The process of pregnancy smoking cessation: implications for interventions.

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

A process evaluation model for patient education programs for pregnant smokers.

OBJECTIVE: To describe and apply a process evaluation model (PEM) for patient education programs for pregnant smokers. METHODS: The preparation of a process evaluation plan required each program to define its essential "new" patient assessment and intervention procedures for each episode (visit) of patient-staff contact. Following specification of these core implementation procedures (p) by each patient education program, the PEM, developed by the Smoke-Free Families (SFF) National Program Office, was applied. The PEM consists of five steps: (1) definition of the eligible patient sample (a); (2) documentation of patient exposure to each procedure (b); (3) computation of procedure exposure rate (b/a = c); (4) specification of a practice performance standard for each procedure (d); (5) computation of an implementation index (c/d = e) for each procedure. The aggregate of all indexes (e) divided by the number of procedures (P(n)) produced a program implementation index (PII = Sigmae/P(n)). PARTICIPANTS AND SETTINGS: Data from four SFF studies that represent different settings were used to illustrate the application of the PEM. RESULTS: All four projects encountered moderate to significant difficulty in program implementation. As the number and complexity of procedures increased, the implementation index decreased. From initial procedures that included patient recruitment, delivery of the intervention components, and conducting patient follow ups, a variety of problems were encountered and lessons learned. CONCLUSION: This process evaluation provided specific insight about the difficulty of routine delivery of any new methods into diverse maternity care setting. The importance of pilot testing all procedures is emphasised. The application of the PEM to monitor program progress is recommended and revisions to improve program delivery are suggested.

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

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

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care.

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%). CONCLUSIONS: 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.

The use of significant reduction rates to evaluate health education methods for pregnant smokers: a new harm reduction behavioral indicator?

This article evaluates the evidence to support the use of biochemical measurement of significant reduction (SR) rates among pregnant smokers as a new behavioral indicator of "harm reduction" (HR). The results of four studies--three randomized patient education clinical trials of pregnant smokers (Trials I, II, and III) and an epidemiological study (Study IV)--are presented. Among Trial I, II, and III cohorts of pregnant smokers, control group SR rates of 7% (I), 9% (II), and 20% (III) were increased among experimental groups to 17% (I), 18% (II), and 32% (III) by the same patient education methods. Analyses of infant birthweight data in Study IV found that a patient SR rate representing a 50% or more decrease between a baseline and follow-up test was associated with an increase in adjusted birthweight of 92 grams.

Factors associated with occupational exposure and compliance with universal precautions in an urban school district.

Factors associated with occupational exposure and universal precautions (UP) compliance were assessed among employees in one urban school district. Half of the employees surveyed reported responding to bleeding injuries and cleaning blood or other body fluids (e.g., vomit, urine) during the previous school year. Also, 1 in 4 custodians and 1 in 10 teachers/teacher's aides had direct contact with blood or body fluids without protection. In multivariate logistic regression analyses, direct contact was most likely among secondary school employees in unpredictable situations who did not have protective equipment or comply with UP. UP compliance was greater among those who had protective equipment available and felt self-confident. Self-confidence was associated with having received training or protective equipment. Routine communications between administrators and employees, staff training, provision of protective equipment, and exposure incident monitoring are essential to effective implementation of UP policies in schools and work settings where occupational exposure could occur.

Predictors of smoking cessation during pregnancy.

AIMS: The purpose of this study was to determine predictors of smoking cessation from a sample of pregnant Medicaid recipients. Of special interest was whether patient stage of change, based on the transtheoretical model, was predictive of smoking behavior change during pregnancy. PARTICIPANTS/SETTING: The sample was drawn from a cohort of pregnant smokers who were participants in a prospective, randomized clinical trial conducted in four public health maternity clinics in Birmingham, Alabama, USA. DESIGN/MEASUREMENTS: The 435 participants entered prenatal care on or before their 24th week of gestation and had saliva collected for cotinine assays at baseline and follow-up. In this secondary analysis, descriptive statistics defined the sample, cross-tabulation procedures identified a preliminary set of predictor variables, and discriminant function analyses predicted group membership--quitter or smoker. FINDINGS/CONCLUSIONS: Discriminant function analyses revealed that patient baseline cotinine value, duration of smoking habit, self-efficacy, exposure to environmental tobacco smoke, and exposure to patient education methods were predictive of non-smoking status assessed during the third trimester of pregnancy.

