Smoking in pregnancy: patient and provider risk reduction behavior

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Changes in Multiple and Different Tobacco Product Use Behaviors in Women Before and During Pregnancy: An Analysis of Longitudinal Population Assessment of Tobacco and Health Data

INTRODUCTION

Changes in tobacco use behaviors among women with respect to pregnancy are expected to be significant and dynamic, with a strong desire for smoking cessation, diversification of tobacco products, and perceived relative safety on noncigarette tobacco products. This study aims to illustrate how multiple and different tobacco use behaviors change before and during pregnancy.

METHODS

Data were extracted from 864 pregnant, nationally representative U.S. women, who were prospectively followed with the Population Assessment of Tobacco and Health study between 2013 and 2017. Smoking statuses were defined on the basis of the number and type of 7 different tobacco products under current use. Differences in maternal characteristics were investigated in relation to tobacco cessation statuses during pregnancy. Weighted percentages and 95% CIs were calculated.

RESULTS

Only 50.4% of prepregnancy tobacco users achieved complete abstinence with varying rates of cessation, depending on the number and type of products used prepregnancy. The lowest cessation rates were observed among prepregnancy poly-tobacco users (23.3%) and conventional cigarette smokers (45.5%). During pregnancy, 11.3% and 2.8% of women reported smoking cigarettes and e-cigarettes, respectively. Persistent tobacco users during pregnancy were more likely to be white, be older, and have nonprivate or no medical insurance (all p<0.05).

CONCLUSIONS

This study demonstrates a widespread prenatal tobacco use and low rates of complete cessation in major subgroups of tobacco users. Current findings on the concurrent use of multiple products and noncigarette tobacco products highlight the urgent need for further research and comprehensive public health intervention for smoking cessation during pregnancy.

What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis

BACKGROUND

Pregnancy is an opportunity for health providers to support women to stop smoking.

OBJECTIVES

Identify the pooled prevalence for health providers in providing components of smoking cessation care to women who smoke during pregnancy.

DESIGN

A systematic review synthesising original articles that reported on (1) prevalence of health providers' performing the 5As ('Ask', 'Advise', 'Assess', 'Assist', 'Arrange'), prescribing nicotine replacement therapy (NRT) and (2) factors associated with smoking cessation care.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using 'smoking', 'pregnancy' and 'health provider practices'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies included any design except interventions (self-report, audit, observed consultations and women's reports), in English, with no date restriction, up to June 2017.

PARTICIPANTS

Health providers of any profession.

DATA EXTRACTION, APPRAISAL AND ANALYSIS

Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using, for example, 'often/always' and 'always/all'. Meta-regressions were performed of 5As for 'often/always'.

RESULTS

Of 3933 papers, 54 were included (n=29 225 participants): 33 for meta-analysis. Health providers included general practitioners, obstetricians, midwives and others from 10 countries. Pooled percentages of studies reporting practices 'often/always' were: 'Ask' (n=9) 91.6% (95% CI 88.2% to 95%); 'Advise' (n=7) 90% (95% CI 72.5% to 99.3%), 'Assess' (n=3) 79.2% (95% CI 76.5% to 81.8%), 'Assist (cessation support)' (n=5) 59.1% (95% CI 56% to 62.2%), 'Arrange (referral)' (n=6) 33.3% (95% CI 20.4% to 46.2%) and 'prescribing NRT' (n=6) 25.4% (95% CI 12.8% to 38%). Heterogeneity (I2) was 95.9%-99.1%. Meta-regressions for 'Arrange' were significant for year (p=0.013) and country (p=0.037).

CONCLUSIONS

Health providers 'Ask', 'Advise' and 'Assess' most pregnant women about smoking. 'Assist', 'Arrange' and 'prescribing NRT' are reported at lower rates: strategies to improve these should be considered.

PROSPERO REGISTRATION NUMBER

CRD42015029989.

Predictors of smoking cessation during pregnancy: a systematic review and meta-analysis

AIM

To identify factors found in the research literature to be associated with smoking cessation in pregnancy.

