Tobacco treatment incorporating contingency management, nicotine replacement therapy, and behavioral counseling for pregnant women who use substances: a feasibility trial.

Introduction: Most pregnant women with substance use problems smoke, and few will quit during their pregnancy. Tobacco treatment is often overlooked, with the focus usually placed on other substance use. Additionally, few targeted effective treatments for this group exist. To address this, the feasibility of an intensive tobacco treatment incorporating contingency management (CM) that featured non-face-to-face delivery was examined. Methods: A single-arm pre-post design feasibility trial was conducted in three antenatal services that support women who use substances in metropolitan Australia. Participants were over the age of 15, had <33-week gestation, and smoked tobacco daily. They received financial incentives for daily carbon monoxide-verified smoking abstinence or reduction through an internet-based CM programme, nicotine replacement therapy (NRT) posted to women and partners or household members who smoked and telephone-delivered behavioral counseling from study enrolment to birth. Results: Of the 101 referrals, 46 women (46%) consented. The mean (SD) age was 31(±6) years, and the gestation period was 22(±6) weeks. Nineteen (41%) of those enrolled were retained for 12-week postpartum. Of 46 women, 32 (70%) utilized CM; 32 (70%) used NRT for ≥2 weeks; 23 (50%) attended ≥1 counseling session; and 15 (22%) received NRT for partners/household members. Fifteen (33%) were verified abstinent from tobacco at delivery after a median (IQR) period of abstinence of 65(36-128) days. All non-smokers at birth utilized NRT and financial incentives, and 9/15 (60%) utilized counseling. Four (9%) were abstinent at 12-week postpartum. Median cigarettes smoked/day reduced from baseline to delivery (10(6-20) to 1(0-6) p =< 0.001). Women who quit smoking had more education (72% vs. 33% p =< 0.02), completed more CO samples (median (IQR) 101(59-157) vs. 2(0-20) p =< 0.001), and received more incentives (median (IQR) $909($225-$1980) vs. $34($3-$64) p =< 0.001). Intervention acceptability was rated favorably by participants (9 items rated 0-10 with scores >5 considered favorable). Discussion: This study demonstrated the feasibility and acceptability of a consumer-informed, non-face-to-face intensive tobacco treatment, highlighting the potential of remotely delivered technology-based CM to reduce the health impact of tobacco smoking in high-priority populations. The intervention demonstrates scale-up potential. Future studies should extend treatment into the postpartum period, utilizing new technologies to enhance CM delivery and improve counseling provision and partner support. Clinical trial registration: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374196, ACTRN1261800056224.

Evaluation of Aboriginal and Torres Strait Islander smoking cessation interventions with pregnant women in Australia: utilising a culturally appropriate tool.

The purpose of this article was to review and evaluate three Australian projects with a focus on smoking cessation and Aboriginal and Torres Strait Islander pregnant women, funded under the Tackling Indigenous Smoking Innovation Grants Scheme, Australian Department of Health. The aim was to determine the impacts of culturally appropriate smoking cessation support for pregnant Aboriginal and Torres Strait Islander women. To provide an equity-focused lens to the review, our team of Indigenous and non-Indigenous researchers utilised an Australian-developed assessment tool: the 'Cultural Identity Interventions Systematic Review Proforma'. The tool was used to measure cultural approaches across a range of domains, and these were independently assessed by two reviewers, along with an assessment of the projects' smoking cessation outcomes. The results were compared to the evidence base in relation to aims, methods, results and conclusions, and consensus for scoring was reached. The review found that these Tackling Indigenous Smoking projects about pregnancy intentionally and effectively incorporated culturally based approaches that sought to work with the participants in culturally informed ways. Each project utilised existing social networks and partnerships to provide their participants with access to a range of community resources, adding value to existing programs.

My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy.

BACKGROUND: Most women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited. AIM: This paper aims to explore Aboriginal women's experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received. METHODS: Qualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed. RESULTS: Major themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation. CONCLUSION: This qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.

Using mixed methods to establish tobacco treatment acceptability from the perspective of clients and clinicians of antenatal substance use services.

