Predictors of smoking in pregnancy and attitudes and knowledge of risks of pregnant smokers

Factors Associated with Smoke-Free Pregnancy among Aboriginal and Torres Strait Women and Their Experience of Quitting Smoking in Pregnancy: A Mixed Method Cross-Sectional Study

Smoke-free pregnancies have long-term health benefits for mothers and babies. This paper quantitatively examines factors associated with smoke-free pregnancies among Aboriginal and Torres Strait Islander women (hereafter Aboriginal women) and qualitatively explores their smoking cessation (SC) experiences during pregnancy. An Aboriginal-led online cross-sectional study on SC was conducted with Aboriginal women and in partnership with Aboriginal communities, between July and October 2020. The present analysis includes participants who made a pregnancy-related quit attempt (N = 103). Chi-squared tests, logistic regression models, and thematic analysis of free-form text responses were performed. The adjusted odds of having smoke-free pregnancies were 4.54 times higher among participants who used Aboriginal Health Services (AHS) (AOR = 4.54, p-value 0.018). Participants living in urban settings had 67% lower odds of having smoke-free pregnancies compared to their regional/remote counterparts (AOR = 0.33, p-value 0.020). Qualitative data revealed strong motivations to reduce tobacco-related harms to the fetus and variability in quitting experiences at different stages of and across pregnancies. Smoking cessation care (SCC) can support Aboriginal women meaningfully if their quitting experiences are considered in SCC development and implementation. Consistent funding for AHS-led SCC is needed to garner health benefits for Aboriginal peoples. More research into urban versus regional/remote differences in maternal SC is recommended.

Health Knowledge of Lifestyle-Related Risks during Pregnancy: A Cross-Sectional Study of Pregnant Women in Germany

This study aimed to investigate (1) pregnant women’s level of knowledge of lifestyle-related risk factors during pregnancy and their potential health impact on their offspring, and (2) the factors affecting women’s knowledge of lifestyle-related risk factors during pregnancy. A cross-sectional observational study of pregnant women was carried out in obstetric and gynecologic care settings at three hospitals in Southern Germany. Data from 209 pregnant women revealed large knowledge gaps on lifestyle-related risk factors during pregnancy and their potential health impact. Factors affecting women’s knowledge of lifestyle-related risk factors during pregnancy were specifically associated with socioeconomic status, e.g., lower household net income, middle educational level, and statutory health insurance status. Women who had received information from their gynecologist had a higher level of knowledge of lifestyle-related risk factors during pregnancy. This study showed that health promotion regarding lifestyle-related risks during pregnancy specifically needs to address women from the low-to-middle socioeconomic status group. Gynecologists seem particularly effective in providing this information.

Experts' Views on Behaviour Change Techniques for Smoking Cessation in Pregnancy: A Qualitative Study

Smoking during pregnancy is a global health problem which has devastating health implications. Behavioural support is an important part of smoking cessation support for pregnant women. Research has identified barriers and facilitators (B&Fs) and effective behaviour change techniques (BCTs) to aid women's quit attempts. However, the extent to which and how these BCTs are used in practice is unclear. The research aimed to establish experts' views on how behavioural support can be optimised and techniques operationalised in clinical practice, by identifying ways to address known B&Fs for smoking cessation in pregnancy. A focus group discussion took place with six experts, which highlighted how BCTs can be used in practice to support women in their quit attempts. A thematic analysis was conducted to elicit overarching themes. Five themes were found: involving the family, empowering women, using incentives to boost motivation, using practical techniques to help women with their quit attempts and managing expectations about nicotine replacement therapy. Empowering women to make their own decisions and encouraging small positive changes in smoking habits, using visual aids (e.g., growth charts) to inform women of the harms of smoking to the baby and treating families holistically were deemed important.