METHODS

Electronic searches of the bibliographic databases of PubMed, EMBASE, PsycINFO, Elsevier, Scopus and ISI Web of Science were conducted to April 2017. All studies reporting factors associated with smoking cessation or continuing smoking during pregnancy were included and reviewed systematically, irrespective of study design. The Newcastle-Ottawa Quality Assessment Scale was used to assess the study quality. The DerSimonian & Laird random-effects model was used to conduct meta-analyses, and where effect estimates were reported for factors included in at least three studies.

RESULTS

Fifty-four studies, including 505 584 women globally who smoked before pregnancy, 15 clinical trials and 40 observational studies, were included in the review and 36 (65.5%) were considered to be of high quality. This review identified 11 socio-demographic, seven socially related, 19 smoking behaviour-related, five pregnancy-related, six health-related and six psychological factors that were associated significantly with smoking cessation during pregnancy. The most frequently observed significant factors associated with cessation were: higher level of education, pooled odds ratio (OR), 95% confidence interval (CI) = 2.16 (1.80-2.84), higher socio-economic status: 1.97 (1.20-3.24), overseas maternal birth: 2.00 (1.40-2.84), Medicaid coverage or private insurance: 1.54 (1.29-1.85), living with partner or married: 1.49 (1.38-1.61), partner/other members of the household do not smoke: 0.42 (0.35-0.50), lower heaviness of smoking index score: 0.45 (0.27-0.77, lower baseline cotinine level: 0.78 (0.64-0.94), low exposure to second-hand smoking: 0.45 (0.20-1.02), not consuming alcohol before and/or during pregnancy: 2.03 (1.47-2.80), primiparity: 1.85 (1.68-2.05), planned breastfeeding:1.99 (1.94-2.05), perceived adequate pre-natal care: 1.74 (1.38-2.19), no depression: 2.65 (1.62-4.30) and low stress during pregnancy: 0.58 (0.44-0.77).

CONCLUSION

A wide range of socio-demographics, relationship, social, smoking-related, pregnancy-related, health and psychological factors have been found to predict smoking cessation in pregnancy.

A Randomized Trial of Text Messaging for Smoking Cessation in Pregnant Women

INTRODUCTION

There is a need for innovation in both the enrollment of pregnant smokers in smoking cessation treatment programs and in the types of treatments offered. The study tests whether an interactive and intensive text messaging program, Quit4baby, can promote smoking cessation for pregnant women already enrolled in a health text messaging program, Text4baby.

METHODS

Between July 2015 and February 2016, a total of 35,957 recruitment text messages were sent to Text4baby subscribers. Eligible pregnant smokers were enrolled and randomized to receive Text4baby (control) or Text4baby and Quit4baby (intervention; N=497). Participants were surveyed at 1 month, 3 months, and 6 months post-enrollment, and saliva samples were collected at 3 months for biochemical verification of smoking status. Data were collected from 2015 to 2016 and analyzed in 2016.

RESULTS

Using an intention-to-treat analysis, 28.80% of the intervention group and 15.79% of the control group reported not smoking in the past 7 days at 1 month (p<0.01), and 35.20% of the intervention group and 22.67% of the control group reported not smoking in the past 7 days at 3 months (p<0.01). Biochemical verification of smoking status at 3 months indicated no significant differences between groups (15.60% in the intervention group and 10.93% in the control group [p=0.13]), although significant differences favoring the intervention were found for older smokers (p<0.05) and for those who enrolled in their second or third trimester of pregnancy (p<0.05). Self-report of late pregnancy 7- and 30-day point prevalence abstinence favored the intervention group (p<0.001, p<0.01). No significant differences were observed at the 6-month follow-up or in the postpartum period.

CONCLUSIONS

Results provide limited support of the efficacy of the Quit4baby text messaging program in the short term and late in pregnancy, but not in the postpartum period.