BACKGROUND: Up to 95% of pregnant women with alcohol and other drug (AOD) problems also smoke tobacco. Challenging psychosocial circumstances and a lack of targeted tobacco interventions contribute to low rates of prenatal abstinence and more effective treatment strategies are required. This study explores smoking in pregnant clients of AOD treatment services from a consumer and healthcare provider perspective to examine characteristics of behaviour change and the acceptability of evidence-based tobacco treatment strategies. Outcomes will support the design and implementation of a comprehensive tobacco intervention. METHODS: A mixed methods triangulated design was used. Thirteen women who smoked and attended antenatal AOD services in New South Wales, Australia, were interviewed and 28 clinicians from the same services were surveyed. Domains including experiences of tobacco smoking in pregnancy, motivators and barriers to cessation and evidence-based strategies to assist cessation during pregnancy were explored. Interviews were analysed using Iterative Categorization, with interpretation guided by Qualitative Description. Online surveys were analysed descriptively. A convergent-parallel mixed methods analysis was performed. RESULTS: Women and clinicians agreed that improving baby's health outcomes was the primary motivation to stop smoking. Negative experiences with nicotine replacement therapy (NRT), financial constraints and maternal contraindications restricted its uptake and effectiveness during pregnancy. Both groups agreed that other AOD use, stopping multiple substances concurrently, difficulty coping with stress and the influence of partners who smoke had the biggest impacts on cessation efforts. Clinicians favoured harm-reduction rather than abstinence-based tobacco interventions and women appeared satisfied with reduction efforts. Both views may influence the attainment of prenatal abstinence-based goals. Although previous evidence suggested the contrary, clinicians were willing to encourage simultaneous cessation of tobacco and other substances. Non-judgmental treatment approaches that provide extra support, education and motivation were important for women. Women and clinicians supported use of NRT despite concerns. Financial incentives, counselling, partner support and offering tobacco treatment with antenatal AOD care were considered acceptable treatment options. CONCLUSIONS: NRT, incentives, counselling and partner support could be utilized in a tobacco intervention for pregnant women with substance use concerns. Non-judgmental education, motivation, and provision of NRT including instruction for correct use are important considerations.

SISTAQUIT: training health care providers to help pregnant Aboriginal and Torres Strait Islander women quit smoking. A cluster randomised controlled trial.

BACKGROUND: About 44% of Indigenous Australian women smoke during pregnancy, compared with 12% of pregnant non-Indigenous women. Health care providers can assist smoking cessation, but they are not typically trained in culturally appropriate methods. OBJECTIVES: To determine whether a health care worker training intervention increases smoking cessation rates among Indigenous pregnant smokers compared with usual care. METHODS AND ANALYSIS: Supporting Indigenous Smokers to Assist Quitting (SISTAQUIT) study is a multicentre, hybrid type 1, pragmatic, cluster randomised controlled trial that compares the effects of an intervention for improving smoking cessation by pregnant Indigenous women (16 years or older, 32 weeks' gestation or less) with usual care. Twenty-one health services caring for Indigenous people in five Australian jurisdictions were randomised to the intervention (ten sites) or control groups (eleven sites). Health care providers at intervention sites received smoking cessation care training based on the ABCD (ask/assess; brief advice; cessation; discuss psychosocial context) approach to smoking cessation for Indigenous women, an educational resource package, free oral nicotine replacement therapy for participating women, implementation support, and trial implementation training. Health care providers in control group services provided usual care. PRIMARY OUTCOME: abstinence from smoking (self-reported abstinence via survey, validated by carbon monoxide breath testing when possible) four weeks after enrolment in the study. SECONDARY OUTCOMES: health service process evaluations; knowledge, attitudes, and practices of health care providers; and longer term abstinence, perinatal outcomes, and respiratory outcomes for babies (to six months). Ethics approval: The human research ethics committees of the University of Newcastle (H-2015-0438) and the Aboriginal Health and Medical Research Council of NSW (1140/15) provided the primary ethics approval. Dissemination of results: Findings will be disseminated in peer-reviewed publications, at local and overseas conferences, and via public and social media, and to participating health services in art-based formats and reports. Policy briefs will be communicated to relevant government organisations. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry, ACTRN12618000972224 (prospective).

Smoking cessation interventions for pregnant women attending treatment for substance use disorders: A systematic review.

