Smoking Cessation

BACKGROUND: Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries. OBJECTIVES: To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. SEARCH METHODS: In this fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data. SELECTION CRITERIA: Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS. MAIN RESULTS: Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing. AUTHORS' CONCLUSIONS: Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy, and reduce low birthweight and preterm births.

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Psychosocial interventions for supporting women to stop smoking in pregnancy

Beyond Adolescence: Problem Behavior and Young Adult Development

Objectives To analyse evidence on the effectiveness of intensive NHS treatments for smoking cessation in helping smokers to quit. Methods A systematic review of studies published between 1990 and 2007. Electronic databases were searched for published studies. Unpublished reports were identified from the national research register and experts. Results Twenty studies were included. They suggest that intensive NHS treatments for smoking cessation are effective in helping smokers to quit. The national evaluation found 4-week carbon monoxide monitoring validated quit rates of 53%, falling to 15% at 1 year. There is some evidence that group treatment may be more effective than one-to-one treatment, and the impact of ‘buddy support’ varies based on treatment type. Evidence on the effectiveness of in-patient interventions is currently very limited. Younger smokers, females, pregnant smokers and more deprived smokers appear to have lower short-term quit rates than other groups. Conclusion Further research is needed to determine the most effective models of NHS treatment for smoking cessation and the efficacy of those models with subgroups. Factors such as gender, age, socio-economic status and ethnicity appear to influence outcomes, but a current lack of diversity-specific analysis of results makes it impossible to ascertain the differential impact of intervention types on particular subpopulations.

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The effectiveness of NHS smoking cessation services: a systematic review

There is increasing evidence that cash transfer (CT) programs decrease intimate partner violence (IPV); however, little is known about how CTs achieve this impact. We conducted a mixed method review of studies in low- and middle-income countries. Fourteen quantitative and nine qualitative studies met our inclusion criteria, of which eleven and six respectively demonstrated evidence that CTs decrease IPV. We found little support for increases in IPV, with only two studies showing overall mixed or adverse impacts. Drawing on these studies, as well as related bodies of evidence, we developed a program theory proposing three pathways through which CT could impact IPV: 1) Economic security and emotional wellbeing, 2) intra-household conflict, and 3) women’s empowerment. The economic security and wellbeing pathway hypothesizes decreases in IPV, while the other two pathways have ambiguous effects depending on program design features and behavioural responses to program components. Future studies should improve IPV measurement, empirical analysis of program mechanisms, and fill regional gaps. Program framing and complementary activities, including those with the ability to shift intra-household power relations are likely to be important design features for understanding how to maximize and leverage the impact of CTs for reducing IPV, and mitigating potential adverse impacts.

A Mixed-Method Review of Cash Transfers and Intimate Partner Violence in Low- and Middle-Income Countries

Introduction Pregnancy is a key time to leverage receptivity to smoking reduction or cessation in both pregnant women and their partners. A partner's smoking status and support for the pregnant/postpartum woman's efforts to reduce or quit smoking may impact her smoking behavior. Methods A systematic literature review of interventions to enhance partner support for pregnant/postpartum women's smoking reduction or cessation and cessation treatments for the partners themselves identified 855 unique references, which were examined for relevance, yielding 9 intervention studies. Results This narrative review analyzed a range of interventions including mass media campaigns, ultrasound scans, video, self-help manuals, counselling, and nicotine replacement therapies (NRTs) aimed at pregnant women and/or their partners. One randomized controlled trial (RCT) showed significant results for an intervention, which included a partner-targeted component in which pregnant women received health counselling, video and printed information, while partners received a booklet explaining the importance of quitting together. Three studies (1 RCT cluster, 1 pre-post test, 1 RCT) demonstrated no effect in improving smoking cessation among pregnant women. Two RCTs included free NRTs, telephone counselling, and multiple contacts as components of effective intervention for male partners, but impact on overall quit rates may not be sustainable postpartum. Seven studies (4 pre-post test, 2 RCT, 1 RCT cluster) found no effect of the intervention on partner smoking cessation. Conclusions Despite the importance of partner smoking, there are very few effective smoking cessation interventions for pregnant/postpartum women that include or target male partners, suggesting the need for further intervention development and research to establish the utility of this approach.

