Clinical trials and tribulations: lessons learned from recruiting pregnant ex-smokers for relapse prevention

Knowledge, Attitudes, and Beliefs about Relapse Prevention Research Involving Bupropion among Current and Former Pregnant Individuals Who Smoke

Introduction

While many individuals quit smoking during pregnancy, most relapse within one year postpartum. Research into methods to decrease smoking relapse postpartum has been hampered by difficulties with recruitment.

Method

We conducted individual interviews with pregnant women (N = 22) who were interested in quitting smoking while pregnant about their attitudes regarding smoking and quitting during pregnancy, clinical trial participation, and smoking cessation medication use.

Results

Participants were aware of the risks of smoking while pregnant. Many wanted to quit smoking before delivery. Few used empirically supported treatments to quit. While research was viewed positively, interest in taking on new commitments postpartum and taking a medication to prevent relapse was low. Medication concerns were evident among most participants, especially among those planning to breastfeed. Further, several women noted medication was unnecessary, as they did not believe they would relapse postpartum. Financial incentives, childcare, and fewer and/or remote visits were identified as facilitators to participating in research. However, these factors did not outweigh women's concerns about medication use and time commitments.

Conclusions

Women are aware that quitting smoking during pregnancy and remaining smoke-free postpartum are important. However, beliefs that personal relapse risk is low and that medications are dangerous reduced enthusiasm for taking medication for postpartum relapse prevention. Future medication trials should educate women about the high likelihood of relapse, prepare to answer detailed questions about risks of cessation medications, and connect with participants' clinicians. For new mothers, studies conducted remotely with few scheduled appointments would reduce barriers to participation.

Recruiting racially and ethnically diverse smokers seeking treatment: Lessons learned from a smoking cessation randomized clinical trial

INTRODUCTION

Recruiting racial/ethnic minorities in smoking cessation trials is a priority. This study described lessons learned from recruiting a diverse sample of African American, White, and Hispanic/Latinx smokers in a smoking cessation trial.

METHODS

We implemented a 42-month recruitment campaign utilizing reactive (e.g., word-of-mouth, newspaper, radio, online ads, flyers, community partnerships) and proactive (e.g., direct invitations) strategies. We included 821 participants in the analysis. We described our recruitment strategies' implementation, their enrollment yield and rate (number enrolled/number screened) by race/ethnicity, and direct cost-per-participant (CPP: total cost/number of enrolled) for paid strategies.

RESULTS

Enrollment yields were higher using reactive strategies than proactive strategies (94.3% vs. 5.7%). The top source of enrollment was word-of-mouth among African Americans (36%) and Whites (44%), and flyers among Hispanics/Latinxs (34%). Proactive recruitment, word-of-mouth, and flyers were more successful among African Americans than other groups. Newspaper and online ads were more successful among Hispanics/Latinxs than other groups (P < .05). Word-of-mouth was cost-free and yielded 23.1% of enrollment. The most economic method among paid strategies was flyer distribution (CPP = $47.6; yield 17.5%), followed by newspaper ($194.7; 23.7%) and online advertisements ($264.6; 24.0%). Radio and television ads were the most expensive and produced the least participant yield ($4,755.6; 0.8%).

CONCLUSION

Recruiting racially/ethnically diverse samples into smoking cessation clinical trials requires implementing multiple strategies and adjusting these strategies based on their enrollment yield and cost. Word-of-mouth, flyers, and newspaper and online ads were more successful among racial/ethnic minorities. Flyers and newspaper ads were the most economic methods for recruitment.

Program uptake of a parent-tailored telephone smoking cessation counselling: An examination of recruitment approaches

INTRODUCTION

Recently, a Dutch proactive parent-tailored telephone smoking cessation counselling program, Smoke-free Parents (SFP), was demonstrated to be effective in helping parents to quit smoking. This study aimed to examine the program’s uptake and the costs of two recruitment approaches (i.e. healthcare vs mass media) for SFP. In addition, parent’s barriers to participating in SFP and the characteristics of participating parents were assessed.

