Effects of cigarette smoking cessation on breastfeeding duration

The Association of Maternal Smoking and Drinking Changes During Pregnancy and Postpartum Breastfeeding Pattern and Duration

Objectives: To conduct a secondary data analysis of how changes in smoking and drinking during pregnancy impact status of any breastfeeding and breastfeeding duration in a national cohort. Materials and Methods: A cross-sectional study was conducted using Pregnancy Risk Assessment Monitoring System (PRAMS) data between 2009 and 2017 (n = 334,203). Univariate and multivariate analyses were conducted on the status of any breastfeeding and breastfeeding duration. Results: A dose-dependent inverse relationship was found in which women who smoked the same or more or resumed smoking during pregnancy showed the lowest likelihood and shortest duration of breastfeeding, followed by reduced smokers, quitters, and nonsmokers. Women with a history of alcohol use were significantly more likely to breastfeed compared with women without a history of alcohol use. Conclusions: The profile of smoking change during pregnancy impacts the likelihood and duration of breastfeeding in a dose-dependent and inverse manner. No such relationship was found with drinking change during pregnancy. Public Health Implications: Significant public health efforts should focus on implementing and sustaining evidence-based interventions for prenatal smoking cessation and educating providers and maternal populations on the adverse effect of postpartum alcohol exposure.

Randomized Controlled Trial Examining the Efficacy of Adding Financial Incentives to Best practices for Smoking Cessation Among pregnant and Newly postpartum Women

We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ2 [2] = 9.01, P = .01), with percent SGA deliveries (+SEM) greatest in BP, intermediate in BP + FI, and lowest in NS (17.65 + 4.13, 10.81 + 3.61, and 2.53 + 1.77, respectively). Reliability analyses supported the efficacy of financial incentives for increasing abstinence antepartum and postpartum and decreasing SGA deliveries; external-validity analyses supported relationships between antepartum cessation and SGA risk. Adding financial incentives to Best Practice increases smoking cessation among antepartum and postpartum women and improves other maternal-infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210832.

Duration of breastmilk feeding of NICU graduates who live with individuals who smoke

BACKGROUND

Breast milk has many benefits for infants, but initiating breastfeeding/pumping can be difficult for mothers of preterm infants, especially those who smoke (or live with individuals who smoke). The primary aim of this study was to identify risks for breastfeeding/pumping cessation with neonatal intensive care unit (NICU) infants' mothers who smoke or live with individuals who smoke, using a novel survival-analytic approach.

METHODS/DESIGN

Mothers (N = 360) were recruited for a secondhand smoke prevention intervention during infants' NICU hospitalizations and followed for ~6 months after infant discharge. Data were obtained from medical records and participant self-report/interviews.

RESULTS

The sample was predominantly ethnic/racial minorities; mean age was 26.8 (SD = 5.9) years. One-fifth never initiated breastfeeding/pumping (n = 67; 18.9%) and mean time-to-breastfeeding cessation was 48.1 days (SD = 57.2; median = 30.4 [interquartile range: 6.0-60.9]). Education, length of stay, employment, race/ethnicity, number of household members who smoke, and readiness-to-protect infants from tobacco smoke were significantly associated with breastfeeding cessation. Further, infants fed breast milk for ≥4 months had 42.7% more well-child visits (p < 0.001) and 50.0% fewer respiratory-related clinic visits (p < 0.05).

CONCLUSIONS

One-quarter of infants admitted to NICUs will be discharged to households where individuals who smoke live; we demonstrated that smoking-related factors were associated with mothers' breastfeeding practices. Infants who received breast milk longer had fewer respiratory-related visits.

IMPACT

One-quarter of NICU infants will be discharged to households where smokers live. Initiating/sustaining breastfeeding can be difficult for mothers of preterm NICU infants, especially mothers who smoke or live with others who smoke. Education, employment, race/ethnicity, length of stay, household member smoking, and readiness-to-protect infants from tobacco smoke were significantly associated with time-to-breastfeeding cessation. Infants fed breast milk for ≥4 months had 42.7% more well-child visits and 50.0% fewer respiratory-related clinic visits, compared to infants fed breast milk <4 months. Data support intervention refinements for mothers from smoking households and making NICU-based healthcare workers aware of risk factors for early breastfeeding cessation.