Smoking Trajectories during the Perinatal Period and Their Risk Factors: The Nationally Representative French ELFE (Etude Longitudinale Française Depuis l’Enfance) Birth Cohort Study

BACKGROUND

In France, rates of perinatal smoking are among the highest worldwide; however, perinatal smoking trajectories and associated factors have still not been adequately researched.

METHODS

Among women participating in the French nationally representative etude longitudinale française depuis l'enfance birth cohort (n = 15,540), perinatal smoking trajectories were estimated using group-based modelling. Associated characteristics were studied using multinomial logistic regression.

RESULTS

Four trajectories were identified: non-smokers (59%), quitters (20%), persistent moderate (12%) and persistent heavy (9%) smokers. Older age, being native French, low socioeconomic position, persistent psychological difficulties and alcohol use in pregnancy, lack of social support, partner's smoking, mistimed pregnancy, and child formula feeding at birth were associated with persistent heavy smoking. Most of these factors were also associated, but to a lesser extent, with persistent moderate smoking, except for age and migrant status, which had opposite effects. Women who successfully lost weight prior to pregnancy had higher levels of quitting smoking.

CONCLUSION

Women's long-term smoking trajectories vary in terms of initial tobacco consumption level but also in relation to socio-demographic, psychological, behavioral and partner characteristics. Health professionals in contact with pregnant smokers should address perceived risks and benefits of smoking, including partner's smoking and weight-gain concerns.

Risk perception in pregnancy: a concept analysis

AIM

To report an analysis of the concept of risk perception in pregnancy.

BACKGROUND

Pregnant women are increasingly exposed to the view that pregnancy and childbirth are intrinsically dangerous, requiring medical monitoring and management. Societal pressures are applied to women that dictate appropriate behaviours during pregnancy. These changes have resulted in increased perception of risk for pregnant women.

DESIGN

Walker and Avant's method was selected to guide this analysis.

DATA SOURCES

Peer-reviewed articles published in English from CINAHL, Scopus, PubMed and Psychinfo. No date limits were applied.

METHODS

Thematic analysis was conducted on 79 articles. Attributes, antecedents and consequences of the concept were identified.

RESULTS

The attributes of the concept are the possibility of harm to mother or infant and beliefs about the severity of the risk state. The physical condition of pregnancy combined with the cognitive ability to perceive a personal risk state is antecedents. Risk perception in pregnancy influences women's affective state and has an impact on decision-making about pregnancy and childbirth. There are limited empirical referents with which to measure the concept.

CONCLUSION

Women today know more about their developing infant than at any other time in history; however, this has not led to a sense of reassurance. Nurses and midwives have a critical role in assisting pregnant women, and their families make sense of the information they are exposed to. An understanding of the complexities of the concept of risk perception in pregnancy may assist in enabling nurses and midwives to reaffirm the normalcy of pregnancy.

Patient-centered Care in Maternity Services: A Critical Appraisal and Synthesis of the Literature

BACKGROUND

Patient-centered care (PCC) has been recognized as a marker of quality in health service delivery. In policy documents, PCC is often used interchangeably with other models of care. There is a wide literature about PCC, but there is a lack of evidence about which model is the most appropriate for maternity services specifically.

AIM

We sought to identify and critically appraise the literature to identify which definition of PCC is most relevant for maternity services.

METHODS

The four-step approach used to identify definitions of PCC was to 1) search electronic databases using key terms (1995-2011), 2) cross-reference key papers, 3) search of specific journals, and 4) search the grey literature. Four papers and two books met our inclusion criteria.

ANALYSIS

A four-criteria critical appraisal tool developed for the review was used to appraise the papers and books.

MAIN RESULTS

From the six identified definitions, the Shaller's definition met the majority of the four criteria outlined and seems to be the most relevant to maternity services because it includes physiologic conditions as well as pathology, psychological aspects, a nonmedical approach to care, the greater involvement of family and friends, and strategies to implement PCC.

CONCLUSION

This review highlights Shaller's definitions of PCC as the one that would be the most inclusive of all women using maternity services. Future research should concentrate on evaluating programs that support PCC in maternity services, and testing/validating this model of care.