Risk of preterm birth following late pregnancy exposure to NSAIDs or COX-2 inhibitors

Pregnant women may take nonsteroidal antiinflammatory drugs (NSAIDs), selective cyclooxygenase (COX)-2 inhibitors, or biological agents to relieve symptoms or manage disease flares in late pregnancy. We aimed to quantify the risk of prematurity associated with late pregnancy exposure to nonselective NSAIDs, selective COX-2 inhibitors, and biological agents. Using data from Quebec Pregnancy Cohort, we performed a population-based cohort study. We included all women who were covered by the Quebec Drug Plan and had a singleton live birth between January 1, 1998 and December 31, 2009. Late pregnancy exposure was defined as having filled at least 1 prescription for nonselective NSAIDs, selective COX-2 inhibitors, or biological agents in the 3 months before delivery. Prematurity was defined as <37 weeks of gestation. Crude and adjusted odds ratios (OR) were obtained using generalized estimation equation models. Covariates included maternal autoimmune diseases, demographics, concomitant drug use, history of pregnancy complications, and other comorbidities. A total of 156,531 pregnancies met inclusion criteria and were considered for analyses. In the 3 months before delivery, 391 pregnancies were exposed to nonselective NSAIDs, 55 to COX-2 inhibitors, and 12 to biological agents. After adjustment for maternal autoimmune diseases, concomitant medication use, and other risk factors, COX-2 inhibitor use in late pregnancy was associated with a 2.46-fold increased risk of prematurity (adjusted OR, 2.46; 95% confidence interval, 1.28-4.72) compared to nonuse; only late pregnancy exposure to celecoxib was found to increase the risk (adjusted OR, 3.41; 95% confidence interval, 1.29-9.02). In conclusion, celecoxib use during late pregnancy may increase the risk of prematurity.

Sociodemographic correlates of smoking in pregnancy and antenatal-care attendance in Indigenous and non-Indigenous women in South Australia

Smoking in pregnancy is a key health issue in Australia, particularly among Indigenous women. However, few studies have examined the sociodemographic factors associated with smoking in pregnancy or the predictors of antenatal-care attendance among Indigenous and non-Indigenous Australian women who smoke. Data from the South Australian perinatal statistics collection of all births from 2000-2010 (n=197538) were analysed separately by Indigenous status to determine the sociodemographic factors associated with smoking in pregnancy and antenatal-care attendance by women who smoke. For Indigenous and non-Indigenous women, smoking in pregnancy was significantly independently associated with socioeconomic disadvantage, residing in regional or remote areas, increased parity, unemployment, being a public patient and attending fewer antenatal care visits. Smoking in pregnancy was associated with younger age and not being partnered only for non-Indigenous women. For Indigenous and non-Indigenous pregnant women who smoked, antenatal-care attendance was lower among women who were of younger age, higher parity, unemployed and not partnered. Differences in attendance within sociodemographic factors were greater for Indigenous women. Therefore, while sociodemographic correlates of smoking in pregnancy and antenatal-care attendance are largely similar for Indigenous and non-Indigenous women, tailored cessation and antenatal-care programs that reflect the differences in sociodemographic groups most at risk may be beneficial.

Improving Behavioral Support for Smoking Cessation in Pregnancy: What Are the Barriers to Stopping and Which Behavior Change Techniques Can Influence These? Application of Theoretical Domains Framework

Behavioral support interventions are used to help pregnant smokers stop; however, of those tested, few are proven effective. Systematic research developing effective pregnancy-specific behavior change techniques (BCTs) is ongoing. This paper reports contributory work identifying potentially-effective BCTs relative to known important barriers and facilitators (B&Fs) to smoking cessation in pregnancy; to detect priority areas for BCTs development. A Nominal Group Technique with cessation experts (n = 12) elicited an expert consensus on B&Fs most influencing women's smoking cessation and those most modifiable through behavioral support. Effective cessation interventions in randomized trials from a recent Cochrane review were coded into component BCTs using existing taxonomies. B&Fs were categorized using Theoretical Domains Framework (TDF) domains. Matrices, mapping BCT taxonomies against TDF domains, were consulted to investigate the extent to which BCTs in existing interventions target key B&Fs. Experts ranked "smoking a social norm" and "quitting not a priority" as most important barriers and "desire to protect baby" an important facilitator to quitting. From 14 trials, 23 potentially-effective BCTs were identified (e.g., information about consequences). Most B&Fs fell into "Social Influences", "Knowledge", "Emotions" and "Intentions" TDF domains; few potentially-effective BCTs mapped onto every TDF domain. B&Fs identified by experts as important to cessation, are not sufficiently targeted by BCT's currently within interventions for smoking cessation in pregnancy.

