A couples-focused intervention for smoking cessation during pregnancy: The study protocol of the Quit Together pilot randomized controlled trial

The Quit Together couples-focused pilot randomized trial of tobacco cessation for pregnant smokers

AIMS

This study reports on the feasibility and preliminary efficacy of prenatal and postnatal couples-focused telephone counseling for pregnant tobacco smokers.

DESIGN AND SETTING

This pilot randomized controlled trial (RCT) was conducted online in Romania and enrolled a total of 90 pregnant smokers and 77 of their life partners.

PARTICIPANTS

90 adult pregnant smokers and 77 of their life partners were randomized either to (1) Motivation and Problem Solving (MAPS) telephone counseling (n = 45 pregnant smokers who received up to 8 pre/postnatal telephone counseling sessions and n = 40 partners who received up to 4 sessions) or (2) usual care (n = 45 pregnant smokers and n = 37 partners).

MEASUREMENTS

The primary outcomes were maternal 7-day self-reported and biochemically verified tobacco point-prevalence abstinence (PPA) and prolonged abstinence (PA) between birth and three months postpartum. Unadjusted group comparisons were used to assess preliminary intervention efficacy.

FINDINGS

20 % of women in the intervention group reported PPA, compared to 15.6 % (p = 0.58) in the usual care group. Women (n = 15) who received three or more counseling sessions had higher PPA (40.0 vs 15.6 %, p < 0.05) than women in the usual care group. 8.9 % of the women in the intervention group had biochemically verified abstinence compared to 4.4 % (p = 0.67) in the usual care group, with a significantly higher rate among women who received at least three counseling sessions (26.7 % vs 4.4 %, p = 0.03).

CONCLUSION

A prenatal and postnatal couple-focused telephone counseling intervention for pregnant smokers is feasible and provides preliminary efficacy of cessation and postpartum abstinence when a minimum intervention dosage is delivered.

Healthful Eating Behaviors among Couples Contribute to Lower Gestational Weight Gain

Through longitudinal analysis from the GLOWING cohort study, we examined the independent and joint relationships between couples' eating behaviors and gestational weight gain (GWG). Pregnant persons (n = 218) and their non-pregnant partners (n = 157) completed an Eating Inventory. GWG was calculated as gestation weight at 36 weeks minus that at 10 weeks. General linear models were used to examine the relationships between GWG and the pregnant persons, non-pregnant partners, and couples (n = 137; mean of pregnant persons and non-pregnant partners) cognitive restraint (range 0-21), dietary disinhibition (range 0-18), and perceived hunger (range 0-14), with higher scores reflecting poorer eating behaviors. The adjusted models included race/ethnicity, education, income, marital status, and age. The pregnant persons and their non-pregnant partners' cognitive restraint, dietary disinhibition, and perceived hunger scores were 9.8 ± 4.7, 4.8 ± 3.2, and 4.4 ± 2.5 and 6.6 ± 4.6, 5.4 ± 3.4, and 4.7 ± 3.2, respectively. Higher cognitive restraint scores among the pregnant persons and couples were positively associated with GWG (p ≤ 0.04 for both). Stratified analyses revealed this was significant for the pregnant persons with overweight (p ≤ 0.04). The non-pregnant partners' eating behaviors alone were not significantly associated with GWG (p ≥ 0.31 for all). The other explored relationships between GWG and the couples' eating behaviors were insignificant (p ≥ 0.12 for all). Among the pregnant persons and couples, reduced GWG may be achieved with higher levels of restrained eating. Involving non-pregnant partners in programs to optimize GWG may be beneficial.

Changing patient preferences toward better trial recruitment: an ethical analysis

While randomized controlled trials are essential to health research, many of these trials fail to recruit enough participants. Approaching recruitment through the lens of behavioral science can help trialists to understand influences on the decision to participate and use them to increase recruitment. Although this approach is promising, the use of behavioral influences during recruitment is in tension with the ethical principle of respect for persons, as at least some of these influences could be used to manipulate potential participants. In this paper, we examine this tension by discussing two types of behavioral influences: one example involves physician recommendations, and the other involves framing of information to exploit cognitive biases. We argue that despite the apparent tension with ethical principles, influencing trial participants through behavior change strategies can be ethically acceptable. However, we argue that trialists have a positive obligation to analyze their recruitment strategies for behavioral influences and disclose these upfront to the research ethics committee. But we also acknowledge that since neither trialists nor ethics committees are presently well equipped to perform these analyses, additional resources and guidance are needed. We close by outlining a path toward the development of such guidance.