Racial segregation and maternal smoking during pregnancy: a multilevel analysis using the racial segregation interaction index

Drawing from both the place stratification and ethnic enclave perspectives, we use multilevel modeling to investigate the relationships between women's race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, Asian, and Hispanic) and maternal smoking during pregnancy, and examine if these relationships are moderated by racial segregation in the continental United States. The results show that increased interaction with whites is associated with increased probability of maternal smoking during pregnancy, and racial segregation moderates the relationships between race/ethnicity and maternal smoking. Specifically, living in a less racially segregated area is related to a lower probability of smoking during pregnancy for black women, but it could double and almost triple the probability of smoking for Asian women and Hispanic women, respectively. Our findings provide empirical evidence for both the place stratification and ethnic enclave perspectives.

Effects of maternal tobacco-smoke exposure on fetal growth and neonatal size

Exposure to tobacco smoke, through both active and passive measures, has a significant impact on women's health, including effects on the cardiovascular, pulmonary and reproductive systems. Of particular interest is the effect of smoking on pregnancy outcomes. One crucial outcome that has been linked to the subsequent development of both neonatal and adult disease is intrauterine or fetal growth restriction. In this article, we will summarize the effects of smoking on newborn size and fetal growth. We will review evidence showing that tobacco consumption during pregnancy leads to a reduction in birthweight, largely through affecting specific anthropometric measures and newborn body composition. We will highlight the role of genetic susceptibility to these effects and discuss how smoking cessation prior to the third trimester results in a reduction in the risk of fetal growth restriction.

Incident smoking during pregnancy and the postpartum period in a low-income urban population

OBJECTIVES

We determined the prevalence of first lifetime use of cigarettes during pregnancy or in the early postpartum period (incident smoking) and identified sociodemographic and health-related characteristics of incident smokers.

METHODS

We used statistics based on data from a longitudinal study of a large cohort of pregnant, low-income, urban women (n = 1,676) to describe the timing of first-time use and to compare incident smokers with those who had never smoked and those who had already smoked prior to pregnancy.

RESULTS

About one in 10 (10.2%) women who had not previously smoked initiated cigarette smoking during pregnancy or in the early postpartum period. Compared with those who had never smoked, incident smokers were more likely to report high levels of stress and to have elevated levels of depressive symptomatology, which may be rooted in relatively poor social and economic conditions.

CONCLUSION

A significant number of women may be initiating smoking during pregnancy or in the early postpartum period. These women have characteristics that are consistent with the risk factors associated with smoking. Further research is warranted to determine prevalence in other populations, identify the risk factors for incident smoking, and assess the potential for primary prevention efforts designed to help women who had previously avoided cigarette use to remain smoke-free throughout pregnancy and in the postpartum period.

Smoking cessation during pregnancy: a systematic literature review

ISSUES

Second-hand smoke presents a health risk for a large group of entirely helpless nonsmokers: unborn children. Reliable data on women continuing to smoke during pregnancy are essential for effective preventive and interventional programs. The aim of this review is therefore to identify this risk group compared with spontaneous quitters of smoking.

APPROACH

This systematic literature review is based solely on empirical original papers derived from samples of pregnant women smoking at the beginning of pregnancy. In accordance with the QUOROM Statement all population or clinic-based samples were included. Collectives from intervention studies were not included. All studies were from developed nations and published between January 1997 and March 2008.

KEY FINDINGS

A total of 19 studies were identified. The rate of quitters was between 4.0% and 69.7% for population-based studies, and 26.5% and 47.0% for clinic-based studies. A smoking partner, a large number of children, a high rate of tobacco consumption, as well as deficiencies in prenatal care were predictors of smoking during pregnancy.

IMPLICATIONS

This study identifies risk factors and correlates and indicates common obstacles for women to quit smoking during pregnancy.

CONCLUSION

The risk groups that can be defined based on our results are a key target population for preventive measures.

