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Telephone Counseling for Pregnant Smokers

Institution: University of California, San Diego
Investigator(s): Shu-Hong Zhu, Ph.D.
Award Cycle: 1999 (Cycle 8) Grant #: 8RT-0103 Award: $828,931
Subject Area: Tobacco-Use Prevention and Cessation
Award Type: Research Project Awards

Initial Award Abstract
Maternal smoking during pregnancy or shortly after childbirth has serious health consequences for the fetus or the developing infant. It is associated with an increased risk for spontaneous abortion, pregnancy complications, premature delivery, low birth weight, and prenatal and neonatal death. The increased risk can be reversed or minimized if women stop smoking soon after they become pregnant. However, it is estimated that 15% of pregnant women in the United States smoke cigarettes. Furthermore, of those who successfully quit during their pregnancy, 70% relapse soon after their baby is born. Thus, there is a pressing need to develop programs that can help these women quit smoking during pregnancy and prevent them from relapsing after childbirth. Unfortunately, few pregnant women have access to a suitable program, one designed to account for their distinctive circumstances and needs. Quitting smoking is difficult at any point in time, but stresses unique to pregnancy and to the postpartum period make it even more challenging for the women.

This study will test the effectiveness of a telephone counseling helpline specifically designed for pregnant women. The counseling will be provided over the phone so that the pregnant women need not leave home to receive the help. The counseling will be tailored to individual needs as each woman will be assigned to a specific counselor who will work with her individually to come up with a quitting plan that suits her personally. The counselor will provide counseling over the phone to assist her to stop smoking (or to stay quit) throughout the pregnancy, and offer counseling and support up to six months postpartum.

This study will recruit participants through the Partnership for Smokefree Families (PSF), a collaboration of three large and integrated health care systems in San Diego, which provide health care for about 20,000 pregnant women each year. It is estimated that about 80% of these pregnant women see their doctor during the first trimester for prenatal care. This provides a prime opportunity to intervene with this population. Physicians can ask their pregnant patients if they smoke. If they do, physicians can advise them to quit, provide written self-help materials, and refer them to the telephone counseling helpline (known as the PSF Helpline). The referral consists of two elements: 1) The smokers will be encouraged to call the helpline; 2) permission to have a counselor call them at home will also be requested. This study will use a proactive calling procedure to enroll these pregnant smokers into counseling if they fail to call the helpline after their visit with the physicians. The physicians can also provide support and a degree of accountability for pregnant smokers by asking about their smoking status at subsequent prenatal visits. As physicians may not have the time or training to offer smoking cessation counseling, the prenatal visit will be used as a springboard to enroll smokers into more extensive assistance, in this case the telephone counseling helpline. This would allow pregnant women to get the attention they need and would minimize the time drain on physicians.

This study is designed to: 1) Determine how often pregnant smokers will call a free helpline for counseling after they are advised to do so in their first prenatal visit. 2) Determine how many pregnant smokers will participate in counseling if contacted proactively. 3) Test if telephone counseling can help pregnant smokers quit smoking and stay abstinent after the baby is born. This will be accomplished with a randomized design.

Determine if quitting as a result of doctors’ advice and/or telephone counseling increases birth weights of babies born to participating women.

Final Report
This study proposed to test the effectiveness of telephone counseling as a routine intervention for pregnant smokers in a healthcare setting. The aim was to find out how many pregnant smokers would call a telephone counseling program after they were encouraged to do so by their healthcare providers during their first prenatal visit. It tested the effectiveness of a proactive telephone counseling approach where pregnant smokers who failed to call the program were contacted by counselors (via phone) to encourage them to participate in counseling. The effectiveness of this approach was tested in a randomized controlled design.

The project successfully established recruitment procedures with three large healthcare systems in San Diego, which formed the Partnership for Smoke-Free Families (PSF). Recruitment was extended through the use of a pregnancy brochure and survey to Kaiser Permenante (Northern California) and Perinatal Care Network, two large groups that were not part of the original proposal. The project developed a specific counseling protocol for pregnant smokers and pilot tested several versions. A specific randomization procedure was piloted and shown feasible. This procedure allowed women in the control group to receive counseling if they called back to request it after randomization. A method to collect saliva samples to test nicotine exposure among these women was implemented. This method was added because of concern that proactive recruitment might increase the rate of misreporting of nonsmoking status among pregnant women.

A reactive recruitment contrast group was added to the study from among callers to the California Smokers’ Helpline (CSH) who were pregnant and agreed to participate in the study. Randomization was stratified by referral source (PSF, CSH, or pregnancy brochure).

The results obtained so far show: a) it is feasible to routinely screen for smoking status during a pregnant woman’s first prenatal care visit. PSF screened over 33,000 pregnant women for smoking status in 2 ½ years through their healthcare providers. The rate of smokers was originally estimated at 10% but proved to be closer to 7%. Physicians continue to refer about 40 women per month and encourage women to call the Helpline. b) only a minority of pregnant smokers (<3%) take the initiative to call a counseling program, even though they have been encouraged to do so during their first prenatal care visit. c) Proactive recruitment is a promising method to enroll pregnant smokers into counseling. From 3/99-7/02, 1,739 pregnant smokers were referred by PSF to CSH resulting in many more pregnant smokers receiving services. Although 23% of women refused service and 30% were not reached by phone, over 32% did agree to enroll in counseling and another 12% chose self-help materials. By collaborating with healthcare providers almost half of these pregnant smokers received urgently needed help, suggesting that proactive recruitment is a very promising strategy for intervention.

The effectiveness of the telephone counseling protocol is currently being evaluated. There have been 1,170 clients randomized into the intervention and control groups (N = 826 reactive referrals and N = 344 proactive referrals). Subjects randomized into the intervention receive counseling at a rate of 69%. The median number of counseling calls is three. Contrary to expectation, preliminary data suggests a higher quit attempt rate among the proactively recruited subjects (62%) than reactively recruited subjects (55%). Although too few evaluations have been conducted so far to examine success by group or referral source, 21% of all randomized clients are quit for 30 days at the point of the third trimester evaluation call.

The study has so far shown that telephone counseling is a promising method to reach pregnant smokers because it does not wait for smokers to show up in a cessation clinic but proactively recruits them into counseling. The effectiveness of the counseling protocol is still being tested. If this study shows that the protocol is effective, the approach has considerable potential for reaching pregnant smokers (who are often hard to reach) and helping them to quit smoking. A reduction in smoking prevalence among pregnant women will not only improve the health of future generations but also substantially reduce medical costs associated with treating complications among newborns.