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NIHR Signal Counselling services help expectant mothers quit smoking

Published on 11 April 2017

doi: 10.3310/signal-000405

Counselling services, including cognitive behavioural therapy and motivational interviewing, help women to stop smoking during pregnancy by increasing quit rates. Feedback and financial incentives may also be effective, though evidence is weaker for both. Education alone and peer support were not found to be effective. Some of the counselling interventions are already at least partly supplied through NHS Stop Smoking Services – two of the UK trials recruited through the Service.

When pooled together, these non-pharmacological interventions, called psychosocial interventions, increased the chances of quitting by over 40% and reduced the chance of giving birth to a low birthweight baby by 17%, and chance of admission to a neonatal ward by 22%.

Smoking during pregnancy is associated with poor health outcomes for mother and child. This high quality Cochrane review included 102 relevant trials in which the researchers had high confidence. It suggests that psychosocial interventions can help pregnant women quit, but that health education alone is not sufficient.

Interventions may need to be targeted for deprived and underserved populations, although it remains unclear how they should be implemented into routine pregnancy care.

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Why was this study needed?

Smoking during pregnancy raises the risk of miscarriage, sudden infant death syndrome, stillbirth and a range of other serious health conditions. For expectant mothers, quitting smoking during pregnancy therefore offers health benefits for both mother and child.

Smoking rates in the UK have fallen since the 1980s, although the decline has not been consistent across society. For example, in Scotland 30% of women living in the most deprived areas continue to smoke during pregnancy, compared to 7% in the least deprived areas. This disparity has been cited as a major driver of inequalities in health outcomes between rich and poor.

This Cochrane review investigated the effectiveness of psychosocial interventions that aim to help women to stop smoking during pregnancy; these are non-pharmacological strategies that use cognitive-behavioural, motivational and other supportive approaches. This is the sixth iteration of the review, and updates the previous 2013 version.

What did this study do?

The systematic review included 102 randomised controlled trials (over 28,000 women) of psychosocial interventions that support smoking cessation in pregnancy, compared to either usual care or “less intensive” versions of the intervention.

Interventions were categorised as: counselling, including motivational interviewing and cognitive behaviour therapy; health education; feedback on how smoking is impacting the foetus during pregnancy; financial incentives offered in return for quitting smoking; social support from peers or partners; and exercise.

Nearly all studies were conducted in high-income countries; 18 were from the UK.  This means the findings are generaliseable to an NHS audience.  About half the trials explicitly included women with low socio-economic status. Trials with drug therapies were included if there were differing levels of psychosocial support in the trial arms.

Studies had a low risk of bias, and the main outcomes and findings were supported by high quality of evidence in which the researchers had high confidence.

What did it find?

  • Counselling interventions improved quit rates from about 9% without to 13% with the interventions. A relative increase of about 44% compared with usual care (relative risk [RR] 1.44, 95% confidence interval [CI] 1.19 to 1.73; 30 studies). There was no difference between different types of counselling.
  • Feedback also improved quit rates when compared with usual care, as long as it was provided in conjunction with other strategies, such as counselling (RR 4.39, 95% CI 1.89 to 10.21). However, the wide confidence interval indicates uncertainty in this result. In addition, this was from only two studies, one from Norway and one from the UK, and the UK study had a conflict of interest (the author had directorship of the company producing feedback cotinine tests).
  • The evidence was unclear for health education, social support from peers or partners, incentive-based interventions and exercise.
  • Pooling all the interventions together, women who received psychosocial interventions were 17% less likely to have a low birthweight baby (18 studies), and babies were on average 55.6g heavier at birth (95% CI 29.82g to 81.38g higher). There was also a 22% reduction overall in neonatal intensive care admissions (8 studies).
  • Psychosocial interventions did not appear to have any adverse effects.

What does current guidance say on this issue?

The 2010 NICE guideline on stopping smoking in pregnancy and after childbirth recommends that cognitive behaviour therapy and motivational interviewing are effective interventions, as is structured self-help and support from NHS Stop Smoking Services.