BACKGROUND AND AIMS: Up to 95% of pregnant women seeking treatment for alcohol and other drug (AOD) use smoke tobacco. Previous reviews indicate few effective smoking cessation treatments for this group. This updated review aimed to identify and measure the efficacy of smoking cessation interventions trialled among pregnant women in AOD treatment settings who smoke tobacco. METHODS: A narrative synthesis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies involving psychological, behavioural or pharmacological interventions used to treat tobacco use, including electronic nicotine delivery systems, for pregnant women of any age, who smoked tobacco and were seeking/receiving treatment, or in post-treatment recovery for AOD concerns, were reviewed. MEDLINE, PsycINFO, CINAHL, EMBASE and ProQuest databases, grey literature and reference lists were searched, and field experts were contacted for unpublished study data. The Effective Public Health Practice Project tool assessed study quality. The review was pre-registered with PROSPERO no. CRD42018108777. RESULTS: Seven interventions (two randomised controlled trials, two single-arm pilot studies, two program evaluations and one causal comparative study) treating 875 women were identified. All were United States (US)-based and targeted women with drug dependence, but not alcohol dependence. Three interventions used contingency management, five provided behavioural counselling, and one offered nicotine replacement therapy. All reported reductions in cigarette consumption; one contingency management-based study demonstrated higher abstinence rates compared with controls at treatment-end that were not maintained at follow-up. Four of six studies were rated as methodologically weak and one unpublished study was not rated. CONCLUSIONS: Conclusions about the efficacy of smoking interventions for pregnant women with alcohol and other drug concerns who also smoke tobacco are hindered by the paucity of available data and poor methodological quality of included studies.

Factors Associated with Smoke-Free Pregnancy among Aboriginal and Torres Strait Women and Their Experience of Quitting Smoking in Pregnancy: A Mixed Method Cross-Sectional Study.

Smoke-free pregnancies have long-term health benefits for mothers and babies. This paper quantitatively examines factors associated with smoke-free pregnancies among Aboriginal and Torres Strait Islander women (hereafter Aboriginal women) and qualitatively explores their smoking cessation (SC) experiences during pregnancy. An Aboriginal-led online cross-sectional study on SC was conducted with Aboriginal women and in partnership with Aboriginal communities, between July and October 2020. The present analysis includes participants who made a pregnancy-related quit attempt (N = 103). Chi-squared tests, logistic regression models, and thematic analysis of free-form text responses were performed. The adjusted odds of having smoke-free pregnancies were 4.54 times higher among participants who used Aboriginal Health Services (AHS) (AOR = 4.54, p-value 0.018). Participants living in urban settings had 67% lower odds of having smoke-free pregnancies compared to their regional/remote counterparts (AOR = 0.33, p-value 0.020). Qualitative data revealed strong motivations to reduce tobacco-related harms to the fetus and variability in quitting experiences at different stages of and across pregnancies. Smoking cessation care (SCC) can support Aboriginal women meaningfully if their quitting experiences are considered in SCC development and implementation. Consistent funding for AHS-led SCC is needed to garner health benefits for Aboriginal peoples. More research into urban versus regional/remote differences in maternal SC is recommended.

Perspectives about smoking cessation during pregnancy and beyond of Aboriginal women in Australia: A qualitative analysis using the COM-B model.

OBJECTIVE: Aboriginal and Torres Strait Islander women (hereafter Aboriginal) and their babies experience poor health outcomes for which smoking is a major risk factor. This paper explores Aboriginal women's perspectives on and experiences of smoking cessation, within and outside pregnancy, and their use of smoking cessation services using the COM-B (Capability, Opportunity, Motivation as determinants of Behaviour) model to understand Aboriginal women's capabilities, opportunities, and motivation for smoking cessation. METHODS: Data came from 11 focus groups conducted in regional New South Wales, Australia, with 80 women aged between 16 and 68 years. Thematic analysis was performed following the COM-B model. RESULTS: Seven themes related to capability, opportunity, motivation, and smoking cessation behaviors were identified. The themes highlighted that agency, knowledge, and self-efficacy (as capability), a supportive social environment, and access to culturally appropriate services and resources (as opportunities), together with automatic and reflective motivations for quitting, may enable short- or long-term smoking cessation. CONCLUSION: Smoking cessation interventions may be more effective if the dynamics of the COM-B factors are considered. Policy and practice changes for further enhancing regional Aboriginal women's psychological capability and supportive social environments, and making smoking cessation services culturally appropriate are warranted.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies.

BACKGROUND: Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework. METHODS: A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW's and HPs' quotes, as well as the authors' analysis, were extracted and double-coded (30%) using the COM-B framework. RESULTS: Thirty-two studies included research from 5 continents: twelve on HPs' perspectives, 16 on PW's perspectives, four papers included both. HPs' capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women's psychological state (capability) and stressors into consideration. Pregnant women's physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women's motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement. CONCLUSIONS: HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs' and PW's attitudes and supportive campaigns for pregnant smokers.

