, physicians and nurse midwives rarely mention smoking issues with women who smoked early in pregnancy, but quit prior to their first prenatal visit.8 Prenatal visits offer repeated opportunities to advise and counsel women to stay quit and to address concerns women may have in their efforts to remain abstinent from smoking. This paper describes the results of a trial of prompted advice given by trained physicians followed by on-site referral to individual relapse prevention counseling during prenatal care.

Section snippets

Methods

This randomized controlled trial was undertaken in the offices of the University Associates in Obstetrics and Gynecology, among women receiving their prenatal care through the Maternal Infant Care (MIC) clinic, a state-supported clinic for underinsured or uninsured women, or through the Adolescent clinic. In the MIC clinic, prenatal care is provided by obstetric and family practice residents under the supervision of a faculty member and in the Adolescent clinic by an obstetrician and nurse

Comparability of groups

At baseline, there were no significant differences between the intervention and usual-care groups for any of the variables measured among those also interviewed at the 36-week follow-up (see Table 1, Table 2).

Ninety-six percent of the women had high levels of motivation to stay quit during pregnancy, while a much smaller proportion, 11%, also had high levels of motivation to resume smoking. A large proportion of women, 94%, had high levels of confidence in being able to stay quit during the

Discussion

We were unable to show any effect of brief physician advice supported by individual relapse prevention counseling on multiple occasions in preventing relapse to smoking during pregnancy. During the postpartum follow-up, further relapse occurred in both groups, but with no significant difference between them. However, even the conservative estimate of the postpartum relapse rate, 51% for the combined groups, including all those lost to follow-up as smokers, was substantially less than we

Acknowledgements

We are most grateful to the late Sandra S. Lepage, MSN, for all she did to help intervention group participants maintain their nonsmoking behavior. We also thank Jane E. Crammond, RN, for enrolling women into this study and conducting the interviews. Support for this study was provided by the National Institutes of Health, grant numbers HL29957 and CA22435.

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Cited by (61)