The guideline further states that though the provision of incentives to quit has been shown to be effective in other countries, research is required to see whether it would work in the UK. They do not consider that giving pregnant women feedback on the effects of smoking on the unborn child and on their own health is effective.

What are the implications?

Counselling to stop smoking should be considered for women who are pregnant, or seeking to become pregnant. Studies suggest women expect and appreciate the support, and psychosocial interventions are more likely to improve women's psychological well-being than worsen it.

This study provides some information to help midwives to inform women of the likely risks to them and their baby. The provision of health education and risk advice alone is unlikely be sufficient, and so any education-based intervention should include additional components, such as counselling or feedback.

New trials have been published during the preparation of the review; these will be included in the next update.

The NIHR Dissemination Centre has produced a recent themed review of all NIHR funded studies on health promotion during pregnancy, including substantive research on smoking cessation initiatives.

Citation and Funding

Chamberlain C, O'Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2:CD001055.

Cochrane UK and the Pregnancy and Childbirth Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

NHS Choices. Breastfeeding and smoking. London: NHS Choices; 2016.

NICE. Smoking: stopping in pregnancy and after childbirth. Public health guideline PH26. London: National Institute for Heath and Care Excellence; 2010.

Tappin DM, MacAskill S, Bauld L, et al. Smoking prevalence and smoking cessation services for pregnant women in Scotland. Substance Abuse: Treatment, Prevention, and Policy. 2010;5:1.

Wanless D. Securing Good Health for the Whole Population. London: TSO; 2004.

Why was this study needed?

Smoking during pregnancy raises the risk of miscarriage, sudden infant death syndrome, stillbirth and a range of other serious health conditions. For expectant mothers, quitting smoking during pregnancy therefore offers health benefits for both mother and child.

Smoking rates in the UK have fallen since the 1980s, although the decline has not been consistent across society. For example, in Scotland 30% of women living in the most deprived areas continue to smoke during pregnancy, compared to 7% in the least deprived areas. This disparity has been cited as a major driver of inequalities in health outcomes between rich and poor.

This Cochrane review investigated the effectiveness of psychosocial interventions that aim to help women to stop smoking during pregnancy; these are non-pharmacological strategies that use cognitive-behavioural, motivational and other supportive approaches. This is the sixth iteration of the review, and updates the previous 2013 version.

What did this study do?

The systematic review included 102 randomised controlled trials (over 28,000 women) of psychosocial interventions that support smoking cessation in pregnancy, compared to either usual care or “less intensive” versions of the intervention.

Interventions were categorised as: counselling, including motivational interviewing and cognitive behaviour therapy; health education; feedback on how smoking is impacting the foetus during pregnancy; financial incentives offered in return for quitting smoking; social support from peers or partners; and exercise.

Nearly all studies were conducted in high-income countries; 18 were from the UK.  This means the findings are generaliseable to an NHS audience.  About half the trials explicitly included women with low socio-economic status. Trials with drug therapies were included if there were differing levels of psychosocial support in the trial arms.

Studies had a low risk of bias, and the main outcomes and findings were supported by high quality of evidence in which the researchers had high confidence.

What did it find?

  • Counselling interventions improved quit rates from about 9% without to 13% with the interventions. A relative increase of about 44% compared with usual care (relative risk [RR] 1.44, 95% confidence interval [CI] 1.19 to 1.73; 30 studies). There was no difference between different types of counselling.
  • Feedback also improved quit rates when compared with usual care, as long as it was provided in conjunction with other strategies, such as counselling (RR 4.39, 95% CI 1.89 to 10.21). However, the wide confidence interval indicates uncertainty in this result. In addition, this was from only two studies, one from Norway and one from the UK, and the UK study had a conflict of interest (the author had directorship of the company producing feedback cotinine tests).
  • The evidence was unclear for health education, social support from peers or partners, incentive-based interventions and exercise.
  • Pooling all the interventions together, women who received psychosocial interventions were 17% less likely to have a low birthweight baby (18 studies), and babies were on average 55.6g heavier at birth (95% CI 29.82g to 81.38g higher). There was also a 22% reduction overall in neonatal intensive care admissions (8 studies).
  • Psychosocial interventions did not appear to have any adverse effects.

What does current guidance say on this issue?