Ngaa-bi-nya-nhumi-nya (to Test First): Piloting the Feasibility of Using the Growth and Empowerment Measure with Aboriginal Pregnant Women Who Smoke.

INTRODUCTION: Aboriginal pregnant women who smoke experience barriers to quitting, including challenges to social and emotional well-being, but these are infrequently quantified. Finding an appropriate measurement tool in this setting is crucial to increase knowledge for holistic smoking cessation interventions. AIMS: To pilot the Growth and Empowerment Measure (GEM) with a sample of pregnant Aboriginal women who smoke. METHODS: Aboriginal women participating in the step-wedge ICAN QUIT in Pregnancy pilot study completed the GEM comprised of 14-item Emotional Empowerment Scale (EES14), 12 Scenarios (12S), and K6 items at baseline, 4 weeks, and 12 weeks. Qualitative interviews with service staff were held at the end of the study to assess feasibility. RESULTS: 15 pregnant Aboriginal women took part between November 2016 and July 2017. At 12 weeks, n = 8/12 (67%) of women reported an increase in both the EES14 and 12S scores. Total 12S scores were significantly higher at 12 weeks (p = 0.0186). Total K6 had a nonsignificant trend for reduction (p = 0.0547). Staff reported that the length of the survey presents challenges in this setting. CONCLUSIONS: A shortened, modified GEM is recommended in this setting. We recommend the GEM to be tested in a larger study, powered to assess its associations with smoking behaviours.

Feasibility of Audio-Recording Consultations with Pregnant Australian Indigenous Women to Assess Use of Smoking Cessation Behaviour Change Techniques.

INTRODUCTION: Behavioural counselling is an effective method to improve smoking cessation during pregnancy. Audio recordings of consultations have been used previously to assess fidelity in specialized smoking cessation services, but not in primary care. AIMS: The study is aimed at assessing the feasibility of audio-recording smoking cessation counselling as part of an intervention in primary care settings and exploring the number and type of behaviour change techniques (BCTs) delivered. METHODS: This study was a nested feasibility study within a larger trial. Health providers (HPs) and pregnant women were asked to agree or decline audio recording their smoking-related consultations. Data collected included percentage providing consent, number of recordings performed, HP type, and date (pre/post intervention). Interviews were conducted to assess the trial procedures' acceptability. RESULTS: Two services provided seven recordings, all pre-intervention. Of the 22 recruited women, 14 consented to being audio recorded (64%) and five provided recordings; of the 23 recruited HPs, 16 agreed (69%), and two provided recordings. Qualitative data suggest that HPs found audio recording difficult to remember. HPs spent on average two minutes discussing smoking and used few BCTs. CONCLUSIONS: Audio recordings of smoking-related counselling were not feasible as planned. Future research will need to explore acceptable methods to assess BCT use in primary care.

The effectiveness of technology-based interventions for smoking cessation: An umbrella review and quality assessment of systematic reviews.

ISSUES: With the advancement and rapid increase in the public's interest in utilisation of Internet and mobile phones, technology-based interventions are being implemented across a range of health conditions to improve patient outcomes. The aim of this review was to summarise findings from systematic reviews that evaluated the effectiveness of technology-based smoking cessation interventions and to critically appraise their methodological qualities. APPROACH: An umbrella review was conducted using studies identified from a comprehensive literature search of six databases and grey literature. All included systematic reviews were checked for eligibility criteria and quality using the Assessment of Multiple Systematic Reviews tool. The level of evidence for each intervention category was assessed, citation matrices were generated and corrected covered area was calculated. KEY FINDINGS: Five systematic reviews with a total of 212 randomised controlled trials and 237 760 participants were included. Fourteen intervention approaches were identified and classified into three categories: stand-alone web-based; stand-alone mobile phone-based and multicomponent interventions. Incorporating web and/or mobile-based interventions with face-to-face approach improved the rate of smoking cessation. However, there was no consistent evidence regarding the effectiveness of stand-alone Internet or mobile-based interventions. IMPLICATIONS: Policymakers are recommended to develop strategies that enable health professionals to integrate these approaches with face-to-face smoking cessation support. Health professionals are recommended to be trained and equipped for online and mobile-based interventions. CONCLUSION: Adding technology-based intervention to face-to-face smoking cessation support improves smoking cessation. Further research is needed to evaluate stand-alone web-based and mobile phone-based interventions.