METHODS

As part of an effectiveness-implementation hybrid trial, 402 smoking parents were recruited via healthcare settings and mass media for an informal, proactive, and free phone call with a smoking cessation counsellor about SFP (the Netherlands, September 2016 – September 2018). Parents were asked whether they wanted to participate in SFP. If parents refused, reasons for decline and additional information (e.g. educational level) were collected.

RESULTS

Results revealed that 26.4% of the recruited parents participated in SFP. Although the program uptake of parents recruited via mass media was slightly, but not significantly, higher than via healthcare (27.3% vs 26.8%, p=0.92), the healthcare approach resulted in lower costs per participant (€99.62 vs €205.72). Smoking cessation counsellors were unable to reach almost one-third (32.7%) of the parents after they had agreed to be called about SFP.

CONCLUSIONS

The present study showed that more than a quarter of all recruited parents participated in SFP and that the mass media approach and healthcare approach can be used to recruit parents for SFP. To increase the number of parents participating in SFP, it is important to overcome the identified barriers that prevent parents from participating.

A Pilot Randomized Controlled Trial of a Phone-based Intervention for Smoking Cessation and Relapse Prevention in the Postpartum Period

OBJECTIVES

To pilot-test a Phone-based Postpartum Continuing Care (PPCC) protocol developed from existing evidence-based approaches to address both postpartum smoking relapse among low-income women who quit smoking during pregnancy and postpartum smoking increase among those who had cut down.

METHODS

One hundred thirty low-income pregnant women who were current or recently quit tobacco smokers were recruited at their first prenatal appointment and randomized to either a Control (standard care) or Experimental (standard care + PPCC) group. An intent-to-treat analysis was conducted on biochemically verified data from 6 in-person interviews during pregnancy and postpartum. Feasibility with regard to recruitment, randomization, assessment, and implementation of PPCC were assessed, along with acceptability among the target population.

RESULTS

PPCC was found to be feasible and acceptable to some participants, but not all. There were no significant differences in tobacco products per day at 6 months postpartum between groups; however, effect sizes differed at 6 weeks compared with 6 months postpartum. Similarly, there were no significant differences between groups in cessation rate (24% in each group) and past 90-day tobacco use (59 vs 55 days, for Control and Experimental groups, respectively).

CONCLUSIONS

The PPCC intervention did not differentially reduce tobacco use postpartum compared with a controlled comparison group, though it was found to be acceptable among a subpopulation of low-income pregnant women and feasible with regard to recruitment, randomization, assessment procedures, and implementation. Further research is needed to identify an intervention that significantly improves smoking relapse rates postpartum.

Recruitment Techniques and Strategies in a Community-Based Colorectal Cancer Screening Study of Men and Women of African Ancestry

BACKGROUND

Recruiting ethnically diverse Black participants to an innovative, community-based research study to reduce colorectal cancer screening disparities requires multipronged recruitment techniques.

OBJECTIVES

This article describes active, passive, and snowball recruitment techniques, and challenges and lessons learned in recruiting a diverse sample of Black participants.

METHODS

For each of the three recruitment techniques, data were collected on strategies, enrollment efficiency (participants enrolled/participants evaluated), and reasons for ineligibility.

RESULTS

Five hundred sixty individuals were evaluated, and 330 individuals were enrolled. Active recruitment yielded the highest number of enrolled participants, followed by passive and snowball. Snowball recruitment was the most efficient technique, with enrollment efficiency of 72.4%, followed by passive (58.1%) and active (55.7%) techniques. There were significant differences in gender, education, country of origin, health insurance, and having a regular physician by recruitment technique (p < .05).

DISCUSSION

Multipronged recruitment techniques should be employed to increase reach, diversity, and study participation rates among Blacks. Although each recruitment technique had a variable enrollment efficiency, the use of multipronged recruitment techniques can lead to successful enrollment of diverse Blacks into cancer prevention and control interventions.