Using the postpartum hospital stay to address mothers' and fathers' smoking: the NEWS study

OBJECTIVE

The objective of this study was to test the feasibility and acceptability of introducing an intervention to address mothers' and fathers' smoking during the postpartum hospitalization.

METHODS

During a 14-month period (February 2005 to April 2006), we assessed the smoking status of both parents of all newborns who were delivered at a hospital child birth center. Parents who were current smokers (1 cigarette, even a puff, in past 30 days) or recent quitters (smoked since 1 month before conception) were eligible for the study. Parents were assigned to intervention or usual care control condition on the basis of day of study enrollment. Smoking outcomes were assessed at 3 months by telephone survey and cotinine confirmation; quitline use was assessed at 3 months by using quitline database.

RESULTS

A total of 101 (64%) of 159 eligible parents enrolled in the study (n = 53 control subject, n = 48 intervention), including 72 (71%) current smokers and 29 (29%) recent quitters. All parents in the intervention group received the in-hospital counseling session, 94% had a fax sent to a provider, and 36 (75%) accepted quitline enrollment. In an intention-to-treat analysis that included both current smokers and recent quitters, self-reported 7-day abstinence decreased from 31% to 25% among intervention parents versus 38% to 23% among control subjects (effect size 9.4%; nonsignificant). Among current smokers at baseline who were reached at follow-up (n = 36), self-reported 24-hour quit attempts were higher in the intervention group versus control group (64% vs 18%; P = .005), whereas the cotinine-confirmed 7-day abstinence rates at follow-up were 9% in the intervention group and 3% in the control group (nonsignificant).

CONCLUSIONS

Enrolling mothers and fathers into tobacco treatment services during the immediate postpartum hospital stay is feasible and seems to stimulate quit attempts. The birth of an infant presents a teachable moment to reach both parents and to provide cessation assistance.

Improving maternal care with a continuous quality improvement strategy: a report from the Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network

BACKGROUND

Maternal medical care (prenatal and postpartum) involves a set of clinical interventions addressing risk factors associated with important maternal and infant outcomes. Programs to increase the rate of delivery of these interventions in clinical practice have not been widely implemented.

METHODS

A practice-based research network focused on developing continuous quality improvement (CQI) processes for maternal care among 10 family medicine residency training sites in the northeastern United States (the IMPLICIT Network) from January 2003 through September 2007. Documented delivery of 5 standard maternal care interventions was assessed before and after initiating a program to increase their frequency. Proportion chart analyses were conducted comparing the period before and after implementation of the CQI interventions.

RESULTS

Data were available for 3936 pregnancies during the course of the study period. Results varied across the clinical interventions. Significant improvement in care processes was seen for 3 screening activities: (1) prenatal depression symptomatology (by 15 weeks' gestation); (2) screening for smoking at 30 weeks' gestation; (3) and postpartum contraception planning. Screening for smoking by 15 weeks' gestation and testing for asymptomatic bacteriuria were already conducted >90% of the time during the baseline period and did not increase significantly after initiating the CQI program. Screening for postpartum depression symptomatology was recorded in 50% to 60% of women before the CQI program and did not increase significantly.

CONCLUSIONS

A practice-based research network of family medicine residency practices focused on CQI outcomes was successful in increasing the delivery of some maternal care interventions.

Postpartum physical symptoms in new mothers: their relationship to functional limitations and emotional well-being

BACKGROUND

Postpartum physical health problems are common and have been understudied. The purpose of this investigation was to explore the associations among reported physical symptoms, functional limitations, and emotional well-being of postpartum women.

METHODS

The study included data from interviews conducted at 9 to 12 months postpartum from 1,323 women who had received prenatal care at nine community health centers located in Philadelphia, Pennsylvania, United States, between February 2000 and November 2002. Emotional well-being was assessed with the Center for Epidemiological Studies Depression Scale and perceived emotional health. Functional limitations measures were related to child care, daily activities (housework and shopping), and employment. A summary measure of postpartum morbidity burden was constructed from a checklist of potential health problems typically associated with the postpartum period, such as backaches, abdominal pain, and dyspareunia.