Determinants of Full Breastfeeding at 6 Months and Any Breastfeeding at 12 and 24 Months among Women in Sydney: Findings from the HSHK Birth Cohort Study

The aim of this study was to report on breastfeeding duration up to 24 months and determine the predictors of breastfeeding duration among women in South Western Sydney, one of the most culturally diverse and socioeconomically disadvantaged regions of New South Wales (NSW), Australia. Mother–infant dyads (n = 1035) were recruited to the Healthy Smiles Healthy Kids birth cohort study. Study data were collected through telephone interviews at 2, 4, 8, 12, and 24 months postpartum. Cox proportional hazards models were used to determine factors associated with the risk of stopping full breastfeeding at six months and any breastfeeding at 12 and 24 months. The majority of mothers (92.3%) had initiated breastfeeding. At six months, 13.5% of infants were fully breastfed, while 49.9% received some breast milk. Only 25.5% and 2.9% of infants received some breast milk at 12 and 24 months, respectively. Lower maternal education level, lower socioeconomic status, full-time employment, maternal smoking during pregnancy, and caesarean delivery were associated with increased risk of stopping full breastfeeding at six months and any breastfeeding at 12 and 24 months. Older maternal age and partner’s preference for breastfeeding were associated with an increased likelihood of continuing any breastfeeding at 12 and 24 months. These findings present a number of opportunities for prolonging breastfeeding duration in disadvantaged communities in NSW.

Early Recognition of the Preference for Exclusive Breastfeeding in Current China: A Prediction Model based on Decision Trees

Exclusive breastfeeding (EBF) is affected by multiple risk factors. Therefore, it is difficult for clinical professionals to identify women who will not practice EBF well and provide subsequent medical suggestions and treatments. This study aimed to apply a decision tree (DT) model to predict EBF at two months postpartum. The socio-demographic, clinical and breastfeeding parameters of 1,141 breastfeeding women from Nanjing were evaluated. Decision tree modelling was used to analyse and screen EBF factors and establish a risk assessment model of EBF. The Chinese version of the Breastfeeding Self-Efficacy Scale (CV-BSES) score, early formula supplementation, abnormal nipples, mastitis, neonatal jaundice, cracked or sore nipples and intended duration of breastfeeding were significant risk factors associated with EBF in the DT model. The accuracy, sensitivity and specificity of the DT model were 73.1%, 75.5% and 66.3%, respectively. The DT model showed similar or better performance than the logistic regression model in assessing the risk of early cessation of EBF before two months postpartum. The DT model has potential for application in clinical practice and identifies high-risk subpopulations that need specific prevention.

Using the behaviour change wheel to explore infant feeding peer support provision; insights from a North West UK evaluation

Background

Breastfeeding peer support is advocated in national and international guidelines, but the evidence base is mixed. In the UK, breastfeeding peer support was found to be ineffective in randomised controlled trials, while women report positive impacts on breastfeeding experiences in qualitative studies. A key criticism levied against breastfeeding peer support is the lack of theory underpinning intervention design. Here we use the Behaviour Change Wheel to structure the analysis of evaluation data from an infant feeding peer support service in one area in North West England. We aimed to provide theoretically informed insights into how peer support can be operationalised to influence women's breastfeeding experiences.

Methods

A 2 year mixed-methods evaluation (2014-2016) comprised surveys and interviews (individual or group) with peer supporters, health and community professionals, project leads and women, and routinely collected infant feeding data. We used the three layers (policies, intervention functions and behaviour-related components) of the Behaviour Change Wheel to structure and interpret the data.

Results

Overall data comprised 23 interviews (n = 14 - individual; n = 9 - group) and 409 completed surveys. The findings are presented in three sections. First, the 'policies' (outer) layer of the Behaviour Change Wheel provides insights into the existing context, infrastructure and resources that underpinned peer support delivery. Then the second (intervention functions) and inner (behaviour components) layers of the Behaviour Change Wheel are used to present three themes, 'developing capabilities for infant feeding', 'motivating guidance and support' and 'opportunities for support'. These findings highlight that a peer support service delivered in a context of effective interdisciplinary partnerships, Baby Friendly Initiative accreditation, and flexible service planning, with peer support provided via different types of instrumental, social, practical and emotional support was perceived to be highly beneficial on women's breastfeeding experiences. In the final section key challenges faced by the service are outlined.

Conclusion

While gaps and areas for development were highlighted, the service enhanced women's capabilities, motivations and opportunities for breastfeeding. These theoretically informed insights into an organic and responsive peer support service help build the evidence base for breastfeeding peer support and to identify positive delivery features for future testing.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Competitions for smoking cessation

BACKGROUND

Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle.

OBJECTIVES

To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions.

SEARCH METHODS

This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes.

DATA COLLECTION AND ANALYSIS

For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively.

MAIN RESULTS

Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated.

AUTHORS' CONCLUSIONS

At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.