Partner support for smoking cessation during pregnancy: a systematic review.

Introduction: Due to the uptake in the use of e-cigarettes (ECs), evidence on their health effects is needed to inform health care and policy. Some regulators and health professionals have raised concerns that the respirable aerosols generated by ECs contain several constituents of potential toxicological and biological relevance to respiratory health. Areas covered: We critically assess published research on the respiratory system investigating the effects of ECs in preclinical models, clinical studies of people who switched to ECs from tobacco cigarettes, and population surveys. We assess the studies for the quality of their methodology and accuracy of their interpretation. To adequately assess the impact of EC use on human health, addressing common mistakes and developing robust and realistic methodological recommendations is an urgent priority. The findings of this review indicate that ECs under normal conditions of use demonstrate far fewer respiratory risks than combustible tobacco cigarettes. EC users and smokers considering ECs have the right to be informed about the relative risks of EC use, and to be made aware that findings of studies published by the media are not always reliable. Expert opinion: Growing evidence supports the relative safety of EC emission aerosols for the respiratory tract compared to tobacco smoke.

https://www.tandfonline.com/doi/pdf/10.1080/17476348.2019.1649146

The effect of e-cigarette aerosol emissions on respiratory health: a narrative review

Production of this report has been made possible through a financial contribution from Health Canada.

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Expecting to Quit: A Best-Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women

This study examined the formulation, adoption, and implementation of a ban on smoking in the parks and beaches in Vancouver, Canada. Informed by Critical Multiplism, we explored the policy adoption process, support for and compliance with a local bylaw prohibiting smoking in parks and on beaches, experiences with enforcement, and potential health equity issues through a series of qualitative and quantitative studies. Findings suggest that there was unanimous support for the introduction of the bylaw among policy makers, as well as a high degree of positive public support. We observed that smoking initially declined following the ban’s implementation, but that smoking practices vary in parks by location. We also found evidence of different levels of enforcement and compliance between settings, and between different populations of park and beach users. Overall success with the implementation of the bylaw is tempered by potential increases in health inequities because of variable enforcement of the ban; greatest levels of smoking appear to continue to occur in the least advantaged areas of the city. Jurisdictions developing such policies need to consider how to allocate sufficient resources to enhance voluntary compliance and ensure that such bylaws do not contribute to health inequities.

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Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy

Purpose: This paper aims to overview the need for tobacco harm reduction, the consumer products that facilitate tobacco harm reduction and the barriers to its implementation. The worldwide endemic of tobacco smoking results in the death of over seven million smokers a year. Cigarette quit rates are very low, from 3%–12%, and relapse rates are high, from 75%–80% in the first six months and 30%–40% even after one year of abstinence. In addition, some smokers do not desire to quit. Cigarette substitution in tobacco harm reduction is one strategy that may reduce the burden of morbidity and mortality.

Design/methodology/approach: This review examines the displacement of smoking through substitution of non-combustible low-risk products such as snus, heated tobacco products and e-cigarettes.

Findings: Toxicological testing, population studies, clinical trials and randomized controlled trials demonstrate the potential reductions in exposures for smokers. Many barriers impede the implementation of product substitution in tobacco harm reduction. These products have been subjected to regulatory bans and heavy taxation and are rejected by smokers and society based on misperceptions about nicotine, sensational media headlines and unsubstantiated fears of youth addiction. These barriers will need to be addressed if tobacco harm reduction is to make the maximum impact on the tobacco endemic.

Originality/value: This review provides the rationale for tobacco harm reduction, evaluates the current products available and identifies the barriers to implementation.

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Renée O’Leary

Papers

Partner support for smoking cessation during pregnancy: a systematic review.

The effect of e-cigarette aerosol emissions on respiratory health: a narrative review

Expecting to Quit: A Best-Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women

Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy

Tobacco harm reduction in the 21st century