A meta-evaluation of smoking cessation intervention research among pregnant women: improving the science and art.

In 1986 Windsor and Orleans described guidelines and standards to evaluate the quality of smoking cessation intervention research among pregnant women. This paper presents a meta-evaluation (ME) of the evaluation research in this area from 1986 to 1998. ME is defined as a systematic review of experimental and quasi-experimental evaluation research using a standardized set of methodological criteria to rate the internal validity--efficacy or effectiveness--of intervention results. Five criteria were used to rate 23 smoking cessation intervention studies among pregnant smokers in prenatal care: (1) evaluation research design, (2) sample representativeness, sample size and power estimation, (3) population characteristics, (4) measurement quality, and (5) replicability of interventions. Eleven studies had sufficient methodological quality to produce results of high internal validity. Poor measurement of smoking status, patient selection biases and incorrect calculation of quit rates were the major methodological weakness. Recommendations for future evaluation research are made.

Quality of measurement of smoking status by self-report and saliva cotinine among pregnant women.

OBJECTIVE: The objectives of this paper were to determine the rate of misclassification of smoking and nonsmoking status by self-reports and saliva continine of pregnant women participating in a smoking cessation trial, determine the relationship of the number of cigarettes smoked per day and saliva continine, and examine whether misclassification was due to an inappropriate saliva continine cutoff point. METHODS: End of pregnancy self-reports of smoking status and saliva continine were used to calculate misclassification rates. RESULTS: The findings revealed that 61 of 441 self-reported smokers had biochemical values inconsistent with smoking status for a smoking misclassification rate of 13.8%. The results also revealed that 28 of 107 self-reported quitters had continine values consistent with smoking status for a nonsmoking misclassification rate of 26.2%. Receiver Operating Characteristic (ROC) curves were then plotted to determine whether misclassification resulted from an inappropriate cutoff point. The continine cutoff point that maximized sensitivity and specificity for all women was 24 ng/ml. Racial ROC comparisons indicated a higher cutoff point for blacks than whites. Use of any of the ROC indicated cutoff points would not change the misclassification rates. CONCLUSIONS: These findings suggest that underreporting of smoking status during pregnancy is high and that social desirability of nonsmoking status may have contributed to the lack of precision in saliva continine to distinguish smoking status in this study.

Cost differences between low birthweight attributable to smoking and low birthweight for all causes.

BACKGROUND: Low birthweight (< 2,500 g) is one of the major predictors of infant mortality. The clinical salience of low birthweight depends on its severity. The impact of smoking on low birthweight is greater in the 1,500-2,499-gm category than below 1,500 gm. This has an important implication for economic analyses of smoking cessation programs for pregnant women. Because health care cost is closely associated with birthweight, the cost of low birthweight attributable to smoking may be different than the average cost of low birthweight for all causes. Little is known about such cost differences. METHODS: The population-attributable risk was used to estimate the number and percentage of low-birthweight infants due to maternal smoking. Costs by birthweight groups were used to determine cost differences between low birthweight due to smoking and for all causes. RESULTS: The net incremental costs per low birthweight due to smoking range from $4,256 to $8,640 compared to the costs of $5,213 to $10,306 per low birthweight by all causes. The cost differences may be up to 18%. CONCLUSION: Considerably lower costs at birth were found in low birthweight due to smoking than for all causes. The cost difference was attributable to the difference in the severity of low birthweight.

The impact on infant birth weight and gestational age of cotinine-validated smoking reduction during pregnancy.