Prospective associations of breastfeeding and smoking cessation among low-income pregnant women

Although low-income pregnant women have high rates of smoking and low rates of breastfeeding, few studies have examined prospective associations between these risk factors in community samples. Doing so may help improve breast-feeding support programs in this population. We used a secondary analysis of 247 low-income pregnant smokers in Memphis, Tennessee, who were interviewed up to 4 times (twice during pregnancy and twice through 6 months postpartum). Smoking cessation during prepartum and postpartum was defined as a self-report of not smoking for ≥1 week and an expired carbon monoxide level of <10 ppm. Multivariable logistic regression analyses were used to determine whether intent to breastfeed was associated with smoking cessation and whether smoking cessation was associated with actual breastfeeding. Models were adjusted for sociodemographic, pregnancy-related, and smoking-related confounders. Thirty-nine percent of participants intended to breastfeed, and 38% did so. Women who intended to breastfeed were 2 times more likely to quit smoking prepartum (adjusted OR = 1.99, 95% CI [1.06, 3.74]), but not postpartum (adjusted OR = 1.27, 95% CI [0.57, 2.84]). Quitting smoking at baseline and during pregnancy was associated with subsequent breastfeeding (adjusted OR 2.27, 95% CI [1.05, 4.94] and adjusted OR = 2.49, 95% CI [1.21, 5.11]). Low-income women who intended to breastfeed were more likely to quit smoking during pregnancy and those who quit smoking at baseline and prepartum were more likely to breastfeed. Simultaneously supporting breastfeeding and smoking cessation may be very useful to change these important health behaviours among this high-risk population.

Contingency management interventions for tobacco and other substance use disorders in pregnancy

Contingency management (CM) is an effective intervention for reducing use of licit and illicit substances in a variety of populations. Pregnant women are a vulnerable population with much to gain from effective interventions for substance use disorders, and for whom CM interventions may be especially well-suited. We reviewed the literature on CM interventions among pregnant women with tobacco and other substance use disorders with 3 aims: (a) describe the effectiveness of CM for reducing use of tobacco and other substances during pregnancy, (b) describe the effects of CM interventions on infant outcomes, and (c) identify needs for future research on CM in pregnancy. Our search strategy revealed 27 primary studies of CM in pregnancy. CM was effective in the majority of studies targeting nicotine abstinence, and results were mixed in studies targeting illicit substances. A variety of methodologies were used within the relatively small number of studies making it difficult to identify underlying mechanisms. Also, very few studies reported maternal and infant outcomes, and significant effects of CM were only apparent when secondary analyses pooled data from multiple studies. Furthermore, there is extremely limited data on the cost effectiveness of CM interventions in pregnancy. Future research should address these 3 areas to better determine the ultimate value of CM as an efficacious treatment for pregnant women with substance use disorders. (PsycINFO Database Record

Postpartum Smoking Relapse and Breast Feeding: Defining the Window of Opportunity for Intervention

Background

Though many women spontaneously quit smoking during pregnancy, a large proportion relapse after delivery. Efforts aimed at reducing postpartum smoking relapse have been largely ineffective. Several studies have reported breast feeding as a primary factor influencing smoking abstinence duration. However, data on the potential role of breast feeding in smoking intervention efforts remain incomplete.

Methods

The Ulm SPATZ Health Study cohort consists of 1006 newborns of 970 mothers recruited in the University Medical Center Ulm, Germany. Kaplan-Meier plots, log-rank tests, and Cox proportional hazards models were used to assess differences in predominant and total breast-feeding duration stratified by smoking abstinence at 2 years and relapse period (by 6 weeks, 6 months, and 2 years postdelivery). Chi-square and Kruskal-Wallis tests were performed to identify significant differences in demographic and lifestyle factors across smoking categories.

Results

Approximately 70% of previous smokers who initiated breast feeding relapsed within 2 years. Relapse by 6 months was significantly associated with noninitiation of predominant breast feeding. Total breast-feeding duration rates among abstaining mothers and those who relapsed after 6 weeks mirrored those of nonsmokers respectively up to 1 year and 3 months. Lower age and education were mostly associated with smoking by 6 weeks. First parity and having a nonsmoking partner were associated with abstinence up to 2 years.

Conclusions

Interventions promoting breast feeding to incentivize continued smoking abstinence may be effective prior to weaning. Those promoting breast feeding longer than 6 months and partner smoking cessation may increase rates of long-term smoking abstinence lasting longer than 2 years postdelivery.

Implications

Most mothers who quit smoking during pregnancy relapse within 6 months of delivery. Though interventions targeting new mothers have been largely unsuccessful, relapse is often delayed until after weaning and targeted breast-feeding promotion has been suggested to enhance smoking cessation interventions. In this study, we assess the relationship between breast-feeding duration and long-term smoking abstinence by longitudinally investigating predominant and total breast-feeding patterns among mothers with a recent history of smoking stratified by period of relapse up to 2 years after delivery.

