"Smoking cessation for pregnancy and beyond: a virtual clinic," an innovative web-based training for healthcare professionals

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.

Connecting the World of Healthcare Virtually: A Scoping Review on Virtual Care Delivery

Virtual care extends beyond the walls of healthcare organizations to provide care at a distance. Although virtual care cannot be regarded as a solution for all health-related inquiries, it provides another care delivery channel for specific patient populations with appointments that do not require in-person physical examinations or procedures. A scoping review was conducted to define the meaning of virtual care, understand how virtual care has influenced the healthcare industry and is being expanded to complement the existing healthcare system, and describe the outcomes of using virtual care for patients and providers. Findings from the scoping review suggest that virtual care encompasses the provision of care using advanced video conferencing technology to support remote care that takes place between patients and providers and the use of virtual reality technology to simulate care environments. Some of virtual care's use in healthcare includes application to pain and anxiety management, virtual consultations and follow-up visits, rehabilitation and therapy services, outpatient clinics, and emergency services. Lastly, from a provider and patient perspective, while both saw benefits of virtual care and scored the service relatively high on satisfaction after using virtual care, the greatest barrier to using virtual care may be technological challenges.

Bupropion for postpartum smoking relapse: A remote protocol for a two-arm, double-blind, placebo-controlled randomized clinical trial

Cigarette smoking among postpartum women remains a significant public health problem despite known health risks to women and their newborns. It is estimated that over 50% of women quit smoking during pregnancy but 90% relapse by one year. Safe and effective postpartum relapse prevention strategies are urgently needed. In an attempt to address this deficit, we will investigate the efficacy of bupropion vs. placebo as a smoking relapse prevention aid in postpartum women. The objective of this paper is to detail an approach to investigate bupropion's efficacy for preventing postpartum smoking relapse among women who quit smoking during pregnancy. Specifically, we designed a two-arm, double-blind, placebo-controlled randomized trial testing the efficacy of bupropion vs. placebo as a relapse prevention tool. Mothers of healthy infants who quit smoking while pregnant will be stratified based on current or past history of major depressive disorder or persistent depressive disorder and randomized to receive either active (bupropion XL 300 mg/day) or placebo medication for 12 weeks. To respond to safety concerns associated with participant and staff exposure to COVID-19, we revised our original protocol and present procedures which allow our trial to be conducted entirely remotely. Primary and secondary outcomes will be assessed at weeks 12, 24, 36 and 52 post-randomization. The primary outcome is 7-day point prevalence abstinence at 24 weeks. Results of this work have the potential to positively impact women and their children by promoting lifelong cessation, eliminating secondhand smoke exposure, and modelling of abstinence to children.

Progesterone and Postpartum Smoking Relapse: A Pilot Double-Blind Placebo-Controlled Randomized Trial

INTRODUCTION

Pregnancy is a strong motivator to quit smoking, yet postpartum relapse rates are high. Growing evidence suggests a role of sex hormones in drug abuse behavior and given the precipitous drop in sex hormones at delivery, they may play a role in postpartum relapse. This pilot study evaluates the feasibility and potential role of exogenous progesterone in postpartum smoking relapse.

METHODS

This 12-week double-blind placebo-controlled randomized pilot trial randomized 46 abstinent postpartum women to active progesterone (PRO; 200mg twice a day) versus placebo (PBO) for 4 weeks. Participants were followed for relapse for 12 weeks. Main study outcomes include abstinence (point prevalence), feasibility (compliance per number of clinic visits attended, pill counts and Electronic Data Capture [EDC] completed) and self-reported acceptability. Safety was also measured by depressive symptom scores, adverse events, and breastfeeding.

RESULTS

Overall retention rate was 87% at week 12. At week 4, abstinence rates were 75% in the PRO group and 68.2% in the PBO group (p = .75). Medication adherence was 68% and clinic visit attendance was 80%, with no differences by randomization. Depressive symptom scores, adverse events, and breastfeeding did not vary by randomization.

CONCLUSIONS

Although the study was not powered to evaluate abstinence rates, we did observe a higher prevalence of abstinence at week 4 in the PRO group. Further, exogenous progesterone was well tolerated and did not adversely affect depressive symptoms or breastfeeding. Thus, the results of this pilot study indicate further investigation into progesterone as a postpartum relapse prevention strategy is warranted.

