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Am Fam Physician. 2003;67(8):1811-1815

Women are believed to be more highly motivated to stop smoking during pregnancy. Four research studies have concluded that programs based on self-help strategies are effective in assisting women to quit smoking during pregnancy. However, most of these studies involved staff who were assigned specifically to the intervention. For widespread use with large numbers of pregnant women, such materials should be applied by health care professionals within routine practice. Moore and colleagues studied the effectiveness and acceptability of self-help materials in the routine antenatal care of 1,295 English patients.

The study randomly assigned 128 midwives to intervention or normal-care groups. The midwives in the intervention group were asked to spend at least five minutes introducing the first booklet of a five-book self-help series to all pregnant women who smoked. The other booklets in the series were delivered directly to the patients in the intervention group. All pregnant women were assessed during their first antenatal visit and were eligible for the study if they were at least 16 years of age, were at less than 17 weeks’ gestation, and had adequate English skills to comprehend the materials. The five booklets comprised a step-by-step program to increase motivation and change behavior for smoking cessation and relapse prevention. At 26 weeks’ gestation, participants completed a questionnaire about smoking and provided a urine sample that was tested by cotinine assay to validate smoking cessation.

Of the 610 women in the intervention group, 564 (92.5 percent) recalled seeing the booklets; of these women, 502 (89.0 percent) reported reading them, and 404 (71.6 percent) reported that the booklets were useful. Of the 707 women in the control group, 29 (4.1 percent) recalled seeing the booklets; of these women, 18 (6.2 percent) reported reading the booklets, and 13 (44.8 percent) found them useful. None of the women in the intervention group recalled the midwives reviewing the first booklet with them, but remembered going through it on their own later.

Although none of the women in the intervention group reported that the booklets had helped them to quit, the booklets were well received, and all women were supportive of initiatives to help pregnant women quit smoking. The self-reported cessation rates were 156 women in the intervention group (25.6 percent) and 207 women (29.3 percent) in the normal-care group. The validated cessation rates were much lower at 18.8 percent in the intervention group and 20.7 percent in the control group. The median self-reported consumption was 10 cigarettes per day in both of the study groups.

The authors conclude that the self-help intervention was acceptable and interesting to pregnant women but ineffective in affecting their smoking behavior. They note that strategies that work well in the research situation may not be feasible in routine practice and that more complex and targeted interventions may be necessary. Finally, they caution that patient report of smoking is likely to be inaccurate, so the success rates that are reported by studies that relied on patient report may be highly inaccurate.

editor’s note: This study could make physicians feel better about the guilt trips we receive from “experts” about not being sufficiently active in helping patients quit smoking. It establishes the following points: circumstances are not the same in practice as they are in research studies; patients may under-report their smoking habits; patients are unimpressed with the anti-smoking education provided by health care personnel; and patients manage to detach themselves from the anti-smoking message of even well-designed materials that have had proven success in targeted situations. Paradoxically, the true message could be that family physicians are essential to helping pregnant women and other patients stop smoking because we are in the best position to personalize health priorities and work with each individual patient until he or she is able to successfully quit. The written materials used in this study might be very successful if a family physician coached the patient to see how they applied in her situation and how she could use them herself. Smoking can seldom be countered by a single intervention. To see a patient right through the process requires consistent help that is adjusted to the patient’s changing needs through the cessation process and relapses. The two things that are not worthwhile are guilt trips and premature congratulations.—a.d.w.

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