Smoking and Smoking Cessation During Pregnancy. An Analysis of a Hospital Based Cohort of Women in Romania

Perinatal smoking is associated with a wide range of negative reproductive and pregnancy outcomes. The aim of the current study was to examine the prevalence and characteristics of women who report smoking prenatally and quit during pregnancy in a large sample of Romanian women. Understanding which women are more likely to quit will contribute to public health knowledge that will help more women stop smoking prior to or during pregnancy and prevent relapse postpartum. This cross-sectional analysis was conducted based on cross-sectional data collected between May 2012 and April 2015 as part of a cohort study of pregnancy implemented in six clinical settings in central Romania (N = 2370). Approximately 28 % of the sample reported smoking in the 6 months prior to learning they were pregnant. Half of the women who reported smoking 6 months before learning of their pregnancy, also reported that they stopped smoking by the time of the interview. Overall, tobacco consumption decreased from a sample mode of 10 cigarettes/day (range: 1-30) before pregnancy, to a sample mode of 5 cigarettes/day (range: 1-25) at the time of the interview. Women who quit had a higher socioeconomic position, were more likely to live in urban areas, partnered, primigravid, nulliparous, and reported lower anxiety and more social support. The combination of a socioeconomic gradient, less anxiety, and more social support suggests that efforts should be increased to target lower income, less educated, multigravid, and multiparous women and to develop programs that heighten social support and alleviate anxiety.

Recruiting pregnant smokers from Text4baby for a randomized controlled trial of Quit4baby

Recruiting pregnant smokers into clinical trials is challenging since this population tends to be disadvantaged, the behavior is stigmatized, and the intervention window is limited. The purpose of this study is to test the feasibility and effectiveness of recruiting pregnant smokers into a smoking cessation trial by sending recruitment text messages to an existing subscriber list. Recruitment messages were sent to subscribers flagged as pregnant in Text4baby, a national text messaging program for pregnant women and mothers. Four recruitment messages were rotated to test the effectiveness of different emotional frames and a financial incentive. Study staff called subscribers who expressed interest to screen for eligibility and enroll eligible women. Between October 6, 2015 and February 2, 2016, 10,194 recruitment messages were sent to Text4baby subscribers flagged as pregnant, and 10.18% (1038) responded indicating interest. No significant increase in cancellation was observed compared to subscribers who received other ad hoc messages. Of respondents, 54.05% (561) were reached by phone for follow-up, and 21.97% (228) were found to be eligible. Among the eligible, 87% (199) pregnant smokers enrolled. The recruitment message with a pride emotional appeal had a significantly higher response (p = 0.02) compared to the recruitment message with no emotional appeal, but enrollment did not significantly differ between recruitment messages with different emotional appeals. The recruitment messages with a reference to financial incentive yielded higher response (p < 0.01) and enrollment (p = 0.03) compared to a recruitment message without. This study demonstrates success recruiting pregnant smokers using text message. Future studies should consider building on this approach for recruiting high-risk populations.

Psychosocial interventions for supporting women to stop smoking in pregnancy

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.

Recruiting Pregnant Indigenous Women Who Smoke into a High Contact Incentivized Cessation Trial: A Feasibility Study

INTRODUCTION

Smoking prevalence among pregnant indigenous women is disproportionately higher than for nonindigenous pregnant women. Incentives have been shown to increase retention in and the effectiveness of smoking cessation programs. To trial if this could work for indigenous women, we aimed to recruit and observe retention of Māori (New Zealand indigenous people) pregnant women that smoke into a cessation program using incentives.

METHODS

A parallel group, randomized controlled feasibility trial was undertaken in New Zealand. Pregnant Māori women who smoked were recruited through health practitioners, social media, and general media advertising. Outcomes included ease of recruitment, enrollment rate, retention, cost, and time and distance traveled to visit participants.

RESULTS

Seventy-four women were referred for the trial over 7 months. The highest enrollment rate was among self-referrals from media (6 of 10), then women referred from cessation providers (47%, 8 of 17). About three-quarters of women referred from health professionals did not enroll. Only 32% (24) were randomized. Nine women completed the intervention, three withdrew, and 12 were lost to follow-up. On average, it took less time to contact abstinent participants (29 vs. 43 minutes for nonabstinent women). No deception was noted.

