What Is Known About Pregnant Smokers
In 1995, researchers estimated that 20 percent of pregnant women smoked during their pregnancies. Smoking during pregnancy was considered the single greatest cause of other serious, preventable pregnancy complications and fetal harms, including low-birthweight babies (babies born to smoking mothers weigh less on average than babies born to nonsmoking mothers), preterm deliveries and perinatal deaths, including those caused by sudden infant death syndrome.
An estimated 20 percent or more of low-weight births could be prevented by eliminating smoking during pregnancy. Thus, for women and their providers, pregnancy represents a unique "teachable moment"—a time of heightened quitting motivation and support. But until 1996, there were no guidelines for the effective treatment of pregnant smokers. RWJF targeted pregnant smokers, especially low-income pregnant smokers who are Medicaid beneficiaries, both because of the heightened health risks of smoking during pregnancy for fetus and mother and because studies have shown that women who smoke are most likely to quit when they are pregnant.
Key RWJF-Sponsored Initiatives: Research
- RWJF's Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy (1993–08) was the Foundation's first and longest-funded cessation-focused national program. It funded 42 small-scale pilot studies to identify effective and innovative strategies to help smokers quit that could be integrated into routine prenatal and postpartum care for all pregnant smokers. The program disseminated the results by creating a coalition of more than 60 organizations and developing almost 70 products. The dissemination office grew to become part of the National Partnership to Help Pregnant Smokers Quit. (See Program Results for more information.)
After the first round of studies, the national program office, directed by Robert Goldenberg, M.D., teamed up with the U.S. Centers for Disease Control and Prevention (CDC), several National Institutes of Health agencies and the American College of Obstetricians and Gynecologists to conduct a systematic review of the existing research on smoking-cessation treatments for pregnant smokers. Then the program funded several studies that tested the United States Public Health Service (USPHS) guideline for cessation counseling protocols among pregnant smokers. (The USPHS guideline, known as the augmented 5 A's, is described in detail in Strategy 1.1, a chapter in this report and in an RWJF Anthology chapter.)
The most successful interventions were those that involved person-to-person advice and counseling to quit that exceeded the minimal three to five minutes recommended in the brief 5-A primary care intervention (i.e. extended individual and group interventions involving at least 12 to 15 minutes of cognitive-behavioral counseling augmented with pregnancy-tailored quitting materials). No medications had been found to be both safe and effective for use in pregnancy.
For more information on this review as well as on the more than 40 research studies and demonstration projects supported by Smoke-Free Families, see the Anthology chapter, the Capstone Meeting Report and Program Results.
Other studies funded by Smoke-Free Families documented that:
- Incentives help. Vouchers and other incentives, particularly when coupled with other interventions, like counseling and follow-up, give pregnant smokers an extra push to quit.
- Quitlines help. Counseling offered directly to pregnant smokers via telephone quitlines is effective.
- Biofeedback of potential smoking-related harms to the baby is a promising supplement to counseling, but is not effective on its own.
- Practice-level changes help. Health care systems can make changes in the way their providers practice that help pregnant women quit. The most effective system changes are those that combine reminders, provider education and feedback to providers.
- Covering treatment in pregnancy is cost-effective. Expanding Medicaid and private coverage for tobacco-cessation counseling for pregnant and parenting women is highly cost-effective, with significant one-year returns on investment due to prevention of pregnancy complications and fetal risks.
Key RWJF-Sponsored Initiatives: Action to Put Research Into Practice
- Smoke-Free Families' systematic synthesis of research related to pregnant smoking was shared with the original 1996 panel of the Agency for Health Care Policy & Research (AHCPR) that created the clinical practice guidelines. AHCPR (now known as the Agency for Healthcare Research & Quality or AHRQ) disseminates guidelines for evidence-based clinical practice to healthcare professionals across the country. Smoke-Free Families' research synthesis helped to form AHRQ's core recommendations for treating pregnant smokers. It also formed the basis for the treatment protocol recommended and promulgated by the American College of Obstetricians and Gynecologists (See Program Results), and the many professional organizations represented by the National Partnership to Help Pregnant Smokers Quit. Similar recommendations were made in the 2008 update of the clinical practice guideline. (See Program Results.)
- National Partnership to Help Pregnant Smokers Quit (2001–08), directed by Cathy Melvin, Ph.D., who directed the national dissemination office of Smoke-Free Families, was a coalition of organizations formed with RWJF funding to reduce smoking among pregnant women by increasing access to effective interventions—cessation treatments, health care system changes and public health policies. The partnership synthesized evidence for use by health care professional and voluntary health organizations in advocating for expended tobacco-cessation treatment coverage and for health care system changes and other public health policies to promote and support treatment use. See Program Results on Smoke-Free Families for more information.
Key RWJF-Sponsored Initiatives: Advocacy & Communications Around What Works
- National Partnership to Help Pregnant Smokers Quit (2001–08) described above, has a Web site, now hosted by the National Tobacco Cessation Collaborative, that reaches thousands of providers each year with fact sheets and tools to guide evidence-based care for pregnant and post-partum smokers. Recommendations for health care decision-makers and policy-makers also are provided. (See the National Action Plan to Reduce Smoking During Pregnancy. Also see the Web site and Program Results on Smoke-Free Families for more information.)
Other Related Resources Funded by RWJF
- A study that investigated why Medicaid-insured pregnant smokers change or do not change their smoking behavior. (See Program Results.)
- A study funded by the RWJF Substance Abuse Policy Research Program (see section 1.3.1) found that tobacco tax and price increases are particularly effective in promoting quitting among pregnant women. (See the RWJF abstract of an article published in the American Journal of Public Health.)
- A study to identify critical "markers" of successful smoking cessation or reduction for women during pregnancy. (See Program Results.)
- Efforts to disseminate tobacco treatment guidelines to obstetricians and gynecologists. (See Program Results.)
- An effort to make the U.S. Public Health Service cessation guidelines a routine part of prenatal care. (See Program Results.)
- A multimedia training tool for prenatal care practitioners. (See Program Results.)
More Than a Decade of Helping Smokers Quit: The Robert Wood Johnson Foundation's Investment in Tobacco Cessation
- 1. Strategy 1 - Science Push
- 2. Strategy 1.1 - United States Public Health Service Guideline
- 3. Strategy 1.2 - Reducing Smoking Among Pregnant Smokers
- 4. Strategy 1.3 - Youth
- 5. Strategy 2 - Capacity Building
- 6. Strategy 3.1 - Increasing Policy Supports and Incentives for Smoking Cessation and Treatment Use
- 7. Strategy 3.2 - Improving the Accessibility, Reach and Use of Proven Cessation Services: Quitlines and Other Cessation Service Delivery Innovations
- 8. Strategy 3.3 - Making Treatment More Affordable - Expanding Coverage
- 9. Strategy 3.4 - Making Treatment More Appealing: Building Consumer Demand for Evidence-Based Tobacco Treatment
- 10. Appendix 1: Major Tobacco-Cessation Grants of the Robert Wood Johnson Foundation