Daughters of Mothers Who Smoke: A Population-based Cohort Study of Maternal Prenatal Tobacco use and Subsequent Prenatal Smoking in Offspring

BACKGROUND

Prenatal exposure to tobacco is associated with adverse health outcomes for the mother and child, and has been associated with an increased risk of tobacco smoking and nicotine dependence in offspring. The objective of this study was to examine the risk of prenatal smoking, among daughters, associated with maternal prenatal smoking.

METHODS

We used a population-based cohort study design, with linked vital records data of mothers and daughters delivering 1984-96 and 1996-2013, respectively, in Washington State. The exposure of interest was mothers' prenatal smoking (any vs. no smoking at any time during pregnancy), while the outcome was daughters' prenatal smoking (similarly assessed). We used multivariable log-binomial regression to obtain estimates of the relative risk (RR) and 95% confidence interval (CI).

RESULTS

Daughters exposed to maternal prenatal smoking were more likely to smoke during their pregnancy, compared to unexposed daughters (RR 1.78, 95% CI 1.72, 1.84, adjusted for the year the daughter delivered, her marital status and educational attainment, and the mothers' race/ethnicity).

CONCLUSIONS

In this relatively young population, we found that daughters exposed to maternal prenatal smoking have an increased risk of smoking later on during their own pregnancy, emphasizing the importance of exposures during the prenatal period. The mechanisms leading to prenatal smoking are multifactorial and likely include behavioural, genetic, epigenetic and environmental factors. An understanding of this risk factor for prenatal smoking may guide health care providers to better target smoking cessation interventions to at-risk populations.

A Preliminary Examination of Cognitive Factors that Influence Interest in Quitting During Pregnancy

The purpose of this study was to examine the relationship between risks associated with smoking and the effectiveness of quit-smoking techniques and interest in quitting among pregnant smokers. It was hypothesised that both knowledge of smoking-related harm and knowledge of efficacious smoking cessation methods would be significant predictors of interest in quitting in the next 30 days. This preliminary study involved 72 pregnant smokers who completed a questionnaire assessing smoking-related knowledge and perceived efficacy of cessation methods. Of the 11 smoking-related risks probed, the least acknowledged were those associated with pregnancy and post-natal conditions, with 38% of the sample responding incorrectly to all four of the pregnancy and post-natal conditions probed. Knowledge of the efficacy of smoking medications was also poor: 32.9% of the sample reported believing that all three pharmacotherapies were ineffective for promoting cessation. A high level of knowledge about the harms of smoking was related to an increased intention to quit in the next 30 days (39.5% versus 15.8%; Odds Ratio [OR] = 3.5). Results from this preliminary study showed support for previous research regarding smoking-related knowledge in non-pregnant smokers. Further research in the area is viewed as particularly important to confirm the current results and guide intervention to increase the level of smoking related knowledge in this at-risk group.

Pregnant Māori Smokers’ Perception of Cessation Support and How It Can Be More Helpful

This study aimed to investigate the perception of smoking cessation services and products by pregnant Māori (New Zealand's Indigenous people) smokers and identify how these can be improved. Semi-structured face-to-face interviews were conducted with 60 pregnant Māori smokers. Most of the women (82%) had been advised to stop smoking, but few (21%) felt influenced by the advice. In addition, the women in this study felt that health provider support needed to be more encouraging, understanding and more readily available. Many (78%) had come across smokefree pamphlets, but few had read them. Only four women had been given a booklet specifically aimed at pregnant Māori women. Several women thought that the promotion of smokefree pregnancies needed to be aimed at the whole whānau (extended family). The main conclusions were that motivation to quit could be enhanced by delivery of a clear, consistent and repeated message from multiple sources, backed up with effective, supportive and encouraging services and education resources about risks and smoking cessation options. Primary health care interventions delivering a range of services need to be flexible – for example, by visiting pregnant women in their home – and need to target the whole expectant whānau, instead of focusing on pregnant women in isolation.

