Smoking during pregnancy

This essay discusses the public health issue of smoking during pregnancy in England. The purpose for selecting this public health issue will be described, utilising government statistics that highlight the extent of the problem. Current smoking cessation interventions in this population will be critiqued, with a focus on Motivational Interviewing (MI) and the acceptability and feasibility of this technique compared to other techniques. Based on the evidence, a programme for tackling smoking during pregnancy will be established, including consideration of those agencies and organisations required to conceptualise, plan and deliver the programme. Indicators of how the programme can be assessed for outcomes and efficacy will be discussed.

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Introduction

Smoking is the single greatest cause of preventable illness and premature mortality in the UK, as well as being the most important preventable cause of a range of adverse outcomes of pregnancy. (1-3) Indeed, smoking during pregnancy is one of the main causes of premature births and miscarriages. It has been shown that women who smoke during pregnancy have 1.5 to 3.5 times more chance of miscarriage when compared to non-smoking women. (4)

The implications of smoking during pregnancy go beyond affecting the mother and her baby, creating additional burden on an already overstretched national health service (NHS). It has been estimated that the increased cost to the NHS of smoking during pregnancy is £1,500 per smoker. (5) Reducing the prevalence of smoking in the general population as well as among higher risk groups, such as pregnant smokers, has become a government priority, as is emphasised in the National Tobacco Control Plan and the Public Health Outcomes Framework. (6)

Given the extent of the problem, as well as current government efforts to address the problem, there is a requirement for evidence-based smoking cessation initiatives specifically targeted at pregnant women. (7) Research conducted by the British Market Research Bureau (BMRB) in 2005 demonstrated that 32% of mothers in England smoked during the 12-months before pregnancy and continued to smoke during pregnancy. (8) Although nearly half (49%) quit smoking before giving birth, three out of ten (30%) started smoking again less than a year after giving birth. It has been proposed that this is because women are usually motivated to stop smoking for the sake of the baby rather than for personal, long-term health reasons. Therefore, not only is there concern for the one in six (17%) women continuing to smoke during pregnancy, but there is also a need to promote long-term abstinence within public health initiatives. Of note, rates of quitting are generally lower among heavy smokers who are unmarried, on a low income, and poorly educated. (9) Therefore, pregnant smokers who meet this demographic profile are a key target group.

Smoking Cessation Interventions

There are already a number of interventions being used to tackle smoking during pregnancy, the majority of which are delivered individually. (10) They include psychological and behavioural interventions, as well as pharmacological treatments. Psychological and behavioural strategies comprise cognitive behaviour therapy (CBT), motivational interviewing (MI), offering incentives, and giving feedback to mothers on foetal health status. Pharmacological strategies comprise nicotine replacement therapy (NRT) and other medication. There remains, however, a need to establish those interventions that are most acceptable, feasible, and cost-effective. There is also a need to identify the intensity level required of such interventions in terms of achieving long-term smoking cessation outcomes, since this has a direct impact on costs of service delivery. It has been established, via a Cochrane systematic review of 30 trials (n=7,000 participants) of individual behavioural counselling for smoking cessation, that there appears to be no significant difference between intensive counselling compared to brief counselling (5 trials, Relative Risk [RR] 0.96, 95% Confidence Interval [CI] 0.74 to 1.25). (11) Significant benefits were found for individual counselling, but not in terms of counselling intensity.

The findings from this Cochrane review contradict the recommendations by the NHS Centre for reviews and dissemination that intensive advice should be offered to pregnant women to support smoking cessation. They specify that a combination of prenatal counselling, 10-minute face-to-face contact, and the provision of tailored written material, can double quit rates to about 15%. (12)

Taking into consideration the evidence and recommendations pertaining to intensive versus brief counselling for smoking cessation, a plausible compromise is the utilisation of MI in smoking cessation initiatives. MI is more intensive than brief counselling and requires specialist communication skills training; however, it is brief in comparison to the more intensive counselling approaches, and is thus likely to offer greater cost-effectiveness.

