Incentives for Smoking Cessation During Pregnancy: An Ethical Framework

Effectiveness of smoking cessation interventions among pregnant women: An updated systematic review and meta-analysis

OBJECTIVE

To carry out a systematic review of systematic reviews with an update of the existing evidence relating to a broad range of smoking cessation interventions, including psycho-social, digital and pharmacologic interventions, for pregnant women.

DATA-SOURCES

Search was conducted in March 2022 in PubMed, EMBASE, and Cochrane in two stages: 1) a search of systematic reviews and meta-analyses, published from January 2012 through January 2022; 2) an update of those that fulfilled eligibility criteria reproducing the primary search strategy.

STUDY ELIGIBILITY CRITERIA

We selected randomized clinical trials (RCTs) that evaluated the effectiveness of pharmacological, digital, and psychosocial interventions in aged 18 years and over who were daily smokers, and compared these with routine care, less intense interventions or placebo.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data from eligible studies were manually extracted by two authors and reviewed by a third. The quality of the reviews was evaluated using the AMSTAR scale, and risk of bias was measured with the Rob-2 tool and GRADE level of evidence.

RESULTS

The meta-analysis included 63 RCTs (n = 19849 women). The interventions found to be effective were: financial incentives (RR:1.77; 95%CI:1.21-2.58), counseling (RR:1.27; 95%CI:1.13-1.43) and long-term nicotine replacement therapy (NRT) (RR:1.53; 95%CI:1.16-2.01). Short-term NRT, bupropion, digital interventions, feedback, social support, and exercise showed no effectiveness. The GRADE level of evidence was moderate-to-high for all interventions, with the exception of long-term NRT.

CONCLUSIONS

Non-pharmacological interventions for smoking cessation are the most effective for pregnant women. The moderator analysis suggests that pregnant women of low socioeconomic status might benefit less from smoking cessation interventions than women of a high socioeconomic status. These women are usually heavier smokers that live in pro-smoking environments and could require more intensive and targeted interventions.

[Considerations for the design and implementation of interventions for the cessation of tobacco, alcohol and cannabis use in pregnancy: A qualitative study]

OBJECTIVE

To explore the opinion of different key stakeholders regarding the requirements that tobacco, alcohol and/or cannabis cessation interventions should meet to be implemented and to be acceptable and useful during pregnancy.

DESIGN

A qualitative study with phenomenological approach. SITE: The study was conducted in Spain in 2022.

PARTICIPANTS

Decision makers, health professionals, pregnant women using tobacco, alcohol and/or cannabis and their partners who are also users.

METHODS

Data were collected through focus groups and in-depth interviews, until discourse saturation was reached and accurately transcribed. Exploratory analysis and inductive open coding were conducted, codes were merged into categories and subcategories were identified.

RESULTS

Four categories and 18 subcategories were identified. The results suggest that interventions should be multicomponent. Among the interventions most accepted by pregnant women and their partners were specific cessation consultations, information, peer support (although they did not specify how) and financial incentives. Among other options to consider, co-oximetry, proposed by managers to obtain an objective register.

CONCLUSIONS

The conclusion is that this intervention should be carried out at the level of prenatal care in primary care. There are doubts regarding the frequency, purpose, and follow-up of this multicomponent intervention, as well as the possibility of incorporating couples.

Piloting a complex intervention to promote a tobacco and alcohol-free pregnancy: the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study

BACKGROUND

Tobacco smoking and alcohol consumption before and during pregnancy increase the risk of adverse health outcomes for mother and child. Interventions to address smoking and drinking before and during pregnancy have the potential to reduce early-life health inequalities. In the Smoke and Alcohol Free with EHealth and Rewards (SAFER) pilot study we aimed to evaluate the acceptability, feasibility and effectiveness of a complex intervention supporting women in smoking and alcohol cessation before and during pregnancy.

METHODS

From February 2019 till March 2021, we piloted the SAFER pregnancy intervention among pregnant women and women planning pregnancy in South-West Netherlands in an uncontrolled before-after study. Participants were supported in smoking and alcohol cessation via up to six group sessions and an online platform. In addition, biochemically validated cessation was rewarded with incentives (i.e. shopping vouchers) amounting up to 185 euros. We aimed to include 66 women. The primary outcome was smoking and/or alcohol cessation at 34-38 weeks of gestation (if pregnant) or after six group sessions (if not pregnant). Quantitative data were analysed using descriptive statistics. Focus group interviews among those involved in the study were conducted at the end of the study to explore their experiences. Qualitative data was analysed using thematic analysis.