Smoking Cessation among Pregnant and Postpartum Women from Low-Income Groups in the United States

INTRODUCTION

Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States.

METHODS

Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach.

RESULTS

Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking.

DISCUSSION

This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

Perceived safety of smoking a few cigarettes during pregnancy and provider advice in a sample of pregnant smokers from Romania

AIMS

To assess the prevalence of the perceived safety of smoking a few (generally fewer than five per day) cigarettes during pregnancy and identify associated factors in a sample of pregnant smokers in Romania, a middle-income country.

DESIGN AND SETTING

Cross-sectional design with a convenience sample using a polled data set collected between 2016 and 2019 in the formative and baseline phases of the Quit Together randomized control trial (RCT) in Romania. Data were collected using a structured questionnaire administered by research assistants in clinics in the formative phase and self-administered through the study website at the RCT baseline.

PARTICIPANTS

A total of 217 pregnant smokers (mean age = 28.5 ± 5.8) enrolled in the formative and RCT phases of the research project.

MEASUREMENTS

The main outcome was the perceived safety of smoking a few cigarettes during pregnancy (generally fewer than five per day). Covariates included the health-care providers' advice towards smoking tobacco cigarettes during pregnancy, socio-demographics, the presence of depression and anxiety symptoms and level of nicotine dependence.

FINDINGS

More than 35% of participants agreed that smoking a few cigarettes during pregnancy was safe for them and their baby. The perceived safety of smoking a few cigarettes during pregnancy was significantly associated with being told by health-care providers that it is acceptable to continue to smoke cigarettes in small amounts [odds ratio (OR) = 3.08; 95% CI = 1.35-6.99; P < 0.01], perceived harm reduction of smoking light cigarettes (OR = 2.67; 95% CI = 1.19-5.97; P = 0.02) and moderate to severe depression and anxiety score (OR = 0.34; 95% CI = 0.13-0.84; P = 0.02).

CONCLUSIONS

More than one-third of pregnant Romanian women appear to believe that smoking 'a few' cigarettes during pregnancy is safe for them and their fetuses. Those who are told by their health-care providers that it is acceptable to smoke in small amounts during pregnancy have higher odds of perceiving smoking 'a few' cigarettes during pregnancy as safe compared with other pregnant Romanian women.

Using Behavioral Nudges to Engage Pregnant Women in a Smoking Cessation Trial: An Online Field Quasi-Experiment

Evidence shows that behavioral nudges could be used to enhance enrollment rates in randomized controlled trials (RCTs) by addressing enrollment barriers, but research on this topic is limited. We conducted an online field quasi-experiment with separate pretest (October 2017-January 2018) and posttest (February-May 2018) samples designed to examine the use of behavioral nudges to engage pregnant smokers in a couple-focused smoking cessation RCT relying on online enrollment through paid Facebook ads and a dedicated website, by reporting aggregate Facebook ads and Google Analytics data. The Facebook ads pretest conversion rate of 1.6% doubled and reached 3.41% in the posttest period. The pretest eligibility assessment rate decreased from 10.3% to 6.46%, but registered a relative increase of approximately 50% in the posttest period, as opposed to the pretest. The number of women who signed the informed consent in the posttest period has increased with 63%, from a proportion of 8.54% in the pretest to 11.73% in the posttest period. These findings might lend support to integrating behavioral nudges in the recruitment and enrollment materials of RCTs to boost enrollment.

Marital status, partner acknowledgment of paternity, and neighborhood influences on smoking during first pregnancy: findings across race/ethnicity in linked administrative and census data

BACKGROUND

Improving prediction of cigarette smoking during pregnancy (SDP), including differences by race/ethnicity and geography, is necessary for interventions to achieve greater and more equitable SDP reductions.

METHODS

Using individual-level data on singleton first births, 2010-2017 (N = 182,894), in a US state with high SDP rates, we predicted SDP risk as a function of reproductive partner relationship (marital status, paternity acknowledgement), maternal and residential census tract sociodemographics, and census tract five-year SDP rate.