OBJECTIVE: To evaluate the impact of cotinine-confirmed smoking reduction during pregnancy on infant birth weight and gestational age at birth. DESIGN: Group analyses from a prospective, randomized smoking-cessation intervention trial using cotinine levels to assess smoking cessation and reduction. SETTING: Four maternity clinics of Jefferson County Health Department in Birmingham, Ala. PATIENTS: A total of 803 pregnant smokers and 474 never smokers with a fetal gestational age of 32 weeks or less at the first prenatal visit to a clinic. MAIN OUTCOME MEASURES: Infant birth weight and gestational age at birth. RESULTS: Infants who were born to women who quit smoking (quitters) had the highest mean birth weight (3371 +/- 581 g), followed by infants who were born to women who did not change smoking behavior (no changers) (3043 +/- 587 g). The mean infant birth weight of infants born to the quitters, adjusted by mother's age, race, height, weight at baseline, and gestational age at delivery was 241 g heavier than that among the no changers (P = .0008) and 167 g heavier than the reducers (P = .04). The adjusted mean infant birth weight of infants born to the reducers was 92 g heavier than that among the no changers (P = .08). White reducers with baseline cotinine levels greater than 100 ng/mL had infants who were 241 g heavier than did white no changers. A 220-g difference was also seen in black reducers with a baseline cotinine level of 100 ng/mL or less. Although smoking cessation increased infant gestational age at delivery by 1 week, smoking reduction had little effect. CONCLUSION: Cotinine-validated smoking reduction rates were positively associated with an increase in infant birth weight. While smoking cessation must continue to be the primary objective for pregnant smokers, specific intervention methods should also be directed toward smoking reduction for women who cannot quit.

The dissemination of smoking cessation methods for pregnant women: achieving the year 2000 objectives.

The smoking prevalence rate among adult women and pregnant women has decreased only 0.3 to 0.5% per year since 1969. Without a nationwide dissemination of efficacious smoking cessation methods based on these trends, by the year 2000 the smoking prevalence among pregnant women will be approximately 18%. This estimate is well above the US Department of Health and Human Services Year 2000 Objective of 10%. The US dissemination of tested smoking cessation methods could help an additional 12,900 to 155,000 pregnant smokers annually and 600,000 to 1,481,000 cumulatively to quit smoking during the 1990s. Dissemination could help achieve 31 to 78% of the Year 2000 Objectives for pregnancy smoking prevalence. (With dissemination, at best a 15% smoking prevalence during pregnancy, rather than the 10% objective, is likely to be observed.) Our results confirm a well-documented need for a national campaign to disseminate smoking cessation methods.

Health education for pregnant smokers: its behavioral impact and cost benefit.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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). CONCLUSION: Health education methods are efficacious and cost beneficial for pregnant smokers in public health maternity clinics.

A meta-evaluation of nutrition education intervention research among pregnant women.

Inadequate nutrition during pregnancy retards human fetal growth and increases the risk of delivering a low birthweight (LBW) infant. Some studies place particular emphasis on reducing LBW through improved nutrition. Consensus documents have strongly recommended intense nutrition education programs for patients at risk. Despite this well-defined need few methodologically rigorous studies have been conducted to evaluate the behavioral impact of nutrition education for pregnant patients. Criteria are recommended in the following areas: (1) research design, (2) sample size and power, (3) specification of population characteristics, (4) measurement quality, and (5) replication. The methodological quality of completed evaluations are reviewed using these criteria. The authors advocate guidelines for future investigators for conducting rigorous trials in this critical public health area.

Evaluation of the impact of dissemination of smoking cessation methods on the low birthweight rate and on health care costs: achieving year 2000 objectives for the nation.

Nationwide dissemination of efficacious and cost-effective smoking cessation methods during the 1990s represents an important part of the solution to reducing the low birthweight (LBW) rate and associated health care costs. A minimum of 250,000 LBW births must be prevented during the 1990s to achieve the year 2000 LBW rate objective of 5% of total births. Annually 1,500 to 6,000 LBW births might be prevented between 1991 and 2000, and cumulatively 29,000 to 44,000, by dissemination of tested smoking cessation methods. Twelve to eighteen percent of the objective might be accomplished by dissemination. LBW births attributable to smoking might be reduced from the current 20% to 26% rate to a rate of 9% to 12% if the overall maternal smoking prevalence rate is reduced to 10% as projected in the Year 2000 Objectives. Smoking-attributable health care cost savings from dissemination would range from $22 million to $59 million.

Quality assurance methods for managing employee health-promotion programs: a case study in smoking cessation.

Many worksite health-promotion projects only evaluate a program by documenting employee program utilization or by determining what behaviors have or have not been changed. The failure of a program may be due to its implementation rather than to the science of the intervention. Often, program implementation problems are overlooked. Many managers do not set up an implementation monitoring program to assess problems prior to breakdowns. This article describes how to monitor program implementation through the establishment of a Quality Assurance System in a worksite health-promotion program. A case study approach for a quit-smoking program administered to a large corporation will be used to demonstrate this method.