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.

Financial Incentives for Reducing Smoking and Promoting Other Health-Related Behavior Change in Vulnerable Populations

Substantial reductions in U.S. cigarette smoking and associated chronic diseases over the past 50 years have benefited health. Unfortunately, those reductions have distributed unevenly throughout the population. Smoking remains prevalent and even increasing among certain vulnerable populations: economically disadvantaged groups, those with other substance-use disorders or mental illness, certain ethnic and racial minorities, and gender and sexual minorities. Moreover, other unhealthy behavior patterns (physical inactivity, unhealthy food choices, risky sexual behavior, poor adherence to medical preventive regimens) and associated chronic diseases are also overrepresented in many of these same populations. Disparities in unhealthy behavior patterns contribute to health disparities and escalating health care costs, underscoring the need for more effective behavior-change strategies. This report reviews research on the efficacy of financial incentives for reducing smoking in vulnerable populations, while also touching on applications of that behavior-change strategy for promoting other health-related behavior changes in vulnerable populations.

Maternal smoking and newborn sex, birth weight and breastfeeding: a population-based study

OBJECTIVE

Today, it is acknowledged that smoking during pregnancy and/or the postnatal period has significant risks for a foetus and newborn child. This research examines the relationship between smoking only postnatally, both during pregnancy and postnatally, and the newborn sex, birth weight and breastfeeding.

METHODS

Total 664 women of randomly selected five primary healthcare centres between the dates 20 February 2010 and 20 July 2010 were included in the research. Statistical analyses were performed with SPSS for Windows 19.0 (Statistical Package for Social Sciences software package). Data were described as mean, standard deviation, percentages and Chi-square tests and backward stepwise logistic regression were analysed.

RESULTS

It was found that the percentage of smoking women with daughters is 2.5 times higher than women with sons. Women who smoke are 3.9 times more likely to start feeding their baby with supplementary infant foods at 4 months or earlier than those who do not smoke. Finally, the risk of a birth weight under 2500 g is 3.8 times higher for maternal smokers.

CONCLUSIONS

This study suggests that women who expect a girl smoke more heavily than those who expect a boy. The birth weight of maternal smokers' newborns is lower. Those women who smoke while breastfeeding start feeding their babies with supplementary infant foods at an earlier age.

Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review

Approximately 10% of women report smoking during pregnancy. The number of breastfeeding women who relapse back to smoking is even greater. Smoking may cause adverse changes to the milk's composition by not only reducing its protective properties, but also by affecting the infant's health. The pathophysiological mechanisms underlying these adverse effects are not entirely known. This article is a review of previous reports about the effects of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, using a MEDLINE data. The key search terms were "smoking and breastfeeding", "smoking and lactation", "smoking and milk composition", "nicotine and breast milk". Studies have shown that nicotine levels in breast milk of women who smoke are three times higher than those in the plasma levels. Breast milk volume is reduced and the duration of lactation period is shorter. Smoking causes adverse changes to the milk's composition by not only reducing its protective properties, but also affecting infants' response to breastfeeding and to breast milk.

Systematic Review of Interventions for Racial/Ethnic-Minority Pregnant Smokers

INTRODUCTION

Large disparities exist in smoking rates during pregnancy by racial/ethnic status.

AIMS

The current review examined controlled studies that predominantly included racial/ethnic-minority pregnant smokers for providing smoking cessation treatment.

METHODS

Two authors independently conducted the literature searches in the standard databases using a combination of the keywords with minority, pregnancy, smoking, and cessation identifiers.

RESULTS

The searches identified nine articles that met the inclusion criteria. Only two studies exclusively targeted specific minority groups. Most of them provided some form of brief smoking cessation counseling, with two combining with incentives and one combining with pharmacotherapy. Two studies provided intensive cognitive interventions. Pregnant smokers of American Indian or Alaska Native, Hispanic subgroups, and Asian or Pacific Islander are under-studied.

CONCLUSIONS

Future studies to treat minority pregnant smokers could target under-studied minority groups and may need to directly and intensely target smoking behavior, address cultural and psychosocial issues in an individualized and comprehensive manner, and analyze cost-benefit of an intervention.

Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women

Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes and immediate and longer-term adverse health outcomes among exposed offspring. Developing more effective smoking-cessation interventions for pregnant women has been a public-health priority for more than thirty years. We review developments over the past three years (2012-15) on the use of financial incentives to promote smoking cessation among pregnant women. We searched the literature for reports on primary and secondary analyses and reviews of controlled trials on this topic published in peer-reviewed journals using the search engine PubMed, reviewed bibliographies of published articles, and consulted expert colleagues. The search revealed several important developments, with the following three being especially noteworthy. First, the review identified four new randomized controlled trials, three of which further supported the efficacy of this treatment approach. One of the three trials supporting efficacy also included the first econometric analysis of this treatment approach showing financial incentives with pregnant smokers to be highly cost-effective. Second, two Cochrane reviews were published during this 3-year period covering the more recent and earlier efficacy trials. Meta-analyses in both reviews supported the efficacy of the approach. Lastly, the first effectiveness trial was reported demonstrating that financial incentives increased abstinence rates above control levels when implemented by obstetrical clinic staff in a large urban hospital working with community tobacco interventionists. Overall, there is a growing and compelling body of evidence supporting the efficacy and cost-effectiveness of financial incentives for smoking cessation among pregnant women.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

BACKGROUND

Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.

AIM

To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.

DESIGN

Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.

SETTING

UK.

PARTICIPANTS

The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.

METHODS

(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.

RESULTS

Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage.

LIMITATIONS

Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.

CONCLUSIONS

Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012001980.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Financial incentives for smoking cessation among depression-prone pregnant and newly postpartum women: effects on smoking abstinence and depression ratings

INTRODUCTION

We examined whether pregnant and newly postpartum smokers at risk for postpartum depression respond to an incentive-based smoking-cessation treatment and how the intervention impacts depression ratings.

METHODS

This study is a secondary data analysis. Participants (N = 289; data collected 2001-2013) were smokers at the start of prenatal care who participated in 4 controlled clinical trials on the efficacy of financial incentives for smoking cessation. Women were assigned either to an intervention wherein they earned vouchers exchangeable for retail items contingent on abstaining from smoking or to a control condition wherein they received vouchers of comparable value independent of smoking status. Treatments were provided antepartum through 12-weeks postpartum. Depression ratings (Beck Depression Inventory [BDI]-1A) were examined across 7 antepartum/postpartum assessments. Women who reported a history of prior depression or who had BDI scores ≥ 17 at the start of prenatal care were categorized as depression-prone (Dep+), while those meeting neither criterion were categorized as depression-negative (Dep-).

RESULTS

The intervention increased smoking abstinence independent of depression status (p < .001), and it decreased mean postpartum BDI ratings as well as the proportion of women scoring in the clinical range (≥17 and >21) compared with the control treatment (ps ≤ .05). Treatment effects on depression ratings were attributable to changes in Dep+ women.

CONCLUSIONS

These results demonstrate that depression-prone pregnant and newly postpartum women respond well to this incentive-based smoking-cessation intervention in terms of achieving abstinence, and the intervention also reduces the severity of postpartum depression ratings in this at-risk population.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

Does impulsiveness moderate response to financial incentives for smoking cessation among pregnant and newly postpartum women?

We examined whether impulsiveness moderates response to financial incentives for cessation among pregnant smokers. Participants were randomized to receive financial incentives delivered contingent on smoking abstinence or to a control condition wherein incentives were delivered independent of smoking status. The study was conducted in two steps: First, we examined associations between baseline impulsiveness and abstinence at late pregnancy and 24-weeks-postpartum as part of a planned prospective study of this topic using data from a recently completed, randomized controlled clinical trial (N = 118). Next, to increase statistical power, we conducted a second analysis collapsing results across that recent trial and two prior trials involving the same study conditions (N = 236). Impulsivity was assessed using a delay discounting (DD) of hypothetical monetary rewards task in all three trials and Barratt Impulsiveness Scale (BIS) in the most recent trial. Neither DD nor BIS predicted smoking status in the single or combined trials. Receiving abstinence-contingent incentives, lower baseline smoking rate, and a history of quit attempts prepregnancy predicted greater odds of antepartum abstinence across the single and combined trials. No variable predicted postpartum abstinence across the single and combined trials, although a history of antepartum quit attempts and receiving abstinence-contingent incentives predicted in the single and combined trials, respectively. Overall, this study provides no evidence that impulsiveness as assessed by DD or BIS moderates response to this treatment approach while underscoring a substantial association of smoking rate and prior quit attempts with abstinence across the contingent incentives and control treatment conditions.

Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: a survey of the British public

OBJECTIVE

To survey public attitudes about incentives for smoking cessation in pregnancy and for breast feeding to inform trial design.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

British general public.

METHODS

Seven promising incentive strategies had been identified from evidence syntheses and qualitative interview data from service users and providers. These were shopping vouchers for: (1) validated smoking cessation in pregnancy and (2) after birth; (3) for a smoke-free home; (4) for proven breast feeding; (5) a free breast pump; (6) payments to health services for reaching smoking cessation in pregnancy targets and (7) breastfeeding targets. Ipsos MORI used area quota sampling and home-administered computer-assisted questionnaires, with randomised question order to assess agreement with different incentives (measured on a five-point scale). Demographic data and target behaviour experience were recorded. Analysis used multivariable ordered logit models.