CONCLUSIONS

Recruitment was difficult and varied by source of first contact. Once enrolled, it was feasible to maintain intensive contact with participants who stayed engaged. The number lost to follow-up was high. We concluded that the tenor of trial promotion could have influenced recruitment and retention rates. Further research with indigenous women is needed to identify better recruitment and retention methods.

IMPLICATION

With the rising cost of research and the increased competition for funds, it is important to have evidence that intervention studies with minority group pregnant women who smoke are feasible. Maintaining contact with participants seemed feasible, but the tenor of trial promotion and type of recruitment strategy could influence enrollment and retention of sufficient numbers of participants. Nonjudgmental supportive advertising and invitations direct to women may work better than relying on health professionals as recruiters.

Nicotine Dependence Measures for Perinatal Women

This integrative review provides an overview of nicotine dependence measures used with perinatal women and an evaluation of their psychometric properties. Fifty-five articles that met inclusion and exclusion criteria were identified from five different databases. Most of the studies used the Fagerström Test for Nicotine Dependence (FTND). Other approaches included diagnostic tests, the Wisconsin Inventory of Smoking Dependence Motives (WISDM), the Tobacco Dependence Screener, and single-item measures. This review indicated that the FTND may not be the best option for measuring nicotine dependence in this population. The WISDM is a newer instrument that has excellent psychometric properties and captures nonnicotinic dimensions of nicotine dependence relevant to women. Future research is needed to assess its reliability in the perinatal population. Other recommendations from this review include the use of biomarker validation, thorough psychometric reporting on nicotine dependence instruments, and the use of multiple instruments to maximize comparability between nicotine dependence instruments.

A couple-focused intervention to prevent postnatal smoking relapse: PRISM study design

BACKGROUND

Maternal smoking is one of the most modifiable factors with clear adverse effects for the fetus and the entire family. Addressing the dearth of pregnancy smoking interventions with partner support, PRISM (Prevent Relapse In SMoking) is a partnership between a research institution and the two largest state-owned obstetrics and gynecology clinics in Cluj-Napoca, Romania. The study will assess the efficacy of a couple-focused telephone-counseling program to prevent smoking relapse among mothers who quit smoking closely before or during pregnancy.

METHODS/DESIGN

The intervention is a program for couples based on motivational interviewing delivered over the phone after birth. The study is an ongoing randomized controlled trial of 250 Romanian women recruited soon after childbirth, who quit smoking in the six months before pregnancy or no later than the end of the first pregnancy trimester and remained abstinent (which was biochemically verified) until delivery. Participants were randomized to: (1) a control arm (usual care); and (2) an intervention arm consisting of up to 4 postnatal counseling calls for mothers and their partners using motivational interviewing to encourage the woman to remain smoke-free and the partner to support her decision. The primary outcome is maternal smoking abstinence at 6 months postpartum (biochemically verified).

DISCUSSION

PRISM has the potential to identify strategies to reduce maternal postnatal relapse and increase partner quitting. If successful, the program may be an effective method to prevent and reduce smoking, which may lead to improved child, mother, and partner health both in the short and the long term.

Strategies to Avoid Returning to Smoking (STARTS): a randomized controlled trial of postpartum smoking relapse prevention interventions

The majority of women who quit smoking during pregnancy relapse postpartum and many experience increased depressive symptoms and concerns about body shape and weight. Given the relationship of weight concerns and negative mood to smoking relapse, interventions designed to address the postpartum experience are indicated. However, there are several challenges to research with postpartum women. We describe the rationale of a randomized controlled trial of postpartum smoking relapse prevention intervention and discuss methods to address the specific challenges to recruiting, retaining and conducting health behavior interventions among postpartum former smokers. Pregnant women who had quit smoking for at least one month prior to the 34 week of pregnancy and who were motivated to stay quit postpartum were recruited. Women were randomized either to a postpartum specific intervention designed to address concerns about mood, stress and weight using cognitive-behavioral techniques or to a support-only condition designed to control for time and attention. Intervention continues through six months postpartum and women complete follow-up assessments at 12-, 24- and 52-weeks after delivery. Women (n=300) who had quit smoking as a result of pregnancy were recruited and are being followed. The intervention described in this report is designed to address stress, negative mood and concerns about weight that mediate smoking relapse postpartum to sustain abstinence and improve maternal and infant health.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth 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 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 fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) 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, and subgroup analyses and sensitivity analysis were conducted in SPSS.