Smoking in pregnant women screened for an opioid agonist medication study compared to related pregnant and non-pregnant patient samples

BACKGROUND

Little is known about the prevalence and severity of smoking in pregnant opioid dependent patients.

OBJECTIVES

To first characterize the prevalence and severity of smoking in pregnant patients screened for a randomized controlled trial, Maternal Opioid Treatment: Human Experimental Research (MOTHER), comparing two agonist medications; and second, to compare the MOTHER screening sample to published samples of other pregnant and/or patients with substances use disorders.

METHODS

Pregnant women (N = 108) screened for entry into an agonist medication comparison study were retrospectively compared on smoking variables to samples of pregnant methadone-maintained patients (N = 50), pregnant opioid or cocaine dependent patients (N = 240), non-pregnant methadone-maintained women (N = 75), and pregnant non-drug-addicted patients (N = 1,516).

RESULTS

Of screened patients, 88% (n = 95) smoked for a mean of 140 months (SD = 79.0) starting at a mean age of 14 (SD = 3.5). This rate was similar to substance use disordered patients and significantly higher compared to general pregnant patients (88% vs. 22%, p < .001).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Aggressive efforts are needed to reduce/eliminate smoking in substance-abusing pregnant women.

Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women

OBJECTIVE

To identify factors associated with antenatal smoking and explore characteristics of smoking behaviour among pregnant Aboriginal and Torres Strait Islander women.

DESIGN AND SETTING

Cross-sectional study using interviewer-administered questionnaires of 145 pregnant Aboriginal and Torres Strait Islander women attending a health service in Far North Queensland between November 2005 and December 2006.

MAIN OUTCOME MEASURES

Prevalence of self-reported smoking; predictors and patterns of smoking in early pregnancy; and relationships between smoking and the prevalence of predisposing, enabling and reinforcing factors, including women's knowledge about and attitudes towards smoking and the risks involved.

RESULTS

Of 145 women, 41% (n = 60) reported being daily or occasional smokers. Knowledge about harms of smoking was generally high. Women who were smokers had a significantly higher rate of smoking partners (n = 36) than women who were non-smokers (n = 31) (77% v 41%, P < 0.001). Level of daily stress was significantly higher among smokers than non-smokers (P = 0.001).

CONCLUSION

Shifted population norms among Aboriginal and Torres Strait Islanders are accompanied by a shift in the factors that can effectively differentiate between smokers and non-smokers within this population. Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals.

Dietary behaviors, physical activity, and cigarette smoking among pregnant Puerto Rican women

BACKGROUND

Few studies have examined predictors of meeting health guidelines in pregnancy among Latina women.

OBJECTIVE

We assessed dietary behaviors, physical activity, and cigarette smoking in the Latina Gestational Diabetes Mellitus Study, a prospective cohort of 1231 prenatal care patients.

DESIGN

Self-reported information on lifestyle factors, demographics, medical history, and physical activity was collected by bilingual interviewers during pregnancy. Fruit/vegetable intake was determined by summing the reported consumption of specific fruit and vegetables on a food-frequency questionnaire designed for this population and then adjusted for reported total daily servings.

RESULTS

Approximately 13% of women met physical activity guidelines [>or=10 metabolic equivalents (MET)-h/wk], 19% met fruit/vegetable guidelines (7 servings/d), 21% of women smoked, and 1.4% consumed alcohol during pregnancy. In multivariate analyses, Spanish-language preference, an indicator of less acculturation, was associated with an approximately 40% less likelihood of both smoking [odds ratio (OR): 0.6; 95% CI: 0.4, 0.8] and meeting physical activity guidelines (OR: 0.6; 95% CI: 0.3, 1.0). College education was associated with a 2-fold greater likelihood of meeting fruit/vegetable guidelines (OR: 2.2; 95% CI: 1.1, 4.3) and a lower likelihood of smoking (OR: 0.2; 95% CI: 0.1, 0.4). A history of adverse pregnancy outcome was associated with a >4-fold greater likelihood of meeting physical activity guidelines. Smoking in pregnancy was associated with a decreased likelihood of meeting the fruit/vegetable guidelines (RR: 0.5; 95% CI: 0.3, 0.9).