Motivational Interviewing

Motivational interviewing is a patient-centred style of communication designed to help people resolve any ambivalence they might have about changing an unhealthy behaviour. It attempts to guide people towards personally choosing to change their unhealthy behaviour, rather than imposing expectations of change upon them, something which is frequently experienced by pregnant women who smoke. (13) This technique is based on the premise that if a person chooses to stop smoking themselves, they are more likely to be successful in their attempts to quit smoking.

The MI technique is based on the transtheoretical model of behaviour change, which posits that to achieve permanent change people go through a process of five distinct stages: pre-contemplation (i.e. not yet acknowledging an unhealthy behaviour that needs to be changed); contemplation (i.e. acknowledging the unhealthy behaviour, but not yet sure whether one is ready or wants to change); preparation (i.e. getting ready to change, perhaps setting a quit date); action (changing the unhealthy behaviour); and, maintenance (i.e. remaining abstinent). (14) Thus, interventions are individually tailored to stage of readiness or levels of motivation to change.

The most frequently adopted MI approach has been one in which smokers are provided with feedback, in a non-confrontational manner, intended to develop a discrepancy between their smoking behaviour and their personal goals. (15) Such a discrepancy is likely to lead to the uptake of any support that is offered to the pregnant woman as she commences attempts to quit smoking.

Evidence for the efficacy of MI in helping pregnant women to stop smoking is growing. Recently, Karatay, Kublay and Emiroglu (2010) found that 39.5% of pregnant women (n=38) taking part in a MI, stage-based smoking cessation intervention, were able to give up smoking, whilst 44.7% were able to reduce their rate of smoking by 60%. (16) Rates of passive smoking pre-intervention, which were 86.8%, decreased to 55.3% post-intervention. Interestingly, mean self-efficacy (confidence to quit) increased substantially from 61.36 pre-intervention to 93.34 post-intervention. Not only had MI facilitated smoking cessation in some of the women, but it also reduced passive smoking and increased confidence in one’s ability to stop smoking and remain abstinent. It could be argued that continued abstinence is a more useful measure of intervention efficacy than smoking cessation per se, since the former offers data on long-term efficacy.

In a trial conducted in Scotland, during maternity booking, all smokers were referred to an opt-out smoking cessation intervention delivered by midwives trained in MI. (17) This involved utilising MI skills over the telephone in order to engage pregnant smokers. Women contemplating quitting were provided with a face-to-face follow-up clinic meeting. Women who had set a date to quit smoking were offered withdrawal oriented therapy with adjuvant NRT. Of 1,936 pregnant smokers referred to the service, face-to-face meetings with midwives were arranged with 20%, 19% set a quit date, and 6% had remained abstinent 4-weeks after their quit date. A total of 117 out of 370 women (32%) who had set a quit date remained abstinent at 4-weeks follow-up. It is important to note, however, that outcomes were not due to MI alone and that augmentation with NRT might be necessary alongside MI. Furthermore, a problem confronted in the delivery of this intervention was that midwives found it difficult to approach pregnant women about smoking, which raises concerns with feasibility.

Additional research has highlighted that the efficacy of MI is dependent on baseline smoking levels. For example, Stotts et al. (2009) found that the effectiveness of MI alongside real-time ultrasound feedback focused on the potential effects of smoking was effective for nearly 34% of light smokers (<10 cigarettes/day), and yet heavy smokers (>10 cigarettes/day) were unaffected by the intervention (n=360). (18) Since pregnant women who are heavy smokers have been identified as reporting lower quit rates (19), further research comprising larger cohorts are required to establish the overall effectiveness of MI with this target group.

There is a paucity of research examining the cost-effectiveness of MI and smoking cessation interventions in general, but those studies that do report such data are, in the main, favourable. Indeed, in a systematic review examining the economic outcomes of smoking cessation interventions for pregnant women (n=51), no incremental cost-effectiveness studies or cost-utility studies were identified. (20) However, a narrative synthesis of the eight studies that met the inclusion criteria found favourable benefit-cost ratios of up to 3:1; for every 61p invested, £1.84 is saved in health-related costs. The researchers suggest that the return on investment will far outweigh the costs for smoking cessation initiatives for this population.