RESULTS

Agreement with incentives was mixed (ranging from 34% to 46%) among a representative sample of 1144 British adults. Mean agreement score was highest for a free breast pump, and lowest for incentives for smoking abstinence after birth. More women disagreed with shopping vouchers than men. Those with lower levels of education disagreed more with smoking cessation incentives and a breast pump. Those aged 44 or under agreed more with all incentive strategies compared with those aged 65 and over, particularly provider targets for smoking cessation. Non-white ethnic groups agreed particularly with breastfeeding incentives. Current smokers with previous stop attempts and respondents who had breast fed children agreed with providing vouchers for the respective behaviours. Up to £40/month vouchers for behaviour change were acceptable (>85%).

CONCLUSIONS

Women and the less educated were more likely to disagree, but men and women of childbearing age to agree, with incentives designed for their benefit. Trials evaluating reach, impact on health inequalities and ethnic groups are required prior to implementing incentive interventions.

TRIAL REGISTRATION NUMBER

CRD42012001980.

Smoking and caesarean deliveries: major negative predictors for breastfeeding in the mother-child cohort in Crete, Greece (Rhea study)

Although benefits of breastfeeding have been widely promoted and accepted, exclusive breastfeeding for the first 6 months of life is far from the norm in many countries. In a prospective mother-child cohort study in Crete, Greece ('Rhea' study), we assessed the frequency of breastfeeding and its socio-demographic predictors. Information on breastfeeding was available for a period of 18 months post-partum for a cohort of 1181 mothers and their 1208 infants. The frequency of exclusive and predominant breastfeeding in the first month post-partum was 17.8% and 3.4%, respectively, with almost three-quarters of women (73.6%) ceasing any breastfeeding after 4 months post-partum. Women were less likely to initiate breastfeeding if they had a caesarean delivery (CD), whereas they were more likely to initiate breastfeeding if they had a higher education or gave birth to a private clinic. Among women breastfeeding, those who had a CD, were ex-smokers or smokers during pregnancy had a statistically significant shorter duration of breastfeeding, whereas higher education and being on leave from work were associated with a longer duration of breastfeeding. Study findings suggest suboptimal levels of exclusive and any breastfeeding and difficulty maintaining longer breastfeeding duration. CD and smoking are common in Greece and are strong negative predictors for breastfeeding initiation and/or duration, necessitating targeting women at risk early in the prenatal period so as to have a meaningful increase of breastfeeding practices in future cohorts of mothers.

Maternal body mass index moderates the influence of smoking cessation on breast feeding

INTRODUCTION

Smoking cessation is associated with greater breast feeding in newly postpartum women, while being overweight or obese is associated with lower rates of breast feeding. The purpose of this study is to examine whether the increases in breast feeding associated with smoking cessation are moderated by maternal body mass index (BMI). To our knowledge, the interaction of maternal smoking status and overweight/obesity on breast feeding has not been previously reported.

METHODS

Participants (N = 370) were current or recent smokers at the start of prenatal care who participated in controlled trials on smoking cessation or relapse prevention during/after pregnancy. Study participants were followed from the start of prenatal care through 24 weeks postpartum. Smoking status was biochemically verified, and maternal reports of breast feeding were collected at 2-, 4-, 8-, 12-, and 24-week postpartum assessments.

RESULTS

Women who reported postpartum smoking abstinence or had a normal/underweight prepregnancy BMI (<25) were more likely to be breast feeding at the time that smoking status was ascertained (odds ratio [OR] = 3.02, confidence interval [CI] = 2.09-4.36, and OR = 2.07, CI = 1.37-3.12, respectively). However, smoking status and BMI interacted such that (a) normal/underweight women showed a stronger association between smoking abstinence and breast feeding (OR = 4.58, CI = 2.73-7.66) than overweight/obese women (OR = 1.89, CI = 1.11-3.23), and (b) abstainers showed an association between normal/underweight BMI and breast feeding (OR = 3.53, CI = 1.96-6.37), but smokers did not (OR = 1.46, CI = 0.88-2.44).

CONCLUSIONS

Overweight/obesity attenuates the positive relationship between smoking abstinence and greater breast feeding among newly postpartum women.

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.

Financial incentives for smoking cessation among pregnant and newly postpartum women

OBJECTIVE

Smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the U.S., causing serious immediate and longer-term adverse effects for mothers and offspring. In this report we provide a narrative review of research on the use of financial incentives to promote abstinence from cigarette smoking during pregnancy, an intervention wherein women earn vouchers exchangeable for retail items contingent on biochemically-verified abstinence from recent smoking.