Socioecological Mapping of Barriers and Enablers to Smoking Cessation in Indigenous Australian Women During Pregnancy and Postpartum: A Systematic Review.

BACKGROUND: With a high prevalence of smoking during pregnancy and limited Indigenous-specific evidence for treatment, we used socioecological mapping to identify multilevel barriers and enablers to smoking cessation related to Indigenous Australian pregnant and postpartum women. METHODS: Nine electronic databases were searched. Original studies except interventions and trials, published in English, up to February 29, 2020 were included. Studies were appraised using the QualSyst tool. Evidence was narratively synthesized. The review protocol was registered with PROSPERO (CRD42019135543). RESULTS: A total of 15 studies (10 quantitative, 5 qualitative) were included, covering 1306 women, 3 partners/family members, 234 health professionals (HP), and 2755 patient records. Complex and overlapping barriers were identified at individual, family, community, societal, and system levels. Socioeconomic disadvantages, inequality, and pervasive racism as legacies of colonization, combined with personal, family, and community circumstances intensified individual experiences of stress, which may be heightened during pregnancy. Inadequate smoking cessation care (SCC), inconsistent antitobacco messages, and ineffectual HP interventions underscore a need for service enhancement and further evidence to develop culturally relevant messages. High motivation of pregnant women to quit, resilience, and supports available in the family and community are strengths that warrant attention in future interventions. CONCLUSIONS: SCC without ameliorating the social disadvantages and the disparities in health determinants between Indigenous and non-Indigenous Australian women may limit the effectiveness of SCC. A comprehensive approach is required that includes policy changes for addressing external stressors the women experience, engagement of family and community, and better training of HP and provision of free pharmacotherapy. IMPLICATIONS: To systematically address barriers to smoking cessation at multiple levels, initiatives to ameliorate social disadvantages and discrepancies in social determinants of health between Indigenous and non-Indigenous Australians are required to be taken in tandem with SCC. Initiatives may include making relevant policy changes and allocating more resources for education, employment, housing, and community development. Enhancement of knowledge, skills, and confidence of HP regarding the provision of high-quality SCC for Indigenous women and their families is warranted. Future interventions may build on high motivation, resilience, and strengths of individual women, and incorporate support strategies engaging family and community.

Supports Used by Aboriginal and Torres Strait Islander Women for Their Health, including Smoking Cessation, and a Baby's Health: A Cross-Sectional Survey in New South Wales, Australia.

This study explored Aboriginal and Torres Strait Islander women's use of supports for their general health, for smoking cessation, and the health of babies or children, and analyzed the women's predictors for seeking types of support. Aboriginal and Torres Strait Islander women were recruited for a cross-sectional survey in two regions of NSW N = 132. The 19-item survey questioned the likelihood that the participant would use the various supports for their health, to quit smoking, and for a baby or child's health. Logistic regression analyses were performed on N = 98 with complete data. Older participants were less likely to use Facebook or the internet for their health, or the health of a child, but were more likely to consult with health professionals. Women who had quit smoking were less likely to use an app for their health compared to smokers. Women who had a child living in their household were less likely to use the internet for a child's health. This community-based study revealed age-related differences for access to health services and differences according to smoking status. Patterns of internet and app use warrant further consideration when planning strategies to improve Aboriginal and Torres Strait Islander women and children's health.

Respiratory, birth and health economic measures for use with Indigenous Australian infants in a research trial: a modified Delphi with an Indigenous panel.