Another study that supplies data on cost-effectiveness is a randomised control trial (RCT) where women (n=302) were assigned to receive MI or usual care. (21) The MI intervention comprised education about the impact of smoking, help with evaluating their smoking behaviour, and the teaching of skills designed to increase self-efficacy for smoking cessation and abstinence. The women were also provided with information on how to reduce passive smoking. At 6-months postpartum, the cost-effectiveness of MI for relapse prevention compared to usual care was estimated to be £523 per life-year (LY) saved and £386 per quality-adjusted life-year (QALY) saved. For smoking cessation, MI cost more without providing additional benefits to usual care. The authors report that the incremental cost-effectiveness of MI versus usual care would have been £71.98/LY saved and £53.05/QALY saved if 8% of smokers had quit. Therefore, MI has the potential to be cost-effective if uptake can be increased.

MI versus Other Smoking Cessation Interventions

When evaluating the utility of MI for tackling the public health problem of smoking during pregnancy, a key consideration is how the technique compares to other interventions. In a study comparing brief advice (3-minute personal talk with a clinician regarding the dangers of smoking) with MI (three successive 20-minute interviews), 3.5% of smokers in the brief advice group were abstinent at 6- and 12-months follow-up compared to 18.4% at both time points in the MI group. (22) The MI intervention was 5.2 times more successful than brief advice.

In contrast, Ahluwalia (2006) compared MI to a health education approach, with the findings favouring the health education approach (RR 0.51; 95% CI 0.34 to 0.76). (23) However, the participants recruited for this study were already actively making quit attempts and using nicotine gum, thus MI might have been inappropriate for this population. MI was designed for motivating quit attempts, thus little is known regarding its effectiveness in facilitating smoking cessation with already motivated individuals.

In a Cochrane systematic review of seventy-two trials comprising over 25,000 pregnant women, the use of incentives was offered the most effective intervention, helping approximately 24% of pregnant women to quit smoking. (24) This was in comparison to CBT, MI, giving feedback to mothers on foetal health status, and NRT or other medications. It could, however, be argued that MI comprises an incentives component since motivation is based on a perceived beneficial outcome (i.e. an incentive that evokes motivation to quit). Thus, the results of this review might not accurately reflect the efficacy of MI.

In another incentive-based study, women were placed in either an ‘abstinence-contingent condition,’ where they earned vouchers that could be exchanged for retail goods by abstaining from smoking, or to a control condition where they received comparable vouchers independent of smoking status. (25) Rates of smoking cessation throughout antepartum was significantly greater in the incentive group compared to the control group (45.2±4.6 vs. 15.5±2.4, p<.001).

There is also the possibility that taking a stage-based approach to smoking cessation, which is a component of MI, is sufficient without the use of MI skills. In other words, merely identifying stage of readiness via utilisation of the transtheoretical model would enable the delivery of stage-matched interventions. Aveyard et al. (2006) explored this via a three-armed RCT comparing a stage-matched intervention versus a stage-mismatched intervention with pregnant women smoking at 12-weeks gestation. One arm comprised standard midwifery advice and a self-help lea¬‚et on smoking cessation. Two arms were stage-based, with women either being matched or mismatched. (26) Women in the stage-based arms were signi¬cantly more likely to move forward in stage than were women in the control arm; the greater relative bene¬t of the stage-based intervention was seen for women in the preparation stage at baseline, highlighting this a potential time to target women. No significant difference was found, however, between the matched and mismatched groups, suggesting that whilst the theoretical framework of the transtheoretical model is effective in facilitating smoking cessation, stage-matching isn’t necessarily behind its efficacy. It is plausible that MI techniques better account for the efficacy of the transtheoretical model framework, although this is speculation that requires testing via further research.