METHODS

Published reports based on controlled trials are reviewed. All of the reviewed research was conducted by one of two research groups who have investigated this treatment approach.

RESULTS

Results from six controlled trials with economically disadvantaged pregnant smokers support the efficacy of financial incentives for increasing smoking abstinence rates antepartum and early postpartum. Results from three trials provide evidence that the intervention improves sonographically estimated fetal growth, mean birth weight, percent of low-birth-weight deliveries, and breastfeeding duration.

CONCLUSIONS

The systematic use of financial incentives has promise as an efficacious intervention for promoting smoking cessation among economically disadvantaged pregnant and recently postpartum women and improving birth outcomes. Additional trials in larger and more diverse samples are warranted to further evaluate the merits of this treatment approach.

Associations between maternal stress and smoking: findings from a population-based prospective cohort study

AIMS

To investigate associations between maternal stress and smoking prior to, during and 6 months after the pregnancy.

DESIGN

A prospective population-based cohort study.

SETTING

Norway.

PARTICIPANTS

A total of 71 757 women in the Norwegian Mother and Child Cohort Study (MoBa) participating twice during pregnancy and at 6 months postpartum.

MEASUREMENTS

Respondents' estimates of anxiety and depression, relationship discord and negative life events were measured, along with self-reports of smoking behaviour and demographic variables. Smoking was assessed at gestation weeks 17 and 30 and at 6 months postpartum.

FINDINGS

Of the 27.5% women who smoked at conception, 55.8% quit smoking during pregnancy. At 6 months postpartum, 28.9% of quitters had relapsed to smoking. In total, 12.9% of the sample reported smoking during the pregnancy. Adjusted for well-known risk factors, women reporting high levels of anxiety and depression had a decreased likelihood of quitting smoking during pregnancy [odds ratio (OR) 0.80, 95% confidence interval (CI): 0.73, 0.88) and an increased likelihood of relapsing after delivery (OR 1.26, 95% CI: 1.11, 1.44). Both relationship discord (OR 0.82, 95% CI: 0.75, 0.90) and exposure to negative life events (OR 0.93, 95%: CI 0.90, 0.96) had a negative influence on quitting smoking during pregnancy but had no influence on relapse to smoking postpartum.

CONCLUSIONS

Maternal stress and relationship discord may inhibit smoking cessation during pregnancy and promote resumption of smoking after pregnancy in women who have achieved abstinence.

Smoking behaviour before, during, and after pregnancy: the effect of breastfeeding

Data for this study were obtained from a population-based follow-up study in 25 Italian Local Health Units (LHUs) to evaluate pregnancy, delivery, and postpartum care in Italy. A sample of 3534 women was recruited and interviewed within a few days of their giving birth and at 3, 6, and 12 months after delivery, by trained interviewers using questionnaires. The objective of the study was to evaluate changes in smoking behaviour from one interview to the next. Of 2546 women who completed the follow-up, smoking prevalences before and during pregnancy were 21.6% and 6.7%; smoking prevalences and smoking relapse at 3, 6, and 12 months were 8.1% and 18.5%, 10.3% and 30.3%, and 10.9% and 32.3%, respectively. Smoking during and after pregnancy was more likely among women who were less educated, single, not attending antenatal classes, employed, and not breastfeeding. The results show that women who are breastfeeding smoke less than not breastfeeding women, even after controlling for other predictors (i.e.,  smoking relapse at 12 months: OR = 0.43, 95%  CI:  0.19, 0.94). A low maternal mood increases the risk of smoking relapse within 6 months of about 73%. This study also suggests that prolonged breastfeeding reduces the risk of smoking relapse and that this reduction may be persistent in time. Interventions targeting breastfeeding promotion may also indirectly support smoking cessation, even in absence of specific interventions.

Prepregnancy body mass index, socioeconomic status, race/ethnicity and breastfeeding practices

OBJECTIVE

While socioeconomic status (SES) and race/ethnicity are known predictors of breastfeeding practices, the added disparity caused by the rising rates of obesity among women of childbearing age remains untested. The purpose of this study was to examine differences in breastfeeding initiation and duration among black, white and Hispanic women of low and middle SES within the context of prepregnancy body mass index (BMI).

METHODS

Data from the Early Childhood Longitudinal Study-Birth Cohort were analyzed. Adjusted logistic regression models were built to examine differences in breastfeeding initiation and duration for the three racial/ethnic groups of low and middle SES.