MAIN RESULTS

Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing.

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 reduce low birthweight and preterm births.

Can we modify the enrollment in a postpartum smoking cessation intervention in Spain?

OBJECTIVE

it is known that very few women who continue to smoke at the time of delivery stop smoking during the postpartum period. Discovering strategies that can be incorporated during pregnancy to help improve women's participation in postpartum interventions could increase the number of women non-smokers. The aim of this study is to identify the predictors of participation by pregnant women smokers in a postpartum smoking cessation intervention.

DESIGN

a cross-sectional study was carried out amongst women smokers who had attended to give birth.

SETTING

women attended the University Clinical Hospital 'Lozano Blesa' of Zaragoza (Spain) who were smokers before pregnancy and reported at delivery to have continued smoking during pregnancy were eligible and were invited to participate in the study.

FINDINGS

2044 women completed the questionnaire 24 hours after giving birth. The smoking prevalence during pregnancy was 18.2% (n=372) and 62.9% of them (n=234) participated. The logistic regression model provided five significant predictors for women who participated: intention to breast feed, having less of an urge to smoke the first cigarette of the day before pregnancy, having reduced consumption during pregnancy by 50% or more, having received advice and being willing to get help.

CONCLUSIONS AND IMPLICATIONS FOR THE PRACTICE

the factors associated with participation show aspects that can be modified by maternal and child health professionals. Advice to stop smoking, received during pregnancy, encourages participation in a postpartum intervention. From the point of view of public health, the huge increase in the prevalence of smoking women poses the need to take advantage of the pregnancy as an opportunity for giving up smoking definitely. It would be necessary to identify what programmes of smoking cessation have better results in pregnant women and to know how to motivate health professionals to implement them.

School-based promotion of cessation support: reach of proactive mailings and acceptability of treatment in smoking parents recruited into cessation support through primary schools

Background

Several forms of cessation support have been shown effective in increasing the chance of successful smoking cessation, but cessation support is still underutilized among smokers. Proactive outreach to target audiences may increase use of cessation support.

Methods

The present study evaluated the efficiency of using study invitation letters distributed through primary schools in recruiting smoking parents into cessation support (quitline support or a self-help brochure). Use and evaluation of cessation support among smoking parents were examined.

Results

Findings indicate that recruitment of smokers into cessation support remains challenging. Once recruited, cessation support was well received by smoking parents. Of smokers allocated to quitline support, 88% accepted at least one counselling call. The average number of calls taken was high (5.7 out of 7 calls). Of smokers allocated to receive self-help material, 84% read at least some parts of the brochure. Of the intention-to-treat population, 81% and 69% were satisfied with quitline support or self-help material, respectively. Smoking parents were significantly more positive about quitline support compared to self-help material (p<.001).

Conclusions

Cessation support is well-received and well-used among smoking parents recruited through primary schools. Future studies need to examine factors that influence the response to offers of cessation support in samples of nonvolunteer smokers.

Trial registration

The protocol for this study is registered with the Netherlands Trial Register NTR2707

Distribution of smoking relapse prevention materials in the Hispanic community: lessons learned

There is a dearth of Spanish language, culturally relevant tobacco-related information available to Hispanics in the USA. The primary aim of this study was to examine the distribution process of Libres para Siempre (Forever Free), a Spanish language smoking relapse prevention booklet series, by health care and social service agencies serving Hispanic individuals in Florida. Representatives (N = 16) from ten agencies that requested copies of the booklets completed a semi-structured interview to assess strategies used to distribute the booklets to their Hispanic clients. As a secondary aim, we obtained feedback regarding the booklets' quality and utility from the representatives. Results revealed that many agencies used both active and passive approaches to distribute the booklets. Issues related to distribution included language barriers between staff and clients and confusion regarding identification of the target population. Results indicated that the booklets were received favorably, and providers would recommend them to future clients.

Interventions for recruiting smokers into cessation programmes

BACKGROUND

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme.