A systematic review of behaviour change techniques within interventions to prevent return to smoking postpartum
2019, Addictive Behaviors
Citation Excerpt :
The majority of studies (25 trials) were conducted in the USA,(Allen et al., 2016; Brandon et al., 2012; Cummins et al., 2016; El-Mohandes et al., 2011; Ershoff et al., 1995; Forray et al., 2016; Forray & Waters, 2015; Kendrick et al., 1995; Kientz & Kupperschmidt, 2005; Levine et al., 2016; Lillington et al., 1995; McBride et al., 1999; McBride et al., 2004; Morasco et al., 2006; Mullen et al., 2001; Pbert et al., 2004; Petersen et al., 1992; Pollak et al., 2016; Reitzel et al., 2010; Ruger et al., 2008; Secker-Walker et al., 1995; Secker-Walker et al., 1998; Strecher et al., 2000; Suplee, 2005; Winickoff, Healey, Regan, et al., 2010) two in Canada,(Edwards & Sims-Jones, 1997; Johnson et al., 2000) two in the UK,(Hajek et al., 2001; Thornton, 1997) and three elsewhere in Europe (Germany, Spain and Poland)(Hannover et al., 2009; Jimenez-Muro et al., 2013; Polanska et al., 2004); all notably high income countries. Less than a third of interventions targeted lower socioeconomic groups or ethnic minorities (El-Mohandes et al., 2011; Kientz & Kupperschmidt, 2005; Levine et al., 2016; Lillington et al., 1995; Morasco et al., 2006; Reitzel et al., 2010; Ruger et al., 2008; Secker-Walker et al., 1998; Suplee, 2005; Thornton, 1997). The details of participants, intervention, comparison group, outcome measures, main findings and BCTs identified are described in Supplementary Table 2.
There is no routine support to prevent postpartum smoking relapse, due to lack of effective interventions. Previous reviews have identified behaviour change techniques (BCTs) within pregnancy cessation trials to specify which components might be incorporated into more effective interventions, but no reviews have identified BCTs for prevention of smoking relapse postpartum. We reviewed BCTs and potential delivery modes, to inform future interventions.
We searched Medline and EMBASE from January 2015–May 2017; and identified trials published before 2015 by handsearching systematic reviews. We included RCTs where: i) ≥1 intervention component aimed to maintain smoking abstinence versus a less intensive intervention; ii) participants included pregnant or postpartum smoking quitters; iii) smoking status was reported in the postpartum period. We extracted trial characteristics and used the Behaviour Change Technique Taxonomy v1 to extract BCTs. We aimed to identify ‘promising’ BCTs i.e. those frequently occurring and present in ≥2 trials that demonstrated long-term effectiveness (≥6 months postpartum). Data synthesis was narrative.
We included 32 trials, six of which demonstrated long-term effectiveness. These six trials used self-help, mainly in conjunction with counselling, and were largely delivered remotely. We identified six BCTs as promising: ‘problem solving’, ‘information about health consequences’, ‘information about social and environmental consequences’, ‘social support’, ‘reduce negative emotions’ and ‘instruction on how to perform a behaviour’.
Future interventions to prevent postpartum smoking relapse might include these six BCTs to maximise effectiveness. Tailored self-help approaches, with/without counselling, may be favourable modes of delivery of BCTs.
Registration: PROSPERO CRD42018075677.
Positive parenting behaviors in women who spontaneously quit smoking during pregnancy: Clues to putative targets for preventive interventions
2018, Neurotoxicology and Teratology
While the majority of pregnant smokers do not respond to intervention, little is known about how a subset of pregnant smokers known as spontaneous quitters achieve sustained biologically-confirmed abstinence through delivery in the absence of intervention. We explore a developmental framework to address this question by viewing spontaneous quitting as an adaptive parenting behavior, facilitated by abilities necessary for sensitive parenting, or responsiveness. Utilizing existing data, we examined responsiveness from parenting assessments in women who exhibited a variety of smoking patterns during pregnancy, including spontaneous quitting.
Participants were N = 305 pregnant women assessed for smoking prospectively and biochemically at 16 weeks, 28 weeks, delivery, and 4 weeks postpartum, then reassessed with their children 5 years later with directly-observed home- and lab-based measures of parenting. We used linear regression analysis to compare spontaneous quitters with women who exhibited other prenatal smoking patterns on parenting responsiveness, controlling for potential confounders.
In home-based observations, spontaneous quitters (n = 22) exhibited greater responsiveness with their children relative to intermittent pregnancy smokers [n = 70; β = 0.258, p = .022]; persistent pregnancy smokers [n = 66; β = 0.228, p = .040]; former smokers (quit before pregnancy) [n = 78; β = 266, p = .028]; and never smokers [n = 69; β = 0.312, p = .009]. Hypothesized differences were not observed in lab-based and self-report measures.
Putative protective characteristics in spontaneous quitters were captured in mother-child interactions at home, but not in lab-based and maternal report measures of responsiveness. Specification of these characteristics using prospective designs that oversample for spontaneous quitters is recommended to enable translation to preventive interventions.
A proactive smoking cessation intervention in postpartum women
2013, Midwifery
Citation Excerpt :