RESULTS

SDP prevalence was 12.7% (white non-Hispanics, WNH), 6.8% (Black/African Americans, AA), 19.5% (Native American, NA), 4.7% (Hispanic, H), and 2.8% (Asian, AS). In WNH and AA, with similar trends in other groups, after adjustment for non-linear effects of maternal age and education and for census tract risk-factors, there was a consistent risk-ordering of SDP rates by reproductive partner relationship: married/with paternity acknowledged < unmarried/acknowledged < unmarried/unacknowledged < married/unacknowledged. Associations with census tract SDP rate, adjusted for maternal and census tract sociodemographics, were stronger for AA and H (OR 2.65-2.67) than for NA (OR = 1.91), WNH (OR = 1.75), or AS (NS). AA SDP was increased in tracts having a higher proportion of WNH residents and was reduced in comparison with WNH at every combination of age, education and partner relationship.

CONCLUSIONS

Inattention to differences by race/ethnicity may obscure SDP risk factors. Despite marked race/ethnic differences in unmarried-partner cohabitation rates, failure to acknowledge paternity emerged as an important and consistent risk-predictor. Census-tract five-year SDP rates have heterogeneous origins, but the association of AA SDP risk with increased racial heterogeneity suggests an important influence of neighbor risk behaviors.

A Cross-Section Study of Relationship Characteristics and Smoking Cessation During Pregnancy in a Sample of Romanian Pregnant Women

INTRODUCTION

Partner support and relationship characteristics may be important factors in effective couple-based pregnancy smoking cessation programs. Research is needed to investigate the links between couple relationship characteristics and maternal smoking cessation to inform the development of such interventions.

METHODS

This paper relies on cross-section data collected during the formative phase in the development of an ongoing couple-focused pregnancy tobacco cessation trial. Data (n = 143 pregnant women) were collected from two large public and one private obstetrics and gynecology clinics located in Cluj-Napoca, Romania. Multiple logistic regression was used to identify correlates of smoking cessation during pregnancy.

RESULTS

Higher education was a significant correlate of smoking cessation during pregnancy. Women with a college degree or more had higher odds to quit smoking during pregnancy in comparison to their counterparts who graduated high school or less (OR 14.3, 95% CI 2.75-74.28). In addition, women with increased positive partner interactions related to their smoking cessation efforts correlated with higher odds of quitting smoking during pregnancy (OR 1.48, 95% CI 1.15-1.91).

DISCUSSION

While pregnancy tobacco cessation interventions with partner support do exist, most were not successful and did not focus on couple-related concepts such as partner interactions, dyadic coping, and dyadic efficacy. The findings of the study are important because they bring new insights regarding the potential role of relationship characteristics to inform future cessation programs focused on pregnant smokers and their life partners.

An mHealth intervention to prevent postnatal smoking relapse: The RESPREMO study protocol

Up to 70% of women who quit smoking relapse after birth, usually within 3 months postpartum. The wide adoption of mobile technologies, especially smartphones, in recent years in low- and middle-income countries (LMICs) offers the possibility of low-cost, novel, and innovative mobile phone-based interventions for smoking relapse prevention. This study presents the protocol of the RESPREMO clinical trial for postnatal smoking relapse prevention for enrolled women, who recently gave birth and quit tobacco smoking before or during pregnancy, and their life partners.

This work relies on data collected in two of the largest government-owned obstetrics and gynecology clinics in Cluj-Napoca, Romania. Seventy-five couples were randomized into one of three groups: a) 24 couples were allocated to the first intervention group and asked to install and use the xSmoker app; b) 26 couples were randomized to the second intervention group, who, in addition to the use of the xSmoker app, received text messages with content focused on motivation, problem solving, and dyadic efficacy; and c) 25 couples were randomized into a control group.

Several measures of engagement with the xSmoker app were assessed, including duration of app use, the frequency of utilizing the tool to calculate savings from quitting, number of app-delivered challenges accepted by users, and number of app-delivered cessation and abstinence tips.

If effective, RESPREMO is expected to have a sustainable impact on the prevention of postnatal relapse tobacco smoking with positive effects for both the mother and the newborn. The implications are beyond tobacco control, and relevant to the design and implementation of other mHealth behavioral interventions focused on the pregnancy and reproductive years in general.