RESULTS

Thirty-nine women who smoked were included; no women who consumed alcohol were referred to the study. Unemployment (51%), financial problems (36%) and a smoking partner (72%) were common. Thirteen women (33%) dropped out, often due to other problems impeding smoking cessation or 'being too busy' to participate in the group sessions. Eleven women (28%) had quit smoking at the study's endpoint. The personal and positive approach was highly valued and biochemical validation was felt to be helpful.

CONCLUSION

The SAFER pregnancy intervention seems appropriate for women in need of extra support for smoking cessation before and during pregnancy. Its impact on alcohol cessation could not be studied due to recruitment issues. Recruitment and prevention of early dropout need attention in further development of this intervention.

TRIAL REGISTRATION

Netherlands Trial Register: NL7493. Date registered: 04/02/2019.

Promoting smoking cessation during pregnancy: A feasibility and pilot trial of a digital storytelling intervention delivered via text-messaging

OBJECTIVE

Smoking during pregnancy causes risks to mother and infant health. We investigated the feasibility and likely success of SKIP-IT, a narrative and picture-based smoking cessation intervention delivered via text messages.

METHODS

A feasibility and pilot trial. We aimed to recruit 70 pregnant women who smoked, randomised to usual care alone, or usual care and the SKIP-IT intervention, between 12 weeks of pregnancy and 6 weeks post due-date. Outcomes assessed were recruitment, retention, acceptability of, and engagement with the intervention, smoking behaviour, intentions, perceived risk, and self-efficacy.

RESULTS

Of 312 women initially approached by smoking cessation services only 54 (17%) agreed to be contacted by the research team. Twenty were then either ineligible or uncontactable and 28 (82%) participated. Most women reported texts to be entertaining and helpful. The proportion of women not smoking at follow-up was lower in the intervention group, but numbers were too small to draw conclusions about effectiveness.

CONCLUSION

The intervention was acceptable, but difficulty in making initial and follow-up contacts meant our methods were unfeasible for a larger trial.

PRACTICE IMPLICATIONS

Digital Storytelling interventions could help women quit smoking, but further research is required to identify alternative methods for studies with pregnant women who smoke.

Improving oral health in people with severe mental illness (SMI): A systematic review

BACKGROUND

Those with severe mental illness (SMI) are at greater risk of having poor oral health, which can have an impact on daily activities such as eating, socialising and working. There is currently a lack of evidence to suggest which oral health interventions are effective for improving oral health outcomes for people with SMI.

AIMS

This systematic review aims to examine the effectiveness of oral health interventions in improving oral health outcomes for those with SMI.

METHODS

The review protocol was registered with PROSPERO (ID CRD42020187663). Medline, EMBASE, PsycINFO, AMED, HMIC, CINAHL, Scopus and the Cochrane Library were searched for studies, along with conference proceedings and grey literature sources. Titles and abstracts were dual screened by two reviewers. Two reviewers also independently performed full text screening, data extraction and risk of bias assessments. Due to heterogeneity between studies, a narrative synthesis was undertaken.

RESULTS

In total, 1462 abstracts from the database search and three abstracts from grey literature sources were identified. Following screening, 12 studies were included in the review. Five broad categories of intervention were identified: dental education, motivational interviewing, dental checklist, dietary change and incentives. Despite statistically significant changes in plaque indices and oral health behaviours as a result of interventions using dental education, motivational interviewing and incentives, it is unclear if these changes are clinically significant.

CONCLUSION

Although some positive results in this review demonstrate that dental education shows promise as an intervention for those with SMI, the quality of evidence was graded as very low to moderate quality. Further research is in this area is required to provide more conclusive evidence.

Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy study: a before-after study protocol

Despite existing interventions, tobacco smoking and alcohol consumption during pregnancy are common. The Smoke and Alcohol Free with EHealth and Rewards (SAFER) pregnancy intervention combines monthly group sessions, access to a web-based platform and incentives upon biochemically validated cessation for a maximum duration of 6 months to promote cessation of smoking and alcohol use before and during pregnancy. To inform development of the SAFER pregnancy intervention, two focus groups with the target population were held beforehand, with results reported here alongside the final SAFER pregnancy study protocol. In a before−after study we aim to include 66 women who are pregnant or have a wish to become pregnant and who smoke and/or consume alcohol (i.e. target population of the SAFER pregnancy intervention). The primary outcome measure is cessation of smoking and/or alcohol use at 34−38 weeks of gestation, or after six group sessions if women did not become pregnant during the study period. Secondary outcomes focus on the barriers and facilitators for implementation of the SAFER pregnancy intervention.