The 2010 NICE guideline on stopping smoking in pregnancy and after childbirth recommends that cognitive behaviour therapy and motivational interviewing are effective interventions, as is structured self-help and support from NHS Stop Smoking Services.

The guideline further states that though the provision of incentives to quit has been shown to be effective in other countries, research is required to see whether it would work in the UK. They do not consider that giving pregnant women feedback on the effects of smoking on the unborn child and on their own health is effective.

What are the implications?

Counselling to stop smoking should be considered for women who are pregnant, or seeking to become pregnant. Studies suggest women expect and appreciate the support, and psychosocial interventions are more likely to improve women's psychological well-being than worsen it.

This study provides some information to help midwives to inform women of the likely risks to them and their baby. The provision of health education and risk advice alone is unlikely be sufficient, and so any education-based intervention should include additional components, such as counselling or feedback.

New trials have been published during the preparation of the review; these will be included in the next update.

The NIHR Dissemination Centre has produced a recent themed review of all NIHR funded studies on health promotion during pregnancy, including substantive research on smoking cessation initiatives.

Citation and Funding

Chamberlain C, O'Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2:CD001055.

Cochrane UK and the Pregnancy and Childbirth Cochrane Review Group are supported by NIHR infrastructure funding.

Bibliography

NHS Choices. Breastfeeding and smoking. London: NHS Choices; 2016.

NICE. Smoking: stopping in pregnancy and after childbirth. Public health guideline PH26. London: National Institute for Heath and Care Excellence; 2010.

Tappin DM, MacAskill S, Bauld L, et al. Smoking prevalence and smoking cessation services for pregnant women in Scotland. Substance Abuse: Treatment, Prevention, and Policy. 2010;5:1.

Wanless D. Securing Good Health for the Whole Population. London: TSO; 2004.

Psychosocial interventions for supporting women to stop smoking in pregnancy

Published on 14 February 2017

C Chamberlain, A O'Mara-Eves, J Porter, T Coleman, S Perlen, J Thomas, J McKenzie

Cochrane Library , 2017

Background Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries. Objectives To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. Search methods In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors. Selection criteria Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy. Data collection and analysis Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14. Main results The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination. In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small. Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention. There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20). High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%). High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health. The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32). Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions. The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions. Authors' conclusions Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update

Counselling interventions are those which provide motivation to quit, support to increase problem solving and coping skills. This includes interventions such as motivational interviewing, cognitive behaviour therapy, psychotherapy, relaxation, problem solving facilitation, and other strategies. Counselling interventions may be provided face-to-face, by telephone, or via interactive computer programs.

Health education interventions are defined as those where women are provided with information about the risks of smoking and advice to quit, but are not given further support or advice about how to make this change. Interventions where the woman was provided with automated support such as self-help manuals or automated text messaging, but there was no personal interaction at all, were coded as health education in this review.

Feedback interventions are those where the mother is provided with feedback with information about the foetal health status or measurement of by-products of tobacco smoking to the mother. This includes interventions such as ultrasound monitoring and carbon monoxide or urine cotinine measurements, with results fed back to the mother.

Incentive-based interventions include those interventions where women receive a financial incentive, contingent on their smoking cessation; these incentives may be gift vouchers.

Social support (peer, professional and/or partner) includes those interventions where the intervention explicitly included provision of support from a peer (including self-nominated peers, 'lay' peers trained by project staff, or support from healthcare professionals), or from partners, as a strategy to promote smoking cessation.

Exercise interventions are those where structured support for exercise is provided with the specific aim of promoting smoking cessation in pregnancy.

Expert commentary

How can we ensure that pregnant smokers receive the support they need to quit? There are some basic requirements: local provision of services with staff delivering effective stop smoking support; midwives trained to sensitively identify women who smoke, for example using carbon monoxide monitors; and clear referral systems to put women quickly in touch with the help they need. By investing in these elements, we could make identifying and treating smoking in pregnancy as routine as blood pressure checks – and likely achieve a greater impact on infants’ and mothers’ health.

Dr Ruth Bell, Clinical Senior Lecturer/Honorary Consultant in Public Health, Newcastle University