RESULTS

Normal BMI Hispanic women of low SES demonstrated higher rates of breastfeeding initiation (74%) compared to other groups. Overweight/obese black women of low SES had lower rates of breastfeeding initiation. Overweight/obese Hispanic women of middle SES were significantly less likely to continue breastfeeding up to 4 months (OR: 0.65, 95% CI: 0.41, 0.98) compared to their white counterparts. Among women who initiated breastfeeding, overweight/obese white women of low SES had the highest rate of stopping within two months of giving birth (66.7%).

CONCLUSIONS

Examination of SES and racial/ethnic differences within the context of prepregnancy weight revealed specific groups with low rates of breastfeeding initiation and duration. Interventions tailored for these at-risk groups are needed to increase the overall proportion of mothers and infants who benefit from the positive health outcomes associated with breastfeeding.

Competitions and incentives for smoking cessation

BACKGROUND

Background Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Public health initiatives in the UK are currently planning to deploy incentive schemes to change unhealthy behaviours. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author (KC) and checked by the second (RP). We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Nineteen studies met our inclusion criteria, covering >4500 participants. Only one study, the largest in our review and covering 878 smokers, demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. This trial referred its participants to local smoking cessation services, and offered substantial cash payments (up to US$750) for prolonged abstinence. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. There is some evidence that recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis was not appropriate to this review, since the efficacy of most of the interventions was not demonstrated.

AUTHORS' CONCLUSIONS

With the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered. Rewarding participation and compliance in contests and cessation programmes may have potential to deliver higher absolute numbers of quitters. The one trial that achieved sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available. Future research might explore the scale and longevity of possible cash reward schedules, within a variety of smoking populations.

Effects of smoking cessation with voucher-based contingency management on birth outcomes

AIMS

This study examined whether smoking cessation using voucher-based contingency management (CM) improves birth outcomes.

DESIGN

Data were combined from three controlled trials.

SETTING

Each of the trials was conducted in the same research clinic devoted to smoking and pregnancy.

PARTICIPANTS

Participants (n=166) were pregnant women who participated in trials examining the efficacy of voucher-based CM for smoking cessation. Women were assigned to either a contingent condition, wherein they earned vouchers exchangeable for retail items by abstaining from smoking, or to a non-contingent condition where they received vouchers independent of smoking status.

MEASUREMENT

Birth outcomes were determined by review of hospital delivery records.

FINDINGS

Antepartum abstinence was greater in the contingent than non-contingent condition, with late-pregnancy abstinence being 34.1% versus 7.4% (P<0.001). Mean birth weight of infants born to mothers treated in the contingent condition was greater than infants born to mothers treated in the non-contingent condition (3295.6 ± 63.8 g versus 3093.6 ± 67.0 g, P = 0.03) and the percentage of low birth weight (<2500 g) deliveries was less (5.9% versus 18.5%, P = 0.02). No significant treatment effects were observed across three other outcomes investigated, although each was in the direction of improved outcomes in the contingent versus the non-contingent condition: mean gestational age (39.1 ± 0.2 weeks versus 38.5 ± 0.3 weeks, P = 0.06), percentage of preterm deliveries (5.9 versus 13.6, P = 0.09), and percentage of admissions to the neonatal intensive care unit (4.7% versus 13.8%, P = 0.06).

CONCLUSIONS

These results provide evidence that smoking-cessation treatment with voucher-based CM may improve important birth outcomes.

Breast feeding is associated with postpartum smoking abstinence among women who quit smoking due to pregnancy

INTRODUCTION

The purpose of this study was to characterize the relationship between breast feeding and postpartum smoking abstinence among women who quit smoking due to pregnancy and who were participating in a randomized clinical trial of an intervention designed to prevent postpartum relapse.

METHODS

A total of 251 women were enrolled in the intervention between 30 and 33 weeks postpartum and were followed through 26 weeks postpartum. Participant characteristics were assessed at the prepartum baseline visit, any breast feeding was assessed at 8 weeks postpartum, and smoking abstinence was assessed at 8 and 26 weeks postpartum.

RESULTS

Although 79.1% of participants intended to breast feed, only 40.2% reported breast feeding at 8 weeks postpartum. Characteristics associated with breast feeding at 8 weeks postpartum included Caucasian race/ethnicity, greater education, higher household income, and being married/living with a significant other. Logistic regression analysis indicated that breast feeding at 8 weeks postpartum was significantly associated with smoking abstinence at 8 weeks postpartum, odds ratio (OR) = 7.27 (95% CI = 3.27, 16.13), p < .001. Breast feeding at 8 weeks postpartum was also associated with abstinence at 26 weeks postpartum after controlling for smoking status at 8 weeks postpartum, OR = 2.64 (95% CI = 1.14, 6.10), p = .02.

DISCUSSION

Encouraging breast feeding among women who quit smoking due to pregnancy may facilitate postpartum smoking abstinence while increasing adherence to current infant feeding guidelines.