SEARCH METHODS

We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ('recruit$', 'invit$', 'enter', 'entry', 'enrolment') combined with ('smok$', 'cigarette', 'smoking cessation', 'tobacco') in the title, abstract or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment phase.

DATA COLLECTION AND ANALYSIS

From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures.Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

MAIN RESULTS

This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95% CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants to a personal phone call improved recruitment of participants (RR 3.38, 95% CI 1.26 to 9.08 and RR 29.07, 95% CI 1.74 to 485.70, respectively); that adding a personal phone call to an existing newsletter can also increase recruitment rates (RR 65.12, 95% CI 4.06 to 1045.4]); that a reactive-proactive recruitment phase is more effective than a proactive phase alone (63.8% versus 47.5%, RR not available); and that active recruitment at schools is more effective than passive recruitment (p < 0.001, denominator not available for calculation of RR). Additionally, a number of studies in this category showed that providing incentives can effectively increase the number of participants recruited into smoking cessation programmes.Out of the 19 included studies, only four reported on the effect of recruitment strategy on smoking cessation at six months or longer. Three of these studies compared strategies that used the same delivery mode with different content. Their results were non-significant. The remaining three studies evaluated adding an additional mode to an existing recruitment intervention. Only one of them showed a significant difference in the levels of smoking cessation that favoured the enhanced recruitment strategy, but this may have reflected the offer of incentives once in the programme rather than the recruitment strategy itself (RR at 15 or 18 months 2.60, 95% CI 1.48 to 4.56).

AUTHORS' CONCLUSIONS

The substantial heterogeneity across the included studies restricts our ability to draw firm conclusions about the effectiveness of different recruitment strategies in relation to recruitment of participants into smoking cessation programmes or levels of smoking cessation. The limited evidence, however, suggests that the following elements may improve the recruitment of smokers into cessation programmes: personal, tailored interventions; recruitment methods that are proactive in nature; and more intensive recruitment strategies (i.e., those strategies that require increased contact with potential participants).

Developing strategies for reducing cancer disparities via cross-institutional collaboration: outreach efforts for the partnership between the Ponce School of Medicine and the Moffitt Cancer Center

The disproportionate burden of cancer among U.S. Hispanics is well documented. Historically, epidemiologic data on U.S. Hispanics and cancer have aggregated all Hispanics as one homogeneous group without appreciating the diversity of this population with regard to nativity (nationality/geographic origin). The authors report on the initial efforts of a collaborative academic institutional partnership between a minority-serving institution and a National Cancer Institute-designated cancer center to address cancer health disparities in two Hispanic communities in Puerto Rico and Florida. This article outlines the joint Outreach Program's initial collaborative strategies and activities in community outreach, cancer education, and research that mutually benefit both the Ponce (Puerto Rico) and Tampa (Florida) Hispanic communities. This partnership program used innovative multipronged community-engagement strategies in the two communities to reduce cancer health disparities. Specific projects and lessons learned from three outreach/cancer education projects and two pilot research projects are discussed. The challenges of balancing service and research agendas in communities with disparate levels of resources and infrastructure are summarized to inform future initiatives in this partnership, as well as serve as an example for similar minority-serving institution/cancer center partnerships to reduce cancer health disparities.

Cultural Acceptability of a Smoking Relapse Prevention Intervention for Pregnant Women in Puerto Rico: Providers' Feedback

Hispanic women are more likely than non-Hispanic women to quit smoking during pregnancy, indicating that relapse-prevention interventions may benefit this population. We conducted qualitative interviews with health care providers in Puerto Rico who serve pregnant women regarding the cultural acceptability of Libres Para Siempre Por Mi Bebé y Por Mi (transcreated from the English version, Forever Free for Baby and Me), a smoking relapse-prevention booklet series. Providers praised the overall quality of the content, interactive activities, vignettes, and partner booklet. Recommendations included condensing the content, and distributing the booklets during one-on-one counseling and via "charlas"(community themed presentations). Overall, these smoking relapse-prevention materials are culturally acceptable among health care providers, yet there is a need to attend to local cultural preferences for delivering the intervention.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.