CONCLUSION

Factors related to engagement in prenatal health behaviors should be addressed in the design of targeted intervention strategies in this underserved and rapidly growing population.

Cost-effectiveness of motivational interviewing for smoking cessation and relapse prevention among low-income pregnant women: a randomized controlled trial

OBJECTIVES

Low-income women have high rates of smoking during pregnancy, but little is known about the costs, benefits, and cost-effectiveness of motivational interviewing (MI), focused on the medical and psychosocial needs of this population, as an intervention for smoking cessation and relapse prevention.

METHODS

A sample of 302 low-income pregnant women was recruited from multiple obstetrical sites in the Boston metropolitan area into a randomized controlled trial of a motivational intervention for smoking cessation and relapse prevention versus usual care (UC). The findings of this clinical trial were used to estimate the costs, benefits, and cost-effectiveness of the intervention from a societal perspective, incorporating published quality-adjusted life-year (QALY) and life-year (LY) estimates. Outcomes included smoking cessation and relapse, maternal and infant outcomes, economic costs, LYs and QALYs saved, and incremental cost-effectiveness ratios.

RESULTS

The cost-effectiveness of MI for relapse prevention compared to UC was estimated to be $851/LY saved and $628/QALY saved. Including savings in maternal medical costs in sensitivity analyses resulted in cost savings for MI for relapse prevention compared to UC. For smoking cessation, MI cost more but did not provide additional benefit compared to UC. In one-way sensitivity analyses, the incremental cost-effectiveness of MI versus UC would have been $117,100/LY saved and $86,300/QALY saved if 8% of smokers had quit. In two-way sensitivity analyses, MI was still relatively cost-effective for relapse prevention ($17,300/QALY saved) even if it cost as much as $2000/participant and was less effective. For smoking cessation, however, a higher level of effectiveness (9/110) and higher cost ($400/participant) resulted in higher incremental cost-effectiveness ratios ($112,000/QALY).

CONCLUSIONS

Among low-income pregnant women, MI helps prevent relapse at relatively low cost, and may be cost-saving when net medical cost savings are considered. For smoking cessation, MI cost more but provided no additional benefit compared to UC, but might offer benefits at costs comparable to other clinical preventive interventions if 8-10% of smokers are induced to quit.

From risky behavior to health risk: continuity across two generations

The purpose of this study was to determine the impact of childhood aggression and social withdrawal on adolescent health risk behaviors and adult health outcomes, and to examine the transfer of health risk to preschool offspring. This was a prospective, longitudinal, and intergenerational study of 114 mothers from disadvantaged neighborhoods, who were identified in childhood as being highly aggressive and/or withdrawn or with low scores on these 2 behavioral risk dimensions, and their preschool offspring aged 1 to 6 years old. The health histories of mothers (adolescent health risk behavior, health during pregnancy, current symptoms) and target children were taken during structured interviews conducted at home. Regression analyses tested the relationship between maternal childhood risk status and subsequent health outcomes, and these were followed by structural equation modeling of a proposed intergenerational pathway. Maternal childhood aggression predicted current health risk behaviors (e.g., daily cigarette smoking), whereas maternal childhood social withdrawal was not associated with maternal health risk at the time of testing. Mothers who had high scores on both aggression and withdrawal were more likely to engage in adolescent health risk behavior, which was directly related to health problems in preschoolers (even after controlling for covariates, such as neonatal health status and sex). In summary, there are distinct health trajectories for women who are highly aggressive and socially withdrawn in childhood, with implications for women's long-term health. Specifically, aggression in girls is likely to lead to health risk behaviors that may also place the next generation at risk for pediatric illness. Results are interpreted in terms of the health-hostility link, best known in adult men and intergenerational models.