IMPLICATIONS

This innovative pilot trial determined the feasibility of delivering exogenous progesterone as a potential prevention of postpartum smoking relapse. We observed high retention and moderate adherence rates, as well as high acceptability among participants. Further, though not statistically significant, more women in the treatment group remained abstinent from smoking during follow-up. This project adds to the growing body of literature on the role of sex hormones in smoking relapse and also provides support for a fully powered clinical trial.

Smoking during pregnancy: a difficult problem to face. Results of a French multi-center study

INTRODUCTION

Smoking tobacco during pregnancy is a preventable risk factor for adverse pregnancy outcomes. The aim of the study was to assess the impact of an information and training program implemented by the perinatal network of Auvergne, France, on smoking during pregnancy.

METHODS

A multi-center before-and-after population-based study, based on two cross-sectional surveys, was carried out between July 2003 and June 2004, and between December 2008 and January 2010. Pregnant women aged over 18 years, with a fluent command of written and spoken French, were eligible. The main outcome was the prevalence of pregnant women who smoked daily. The preventive program consisted of informing women and healthcare providers and training healthcare providers. Multivariate analysis was performed by means of manual logistic regression and crude and adjusted Odds Ratios were calculated.

FINDINGS

"Before" and "after" surveys involved 1027 and 720 women, respectively. In the "after" survey, a higher percentage of women smoked daily at the time of diagnosis (43.49% vs 51.94%, adjusted Odds Ratio 1.45 [1.10; 1.90]) and during the third term (40.53% vs 51.94%, adjusted Odds Ratio 1.62 [1.24; 2.12]). Environmental tobacco smoke exposure among non-smokers was higher in the "after" survey: 52.83% vs 69.57% adjusted Odds Ratio 1.95 [1.54; 2.47].

CONCLUSIONS

The program did not reduce smoking during pregnancy. Exposure to environmental tobacco smoke increased. French public health authorities should introduce a new policy aimed specifically at tackling tobacco use during pregnancy and exposure to second-hand smoke, and which takes into account the entire environment of pregnant women.

Clinicians' awareness of the Affordable Care Act mandate to provide comprehensive tobacco cessation treatment for pregnant women covered by Medicaid

The Affordable Care Act (ACA) requires states to provide tobacco-cessation services without cost-sharing for pregnant traditional Medicaid-beneficiaries effective October 2010. It is unknown the extent to which obstetricians-gynecologists are aware of the Medicaid tobacco-cessation benefit. We sought to examine the awareness of the Medicaid tobacco-cessation benefit in a national sample of obstetricians-gynecologists and assessed whether reimbursement would influence their tobacco cessation practice. In 2012, a survey was administered to a national stratified-random sample of obstetricians-gynecologists (n = 252) regarding awareness of the Medicaid tobacco-cessation benefit. Results were stratified by the percentage of pregnant Medicaid patients. Chi-squared tests (p < 0.05) were used to assess significant associations. Analyses were conducted in 2014. Eighty-three percent of respondents were unaware of the benefit. Lack of awareness increased as the percentage of pregnant Medicaid patients in their practices decreased (range = 71.9%-96.8%; P = 0.02). One-third (36.1%) of respondents serving pregnant Medicaid patients reported that reimbursement would influence them to increase their cessation services. Four out of five obstetricians-gynecologists surveyed in 2012 were unaware of the ACA provision that required states to provide tobacco cessation coverage for pregnant traditional Medicaid beneficiaries as of October 2010. Broad promotion of the Medicaid tobacco-cessation benefit could reduce treatment barriers.

Nicotine replacement therapy and other interventions for pregnant smokers: Pregnancy Risk Assessment Monitoring System, 2009-2010

BACKGROUND

Current U.S. guidelines recommend consideration of nicotine replacement therapy (NRT) for pregnant smokers if behavioral therapies fail, only under close supervision of a provider, and after discussion of known risks of continued smoking and possible risks of NRT. The percentage of pregnant smokers offered NRT by their prenatal care providers is unknown.