BACKGROUND: There is significant disparity between the respiratory health of Indigenous and non-Indigenous Australian infants. There is no culturally accepted measure to collect respiratory health outcomes in Indigenous infants. The aim of this study was to gain end user and expert consensus on the most relevant and acceptable respiratory and birth measures for Indigenous infants at birth, between birth and 6 months, and at 6 months of age follow-up for use in a research trial. METHODS: A three round modified Delphi process was conducted from February 2018 to April 2019. Eight Indigenous panel members, and 18 Indigenous women participated. Items reached consensus if 7/8 (≥80%) panel members indicated the item was 'very essential'. Qualitative responses by Indigenous women and the panel were used to modify the 6 months of age surveys. RESULTS: In total, 15 items for birth, 48 items from 1 to 6 months, and five potential questionnaires for use at 6 months of age were considered. Of those, 15 measures for birth were accepted, i.e., gestational age, birth weight, Neonatal Intensive Care Unit (NICU) admissions, length, head circumference, sex, Apgar score, substance use, cord blood gas values, labour, birth type, health of the mother, number people living in the home, education of mother and place of residence. Seventeen measures from 1-to 6 months of age were accepted, i.e., acute respiratory symptoms (7), general health items (2), health care utilisation (6), exposure to tobacco smoke (1), and breastfeeding status (1). Three questionnaires for use at 6 months of age were accepted, i.e., a shortened 33-item respiratory questionnaire, a clinical history survey and a developmental questionnaire. CONCLUSIONS: In a modified Delphi process with an Indigenous panel, measures and items were proposed for use to assess respiratory, birth and health economic outcomes in Indigenous Australian infants between birth and 6 months of age. This initial step can be used to develop a set of relevant and acceptable measures to report respiratory illness and birth outcomes in community based Indigenous infants.

Intensive Behavioural and Pharmacological Treatment for Tobacco Dependence in Pregnant Women with Complex Psychosocial Challenges: A Case Report.

Up to 95% of women who use other substances also smoke tobacco during pregnancy. Challenging psychosocial circumstances and other barriers that contribute to high levels of tobacco dependence result in few quitting successfully. This case report describes the treatment of a highly tobacco dependent 34-year-old pregnant woman with a history of recent substance use, mental illness and trauma, enrolled in the Incentives to Quit Tobacco in Pregnancy program. Heavy smoking, both during the day and overnight, was reported. An extensive history of quit attempts, as well as a strong desire to cease tobacco use during pregnancy, was also noted. Treatment utilising extensive behavioural supports, including financial incentives for carbon monoxide verified abstinence and telephone-based counselling, in combination with nicotine replacement therapy (NRT), was offered to assist cessation. Excellent uptake and adherence to all aspects of treatment saw tobacco cessation achieved and maintained for 24 weeks while on the program. NRT used at doses well above those recommended for pregnancy was required to alleviate strong withdrawal symptoms and maintain abstinence. Daily monitoring of carbon monoxide, financial incentives for continued abstinence and regular phone support were critical to maintaining motivation and preventing relapse to smoking. Post-program relapse to smoking did occur, as is common, and highlights the need for longer-term intensive support for pregnant women with complex behavioural and social problems. Given the prevalence of tobacco smoking in such populations, long-term harm reduction treatment models using extensive behavioural support in combination with NRT should be considered for inclusion in current smoking cessation guidelines.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting.

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.

Is open defaecation in outdoor recreation and camping areas a public health issue in Australia? A literature review.

ISSUE ADDRESSED: In Australia, natural areas used for outdoor recreation activities or camping often have limited or no sanitation infrastructure. Recreationist and campers may use open defaecation practices where toilets are not provided. Contaminated soils and watercourses are associated with gastrointestinal illnesses. This review aims to determine if open defaecation is a public health issue in outdoor recreation and camping areas in Australia. METHOD: A literature review was conducted using the following search engines: CINAHL, Informit Database, Scopus, ProQuest Science & Technology, Medline (Ovid) and EBSCOhost. Inclusion criteria for this review were both experimental and observational research designs for studies describing the public health issues associated with open defaecation practice. RESULTS: Out of 12 147 papers identified, only three studies met the inclusion criteria, showing a lack of research into this area. Included were two studies that addressed human waste management practices in outdoor environments and the breakdown of human waste in alpine regions of Tasmania. The third study measured water contamination at a freshwater beach on K'gari-Fraser Island, Queensland. Visitors to natural areas are potentially at high risk of illness due to exposure to faecal contamination from other visitors using unsafe open defaecation practices in high-use camping areas. CONCLUSION: The limited number of studies addressing open defaecation in the outdoor recreation and camp areas in Australia indicates this review is a starting point to identify critical areas that may be of concern when managing visitors in an outdoor recreation setting. This review recommends investigating barriers and enablers motivating human disposal waste in these settings to help formulate health promotion content; environmental management policies related to sanitation and hygiene should be also underpinned by public health policy; and providing appropriate sanitation options depending on the ecological and visitor numbers to natural areas. SO WHAT-RELEVANCE OF FINDINGS: Outdoor recreation activities offer physical and mental health benefits for communities. The popularity of outdoor recreation activities is on the increase in Australia. With the rise in visitation to natural areas, management of human waste needs to be addressed to reduce the public health risk of illness.