In the USA, the ‘5 A’s framework’ is advocated for smoking cessation initiatives in pregnant women who want to quit. (27) This is an evidence-based intervention comprising 5-15 minutes of brief counselling delivered by trained clinicians. The ‘5 R’s framework,’ on the other hand, is advocated for women who are not interested in quitting. (28) The utility of these frameworks is their distinction between women who are motivated to quit versus those who are not, which enables clinicians to tailor smoking cessation advice. The 5 R’s takes the same approach as MI in assisting women to negotiate any ambivalence they might have about quitting. The 5 A’s utilises some of the communication skills implicit within MI, such as empathy and the promotion of self-determination.

As demonstrated throughout this critique, the 5 A’s and 5 R’s frameworks are not alone in utilising MI principles. Since so many smoking cessation interventions clearly draw on the principles of this technique, it would seem apt to train healthcare professionals who work with pregnant women in such skills. The evidence suggests that brief counselling is just as effective as intensive counselling, but that some healthcare professionals find it difficult to approach pregnant women about their smoking status. MI provides a stage-based brief intervention requiring specialist communication skills that take it beyond brief counselling but requires fewer resources than intensive interventions. There is a paucity of evidence on its cost-effectiveness, but the evidence that is available shows favourable results.

The Delivery of Smoking Cessation Interventions for Pregnant Women

The need for routine antenatal smoking cessation programmes is unquestionable. (29) MI techniques provide healthcare professionals with the communication skills to target this high risk population. Indeed, as demonstrated in the critiqued literature, MI offers comparable, sometimes better, results than brief counselling, feedback, and NRT for smoking cessation during and after pregnancy.

In order to deliver a training programme for health professionals involved in the care of pregnant women, organisational change is necessary in order for new ways of working to be integrated into everyday practice. This will requires the support of organisation Managers as well as commissioners who might fund pilot studies to test the effectiveness of training staff in MI skills. In addition, input from the NHS, especially NHS Stop Smoking services, is likely to enhance the long-term effectiveness of such initiatives by acting as a resource for professionals to refer pregnant women for follow-up support.

The first step in the delivery of such an initiative would be designing and conducting the initial training, which would be designed to develop communication skills in MI during consultations. Importantly, however, according to a systematic review conducted by Soderlund et al. (2010), follow-up training or ‘refresher’ sessions might be necessary at appropriate intervals and this will need to be considered in terms of resource allocation and cost-effectiveness. (30)

Velasquez et al. (2000) describe the process of training healthcare providers to use MI with pregnant women, demonstrating that public health nurses and social workers are generally enthusiastic about attending training workshops and rate them as effective in preparing them to utilise MI skills in practice. (31) However, the study also highlighted that additional time and resources are required for ongoing skills building and monitoring of intervention delivery, which again raises issues over cost-effectiveness. However, as pointed out by Ruger and Emmons (2008), the projected return on investment of MI is likely to far outweigh the costs for smoking cessation initiatives for this population. (33)

In measuring the effectiveness of this programme of training, a number of outcomes require assessing. The impact of the training on skills development and confidence in utilising these skills could be assessed via interviews or questionnaires with professionals who attend the training. Ideally, this needs to be done pre-training and post-training, as well as 6-12 months later in order to assess the long-term sustainability of changes in service provision for pregnant smokers.

Patient records would also require examination in order to track the rates of smoking in pregnant women, as well as the number of quit attempts (both successful and unsuccessful). Abstinence can be measured via self-reports and tests for carbon monoxide. Furthermore, the monitoring of adverse events related to smoking could provide useful information on the clinical benefits of the programme.

Importantly, patient-reported outcome data can be collected via anonymous questionnaires eliciting information on service user satisfaction with the skills of healthcare workers, the content of consultations, and the usefulness of the support provided for issues such as smoking cessation. This would support government efforts to integrate patient-reported outcomes into assessments of service quality. (33)

Conclusion

This essay has described the public health issue of smoking during pregnancy in England, comparing different smoking cessation interventions with the techniques implicit within motivational interviewing. The evidence presented provides the rationale for a programme of MI training for health professionals who work with pregnant women in efforts to address this problem. MI has been shown to offer comparable, sometimes better, outcomes than other forms of intervention. Furthermore, despite the need for further research on cost-effectiveness, research thus far is favourable in terms of the cost-utility of utilising MI in tackling the public health issue of smoking during pregnancy.

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