Elsevier

Addictive Behaviors

Volume 27, Issue 2, March–April 2002, Pages 275-292
Addictive Behaviors

One-to-One: A motivational intervention for resistant pregnant smokers

https://doi.org/10.1016/S0306-4603(01)00174-5Get rights and content

Abstract

The purpose of this prospective, randomized controlled study was to determine the efficacy of an intensified, late pregnancy, smoking cessation intervention for resistant pregnant smokers (N=269). Participants received 3–5 min of counseling plus a self-help booklet at their first prenatal visit and seven booklets mailed weekly thereafter; at 28 weeks, all had been smoking in the past 28 days. The experimental group received a stage of change-based, personalized feedback letter and two telephone counseling calls using Motivational Interviewing (MI) strategies. The control group received care as usual. The 34th week cotinine data demonstrated no overall difference between groups. However, an implementation analysis suggested that 43% of women who received the full intervention (E2) were classified as not smoking compared to 34% of the control group. At 6 weeks postpartum, 27.1% of the E2 group reported being abstinent or light smokers vs. 14.6% of the controls. No differences were detected at 3 and 6 months postpartum. Results lend preliminary but very modest support for this intervention with resistant pregnant smokers. Improvements in the intervention and implementation issues are discussed.

Introduction

Adverse effects of cigarette smoking on pregnancy outcomes are well documented (e.g., Floyd, Rimer, Giovino, Mullen, & Sullivan, 1993), yet 20–25% of women smoke throughout pregnancy Ernster, 1993, United States Department of Health and Human Services, 1991. The benefits of smoking cessation at any point during pregnancy are substantial. Babies have been found to have higher birth weights even when women quit smoking in their third trimester Hebel et al., 1988, Windsor et al., 1993. Reductions in pregnancy smoking are also associated with increased birth weight (Li, Windsor, Perkins, Goldenberg, & Lowe, 1993), making this a secondary alternative to cessation.

Many smoking cessation interventions, typically self-help materials and brief counseling, have been developed and tested for pregnant women (e.g., Ershoff et al., 1989, Gielen et al., 1997, Kendrick et al., 1995, Windsor et al., 1985). Overall, results across studies suggest increased smoking cessation rates and subsequent infant birthweight as a result of intervention Dolan-Mullen et al., 1994, Floyd et al., 1993. However, smoking quit rates are often modest and vary substantially by the population sampled. Successful interventions with resistant, late pregnancy smokers have yet to be developed (Mullen, 1999).

Recommendations for enhancing interventions for pregnant smokers have included tailoring materials and counseling to the specific needs of the target population, as treatment response has been found to vary among subgroups of pregnant smokers Ershoff et al., 1989, Gielen et al., 1997, Windsor et al., 1993. O'Campo, Davis, and Gielen (1995) recommend, in particular, that clinicians assess a pregnant woman's degree of nicotine dependence and readiness to change and tailor smoking cessation interventions accordingly. The Transtheoretical Model's stages of change have been successfully used for tailoring smoking cessation interventions (e.g., Prochaska & DiClemente, 1992). Additionally, there is evidence to suggest that the provider of the intervention, particularly the counseling component, may be critical. Interventions using peer counselors have proven less effective than those using professional health educators (e.g., Gielen et al., 1997). Programs that have relied on existing staff to deliver the intervention have produced mixed results. Dolan-Mullen et al. (2000), Kendrick et al. (1995), and Velasquez et al. (2000) reported the implementation of pregnancy interventions within existing systems using clinic staff to be problematic and likely to affect studies negatively.

Personalized, process-oriented feedback is an important and effective intervention strategy that may be especially suited for pregnant smokers; at least one early study found that smoking cessation materials tailored to pregnancy are more effective than general guides or manuals for quitting smoking (Windsor et al., 1985). Feedback based on personal questionnaire responses and generated by expert systems has proven to be superior to self-help materials for smoking cessation in many studies DiClemente & Prochaska, 1998, Strecher, 1999. In addition, Motivational Interviewing (MI; Miller & Rollnick, 1991) may be ideal for resistant pregnant smokers as it is designed to increase problem recognition and the need for change. MI is thought to be especially beneficial for the many who are ambivalent about changing, such as those in the earlier stages of change (i.e., precontemplators and contemplators; DiClemente & Prochaska, 1998). Although implementation has been a problem in pregnancy smoking studies (Velasquez et al., 2000), brief MI interventions have demonstrated efficacy in other settings. Positive results have been found for the treatment of hospitalized adult smokers, outpatient and inpatient adolescent smokers, opiate users, and other individuals with addictive behaviors Colby et al., 1998, Miller & Rollnick, 1991, Saunders et al., 1995. Personalized and objective feedback delivered in a supportive, nonconfrontational context using the MI style and strategies may be a powerful intervention through which clients can resolve ambivalence and move to a point of decision and commitment to change (Miller & Rollnick, 1991).

This single-blind, prospective, randomized pilot study was conducted to evaluate the effectiveness of a brief telephone counseling intervention, “One-to-One,” using stage-based personalized feedback and MI strategies to increase smoking cessation in a sample of late pregnancy smokers who failed to stop smoking with a minimal intervention program. It was hypothesized that posttreatment and postpartum smoking rates would be lower for women in the experimental group compared to those receiving only “usual care.” In addition, as the intervention contained several components, secondary analyses were conducted to assess variability in implementation and corresponding intervention response.

Section snippets

Measures

Data for the present study were collected at the first prenatal visit (intake), during the 28th and 34th weeks of pregnancy, and 6 weeks and 3 and 6 months postpartum. Fig. 1 depicts the sample's progression through measurement and intervention.

Results

Initial comparisons of demographic variables revealed no differences between the experimental and control groups (n=269). Overall, at intake, this sample of pregnant smokers had a mean age of 28 years; the majority were White (78.8%), married (68.4%), living with their husband or partner (84.8%), employed at least part-time (78%), and had a high school or higher education level (90%). About 41% were pregnant with their first baby, and 35% were having their second.

Group differences were found on

Discussion

This randomized, small-scale pilot study investigated an intensified, late pregnancy smoking cessation intervention for women who had not stopped smoking spontaneously nor responded to a minimal intervention delivered early in pregnancy. The intervention based on personalized feedback, MI strategies, and the stage-of-change perspective was compared to “usual care” in the prenatal clinics. Cotinine-validated, end-of-pregnancy smoking was comparable between the Randomized Sample experimental and

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