RESULTS

More than two-thirds (69%) of the women reported experiencing at least one physical health problem since childbirth. Forty-five percent reported at least one problem of moderate or major (as opposed to minor) severity and 20 percent reported at least one problem of major severity. The presence, severity, and cumulative morbidity burden associated with postpartum health problems were consistently correlated with reports of one or more functional limitations and measures of emotional well-being including depressive symptomatology.

CONCLUSIONS

Although physical problems typically associated with the postpartum period are often regarded as transient or comparatively minor, they are strongly related both to women's functional impairment and to poor emotional health. Careful assessment of the physical, functional, and emotional health status of women in the year after childbirth may improve the quality of postpartum care.

Combined effects of cigarette smoking and alcohol consumption on perinatal outcome

BACKGROUND

An increase in various congenital abnormalities associated with cigarette smoking and the use of alcohol during pregnancy has been reported in many studies. These exposures also increase the risk of pregnancy complications such as abruptio placentae, unexplained stillbirth, preterm labor and intrauterine growth restriction. However, very few studies have addressed the combined effect of smoking and drinking on pregnancy outcomes.

METHODS

In this review, the adverse effects of smoking or drinking on pregnancy were obtained from publications in which both substances were addressed in the same study population. A special effort was made to find studies in which the combined effect of these substances was investigated.

RESULTS

Preterm labor occurred more frequently in women who drank and smoked during pregnancy. This increased odds ratio was more than the sum of the effects of either smoking or drinking, indicating that the use of both substances by the same woman has a synergistic effect that increases the risk of preterm labor. This synergistic effect was also found for low birth weight and growth restriction.

CONCLUSIONS

As most of the women who drink during pregnancy also smoke cigarettes, attention should be given to the prevention or reduced use of both substances during pregnancy.

Smoking cessation medication use among pregnant and postpartum smokers

OBJECTIVE

To assess how often pregnant and postpartum smokers use medications and how often obstetric providers recommend them.

METHODS

We analyzed end-of-pregnancy and 3-month postpartum surveys of 296 pregnant smokers enrolled in a randomized controlled trial of telephone counseling for smoking cessation that did not include medication. Patients were asked whether any obstetric provider discussed cessation medication and whether they had used medication.

RESULTS

At end of pregnancy, 29.3% of respondents reported discussing a cessation medication with their obstetric providers, more often nicotine replacement (26.5%) than bupropion (12.2%) (P=.001). Ten percent of trial respondents used a medication while pregnant (7.4% nicotine replacement, 3.4% bupropion, P=.023). Obstetricians discussed medication with 29.4% of smokers at the postpartum visit; 14.3% of postpartum smokers used medication. Contrary to guidelines, women who smoked more cigarettes per day or had already tried quitting during pregnancy were not more likely to use medication or to discuss medication with their provider. Medication use was associated with older age, more education, living with a partner, a previous birth, having an obstetric provider who discussed medication, and having private health insurance in a state whose Medicaid program did not cover cessation medications (all P<.05).

CONCLUSION

Pregnant women are more reluctant to use cessation medications than clinical guidelines recommend. More pregnant smokers might use cessation medications if their obstetricians discussed them routinely and if health insurance covered their cost.

LEVEL OF EVIDENCE

II.

Values and beliefs about consequences related to smoking among pregnant and non-pregnant women

The purpose of the study was to test a model based on the product of value and belief, called expected utility (EU), on the addictive behaviour of smoking. A total of 40 pregnant and 40 non-pregnant women over a period of 2 weeks performed judgements on values and beliefs about consequences related to smoking for the conditions of continuing and stopping smoking. There were no differences between pregnant and non-pregnant women in the EU of smoking. Differences in expected utility between the conditions of continuing and stopping smoking were larger for health consequences compared with psychological and social consequences and consequences related to pregnancy. Expected utility gives a good description of judgements over time. Values as well as beliefs related to health consequences should be stressed in smoking cessation programmes, especially among pregnant women.