Assessing maternal perceptions of harmful effects of drug use during pregnancy

Research has shown that perceived risk is an important predictor of health behavior change. In turn, drug use risk education is a vital component of many health campaigns. In pregnant women, perceived risk studies have focused primarily on alcohol and tobacco use. Little is known about perceived risks associated with prenatal exposure to illicit drugs. The present study compared drug use attitude (DUA) in both treatment-seeking and non-treatment-seeking drug-using pregnant women as well as a comparison group of non-drug-using pregnant women. The results suggest that non-treatment-seekers are less knowledgeable about specific potential risks of perinatal substance use. In addition, compared to treatment seekers and non-users, non-treatment-seekers were more likely to endorse cutting down on drug use rather than quitting as a means of reducing harm to the developing child. Results of the present study suggest drug-using women may benefit from additional education about harmful effects of drug use.

Dissemination of an efficacious antenatal smoking cessation program in public hospitals in Australia: a randomized controlled trial

This study investigated the impact of a behaviorally based intervention designed to increase the number of hospitals that routinely provide effective smoking cessation programs for pregnant women. In Queensland, Australia, 70 publicly funded hospitals were matched on numbers of births and maternal socioeconomic status and randomly allocated to an awareness-only intervention group or a behaviorally based intervention group. Success was defined as the routine offer of an evidence-based smoking cessation program to at least 80% of the pregnant clients who smoke. At 1 month, 65% of the behaviorally based intervention hospitals agreed to provide materials about smoking cessation programs for their antenatal patients, compared with 3% of the awareness-only hospitals. After 1 year, 43% of the intervention hospitals still provided the material, compared with 9% of the awareness-only hospitals. These findings show that a brief intervention to hospitals can encourage antenatal staff to provide smoking cessation materials to pregnant women.

Depression and smoking during pregnancy

This study examined the relationship between depression and smoking during a woman's pregnancy. It surveyed 487 pregnant women (aged 17-44) during routine ultrasound examinations at the 18th week of gestation. A multiple regression analysis showed that depression is a significant predictor of smoking during pregnancy, after controlling for other factors such as the desirability of the pregnancy and the presence of other smokers in the household. Both current smokers and former smokers were significantly more likely to report depressive symptoms (using Centers for Epidemiological Studies Depression Scale, CES-D) than never smokers; the rates are 12.9%, 25.1%, and 37.5% for never, former, and current smokers, respectively. Among current smokers, the depressed were significantly less confident about quitting than the nondepressed, although both felt the need to quit. These results suggest that interventions to help pregnant women quit smoking may need to take a more comprehensive approach to be effective.

Prevalence and socio-economic correlates of smoking among lone mothers in Australia

OBJECTIVE

To report smoking prevalence among Australian lone mothers by age and socio-economic group and to examine the extent to which the difference in smoking prevalence between lone mothers and other women is due to socio-economic factors.

METHODS

This was a secondary analysis of data from the 1995 National Health Survey (NHS), which was conducted by the Australian Bureau of Statistics (ABS). Information was collected from 53,800 respondents using face-to-face interviews. This analysis was limited to single mothers (n=1,184) who had at least one dependent child aged under 15. The outcome measure was smoking status, distinguishing regular smokers from occasional smokers, ex-smokers and never-smokers.

RESULTS

The overall smoking prevalence among lone mothers was 46.3% (Cl 43.5%-49.1%). Lone mothers who were younger, less educated, received government pension/benefits, occupied rental housing or who lived in more disadvantaged areas were more likely to smoke than others. A strong 'lone mother effect' remained after controlling for socio-economic variables. The odds of smoking for lone mothers were 2.4 times greater than for married mothers (95% Cl 2.0-2.9) and twice as large as those for women living alone (95% CI 1.62.4).

CONCLUSION

As the prevalence for this population group is considerably higher than the prevalence for other women within each age category, programs to assist lone mothers to quit smoking are a priority for the long-term health of these women and their children. Furthermore, we discuss how policies and interventions that enhance the material conditions and social circumstances of lone mothers can bring about a decline in their smoking prevalence.

The process of pregnancy smoking cessation: implications for interventions

OBJECTIVE

There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy.

DATA SOURCES

Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period.

DATA SYNTHESIS

An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention.

CONCLUSIONS

Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.