Several previous studies that evaluated interventions during the postpartum obtained contradictory results, partly due to the different methodologies used for the design and the characteristics of the intervention (Secker-Walker et al., 1998; Mullen, 2004; Solomon and Quinn, 2004; Goldenberg et al., 2000). These differences include the intensity of the intervention (from self-help materials to visits) (Levitt et al., 2007; Hannöver et al., 2009), the staff who run it (paediatricians, midwives, nurses) (Severson et al., 1997; Hajek et al., 2001; Petersen et al., 2009) or the follow-up and the evaluation of the results, which vary from biochemical validation of abstinence to self-reported status (Secker-Walker et al., 1998; McBride et al., 1999; Valanis et al., 2001). Our study was proposed as a psycho-social intervention with a greater intensity than in a usual brief intervention; following the latest recommendations regarding smoking cessation treatments for pregnant women (Fiore et al., 2008).
to analyse the efficacy of a proactive intervention during the postpartum period to prevent a relapse in recent quitters and to promote progress in the behavioural process of change in smokers.
randomised controlled trial designed for women at the end of the pregnancy using a proactive intervention. Motivational Interviewing (MI) and relapse prevention served as principles for the programme. In the intervention group, four telephone supporting sessions were performed in weeks 3, 6, 9 and 12. For the control group only two check calls in weeks 3 and 12.
women who attended the University Clinical Hospital ‘Lozano Blesa’ of Zaragoza (Spain) to give birth between January 2009 and March 2010. The intervention began after delivery, lasted for 3 months, and finished with a visit to validate abstinence biochemically.
a total of 2,044 women were studied, 30.6% (n=626) smoked before pregnancy; 65.8% (n=412) of them agreed to participate. The results for recent quitters by self-report showed that the probability of remaining abstinent after 12 weeks was 74% for the intervention group and 37% for the control group. Only the half of the sample attended the visit at 3 months to confirm the abstinence biochemically. For smokers, 90.7% of the intervention group said that they would be ready to try to quit in the following 6 months, vs. 18.3% for the control group.
a proactive intervention in the postpartum period may reduce the probability of relapse in recent quitters and helps female smokers to make progress in the behavioural process of change. Such interventions should be included systematically in mother–child health services.
Health care providers' engagement in smoking cessation with pregnant smokers
2010, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing
To review how health care providers' (HCPs) engage in smoking cessation (SC) with pregnant smokers, and to examine the effect of system-level approaches and training initiatives to promote SC provision by HCPs.
A comprehensive search of the CINAHL, COCHRANE Library, EMBASE, ERIC, MEDLINE, PsycINFO, and SIGLE databases was conducted.
Selected studies assessed the behaviors of HCPs working among pregnant/postpartum girls and women, employed a quantitative approach, and had clearly defined behavioral outcomes of HCPs' delivery of SC to pregnant smokers.
A total of 988 studies were obtained from the literature search, of which 28 publications met the inclusion criteria. The data extracted from the articles are presented under the following areas: how HCPs are engaging pregnant smokers and approaches to enhancing SC by HCP with pregnant smokers.
Although more than 50% of HCPs are likely to ask women about their smoking status and advise pregnant smokers to quit, fewer than 50% either assess readiness to change, assist in smoking cessation, or arrange for follow-up appointments/referrals. Important provider-specific, patient-specific, and system/organizational barriers were found to hinder the provision of SC by HCP. Several system-level and training approaches to enhancing HCP's engagement in SC with pregnant smokers show merit.
Few HCPs working with pregnant women use all the components of the Agency for Healthcare Research and Quality clinical guidelines. However, system-level and training approaches are effective ways to enhance HCP's engagement in SC; although, the effects of such initiatives may not be sustained. Factors such as the gender of the provider, geographical location, and the use of women-centered treatment approaches could be further examined in relation to provision of SC by HCPs among pregnant smokers.
Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review
2022, Journal of General Internal Medicine
Relapse prevention interventions for smoking cessation
2019, Cochrane Database of Systematic Reviews

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Research ArticlesSmoking relapse prevention during pregnancy: A trial of coordinated advice from physicians and individual counseling

Abstract

Introduction

Section snippets

Methods

Comparability of groups

Discussion

Acknowledgements

Addict Behav

Am J Prev Med

Smoking during pregnancy

NZ Med J

Comparing the prevalence of smoking in pregnant and nonpregnant women, 1985 to 1986

JAMA

A review of smoking in pregnancyeffects on pregnancy outcomes and cessation effects

Annu Rev Pub Health

Smoking reduction during pregnancy by a program of self-help and clinical support

Obstet Gynecol

Postpartum smoking

Smoking relapse prevention counseling during prenatal and early postnatal care

Am J Prev Med

Training obstetric and family practice residents to give smoking cessation advice during prenatal care

Am J Obstet Gynecol

Research Articles
Smoking relapse prevention during pregnancy: A trial of coordinated advice from physicians and individual counseling