Better Practices: Promising Approaches to Tobacco Cessation During Pregnancy

Maternal smoking during pregnancy remains a serious public health problem. Despite concerted efforts by researchers and health care professionals, approximately 20-30% of pregnant women use tobacco during pregnancy.1 Many of these women do quit smoking during pregnancy, while others manage to reduce their tobacco use. However, cessation is often temporary, with the majority of women returning to cigarette use either during pregnancy or soon after the baby is born. Tobacco cessation during pregnancy has considerable positive health ramifications for both women and fetuses, and reduces health problems for children born to mothers who smoke. However, facilitating successful and sustained tobacco cessation during pregnancy is an ongoing public health challenge.

A thorough review of smoking cessation interventions and programs for pregnant and postpartum women and girls was conducted to determine the most effective strategies to facilitate smoking cessation during pregnancy and into the postpartum period. Over 65 published and unpublished smoking cessation programs and interventions were reviewed. Using a Better Practices model, interventions were evaluated on the strength of their methodology and the evidence of their effectiveness. Based on this process, six interventions were recommended for use with pregnant smokers and fourteen interventions were deemed to be "showing promise." Final Better Practice recommendations were generated based on diis analysis of existing literature, along with an examination of theoretical work and broader literature in the field, and the incorporation of expert opinion.

Recommendations for Better Practice

The Better Practice recommendations generated from this review span practice, research, and structural issues. They include increased emphasis on women's health as a motivation for cessation, increased tailoring of interventions, and incorporation of harm reduction, stigma reduction, and woman-centred approaches into clinical practice. The approaches or perspectives derived from these recommendations, outlined in further detail below, may be applied directly to tobacco cessation interventions for pregnant smokers or integrated into future cessation research.

1. Tailoring

The reasons underlying women's smoking patterns are varied and complex, reflecting social, cultural, economic, and biological influences. The need for tailored interventions, reflecting the specific social and economic contexts of sub-populations of pregnant smokers, became increasingly clear during the course of this review. In particular, effective tailored interventions for certain sub-populations of pregnant smokers, such as teenage girls, Aboriginal women, and heavy smokers, are entirely absent. Similar to intervention trends with smokers in general, tailored approaches to cessation will allow for more precise and effective matches between interventions, components, and pregnant smokers' circumstances.

2. Woman-centred Approach

Historically, smoking cessation interventions for pregnant women have used fetal health as a motivator to encourage quitting. Although this approach has achieved some success, the cessation is generally not sustained. A focus on fetal health fails to provide long-term motivation for abstaining from tobacco use and fails to acknowledge the value of the woman's own health. Adopting a woman-centred approach to smoking cessation during pregnancy shifts the emphasis from pregnancy-related reasons for cessation to motivations that are more universal and long-lasting. In addition, this approach places importance on the woman's health before and during pregnancy, as well as beyond the postpartum period.

Woman-centred cessation interventions are also cognizant of a woman's social, psychological, and economic context. Issues such as financial circumstances, experience of violence, and whether or not a pregnancy was planned, should all be explored. A woman-centred approach views the pregnancy period as a time of hope and a key opportunity for change.

3. Stigma Reduction and Harm Reduction

Increasingly restrictive smoking policies and the move towards denormalization of tobacco use have created an atmosphere where smokers, particularly pregnant smokers, are increasingly condemned and stigmatized. Clinical interventions with pregnant smokers should address the effects of increased public pressures. For example, an intervention using the "Five As" (Ask, Advise, Assess, Assist, Arrange follow-up) could also integrate "Awareness of stigma." Increased public awareness is also needed about tobacco use as a reflection of social and economic circumstances rather than a "lifestyle choice."

Although the principles of harm reduction have been widely used in developing drug and alcohol use interventions, they have never been fully applied to tobacco use. A broad-based harm reduction approach means that all measures possible are undertaken to reduce the harmful effects of smoking to women and their fetuses. Pregnant smokers should be encouraged to decrease the number of cigarettes they smoke, and to cease smoking even at later stages of pregnancy. Interventions using a harm reduction approach could include nutritional improvements to offset the effects of smoking, better integration of nicotine replacement therapies, the promotion of stress reduction techniques, and potentially, supplementation of folate to pregnant smokers.

4. Relapse Prevention

Relapse is a significant problem for pregnant smokers who quit. Relapse rates vary, but are reported as approximately 25% before delivery, 50% within four months postpartum, and 70-90% by one year postpartum.2 Relapse prevention did not emerge as a key component of interventions in this review. It is particularly important to create specific interventions for women who quit spontaneously during pregnancy and postpartum. After giving birth, many women return to smoking as a way of coping with the range of stresses experienced during the postpartum period. Women need additional support when their child is born and fetal health is no longer a daily motivation. Since relapse is delayed when women are breastfeeding, support for breastfeeding may be useful in extending women's experiences of non-smoking post-pregnancy.

5. Partner Support and Social Issues Integration

There are a range of social factors affecting the processes of maintenance, cessation, and relapse, including socioeconomic status, education, ethnicity and maternal age. These factors, in addition to physiological changes in pregnancy, and exposure to health education and wider social messages about pregnancy and smoking, affect the rates of spontaneous and temporary quitting in pregnancy. However, few interventions appeared to focus on women's social environment. Both cessation and relapse are affected by the presence of smokers in close proximity to the pregnant woman, so there is a need to develop and test interventions for partners of pregnant smokers. Interventions that acknowledge the presence of smokers in the lives of pregnant smokers and appreciate the dynamics of these relationships are promising.

Most pregnant smokers are experiencing multiple social and economic pressures. Issues such as unemployment, violence and poverty blur or bury the importance of tobacco cessation and other health behaviours while pregnant. Cessation interventions need to consider the entire context of social and economic factors and offer a wide range of solutions in order to be successful.

While there has been no shortage of attempts, effective smoking cessation programs and interventions for pregnant and postpartum girls and women are scarce. As well as highlighting important sub-populations that require targeted interventions, this review identified the most promising intervention components and approaches to tobacco cessation during pregnancy. These Better Practices will provide a strong foundation for future interventions and help create the conditions necessary for successful tobacco cessation during pregnancy.

For a copy of the full report, Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women, contact:

British Columbia Centre of Excellence for Women's Health

BC Women's Hospital and Health Centre

E311-4500 Oak Street

Vancouver, BC Canada V6H 3N1

www. bccewh.bc.ca

Tel: (604) 875-2633

Fax: (604) 875-3716

bccewh@cw.bc.ca

NOTES

1. Coleman GJ, Joyce T. Trends in smoking before, during, and after pregnancy in ten states. American Journal of Preventive Medicine 2003;24(1):29-35; Connor SK, McIntyre L. The sociodemographic predictors of smoking cessation among pregnant women in Canada. Canadian Journal of Public Health 1999;90:352-355.

2. Klesges LM, Johnson KC, et al. Smoking cessation in pregnant women. Obstetrics and Gynecological Clinics of North America 2001;28(2):269-282.

Lorraine Greaves, Renée Cormier, Karen Devries, Joan Bottorff, Joy Johnson, Susan Kirkland, David Aboussafy, British Columbia Centre of Excellence for Women's Health

Copyright Centres of Excellence for Women's Health Spring 2005
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