PURPOSE

The study aims to calculate the percentage of pregnant smokers offered cessation intervention and NRT and assess independent associations between selected maternal characteristics and being offered NRT.

METHODS

Data were analyzed from the 2009-2010 Pregnancy Risk Assessment Monitoring System from four states that asked about provider practices for prenatal smoking cessation. Adjusted prevalence ratios were calculated to examine associations between being offered NRT, selected maternal characteristics, and smoking level. Variables used in adjusted models were based on factors associated with smoking cessation during pregnancy from prior literature and included race, age, education, insurance type, and stress.

RESULTS

Of 3559 women who smoked 3months before pregnancy, 77.4% (95% CI: 74.2, 80.3) of 3rd trimester smokers and 42% (95% CI: 38.5, 46.4) of women who quit smoking during pregnancy were offered at least one cessation method. Among smokers, 19.1% (95% CI: 16.5, 22.1) were offered NRT and of these, almost all (94%) were offered another cessation method.

CONCLUSIONS

One in five pregnant smokers was offered NRT. About a quarter of pregnant smokers did not receive any interventions to stop smoking. There may still be reluctance to provide NRT to pregnant women, despite known harms of continued smoking during pregnancy.

Intimate partner violence and maternal cigarette smoking before and during pregnancy

OBJECTIVE

To determine the association of intimate partner violence with maternal cigarette smoking before and during pregnancy.

METHODS

Data were obtained for 196,391 U.S. mothers who delivered live neonates from 2004-2008 and completed the Pregnancy Risk Assessment Monitoring System survey 2-9 months postpartum. Intimate partner violence was defined as being physically hurt by a current or expartner in the year before or during pregnancy. Weighted descriptive and multivariate analyses were performed.

RESULTS

Compared with nonphysically abused women, those who experienced physical abuse were 2.1 times more likely to smoke before pregnancy (44.0% compared with 21.0%, P<.001) and 2.6 times more likely to smoke during pregnancy (29.6% compared with 11.4%, P<.001). Smoking prevalence during pregnancy was highest for abused women who were non-Hispanic white (42.3% smoked) and lowest for nonabused college graduates (2.2% smoked). Smoking rates more than tripled for college graduates in abusive relationships (2.2% compared with 7.1%). After adjusting for potential confounding factors, abused women were significantly more likely to smoke during pregnancy than nonabused women (adjusted odds ratio 1.95, P<.001, 95% confidence interval 1.80-2.12).

CONCLUSION

Women who experienced intimate partner violence had significantly higher rates of smoking before pregnancy and were less likely to quit during pregnancy than women who did not experience intimate partner violence. The American College of Obstetricians and Gynecologists and the U.S. Public Services Task Force recommend routine intimate partner violence screening with appropriate interventions to prevent violence against women, optimize safety, and improve health. Additional and targeted intimate partner violence assessment of women who smoke during pregnancy may prove especially beneficial.

Women's perspectives on smoking and pregnancy and graphic warning labels

OBJECTIVES

To explore women's knowledge, attitudes, and beliefs about adverse outcomes associated with smoking during pregnancy and which outcomes might motivate cessation; to explore reactions to graphic warnings depicting 2 adverse outcomes.

METHODS

Twelve focus groups were conducted with women of childbearing age who were current smokers.

RESULTS

Participants had low to moderate awareness of many outcomes and believed it was acceptable to smoke in the first trimester before knowledge of pregnancy. Perceived susceptibility to outcomes was low. Motivators included risk-focused information, especially serious risks to the baby (eg, stillbirth, SIDS). Graphic warnings produced strong reactions, especially the warning with a real photo.

CONCLUSIONS

Despite barriers to reducing rates of smoking during pregnancy, educational information and photos depicting babies' risks could motivate women to quit.

Maternal mortality and morbidity in the United States: where are we now?

This article provides a brief overview of the work conducted by the Division of Reproductive Health at the Centers for Disease Control and Prevention on severe maternal morbidity and mortality in the United States. The article presents the latest data and trends in maternal mortality and severe maternal morbidity, as well as on maternal substance abuse and mental health disorders during pregnancy, two relatively recent topics of interest in the Division, and includes future directions of work in all these areas.