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Self-help programs for smoking cessation may work
- Jean-Francois ETTER (13 December 2002)
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Biochemically validated reduction of smoking in pregnancy
- Graham F. Cope (14 December 2002)
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Multiple intervention models are necessary for smoking cessation
- Aparna devi Gumma, Dr A.Ramesh (15 December 2002)
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WHAT DOES WORK
- TRACEY A BATTERSBY, CAROLE POUGHER LISA FENDALL (24 December 2002)
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The Process of Health Promotion
- David Michael Tappin, Evelyn Mohammed (27 December 2002)
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Jean-Francois ETTER, Lecturer 1211 Geneva 4, Switzerland
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Editor, Moore and colleagues show that giving smoking cessation booklets to pregnant women does not help them quit smoking (1). But the intervention offered to pregnant smokers in this study was not based on previously available evidence that adding booklets to face to face advice does not improve smoking cessation rates (2), and that more intensive interventions are needed to help pregnant smokers quit smoking (3). Nevertheless, a recent meta-analysis indicates that individually-tailored materials produced by computers increase by 80% the odds of quitting smoking, compared to receiving no materials (2). Because computer-tailored programs are based on the relevant personal characteristics of each smoker, participants may be more interested in reading these documents and to apply the advice included therein (4,5). Consequently, individually- tailored documents are 1.36 times more effective than booklets in helping smokers quit smoking (2). In addition, most available computer-tailored programs include a follow-up, which an essential element in the treatment of addictions. Tobacco dependence is a chronic condition with relapses that often needs prolonged treatment. This is a serious condition that is unlikely to be treated with booklets only. But computer-tailored programs can be a useful adjunct to pharmacotherapy and to the advice given by physicians and midwives. Using new information technology (internet, text messages on cell phones, etc), these programs can reach large numbers of smokers at a low cost. Because smoking prevalence among pregnant women increased sharply in recent years in many European countries, and because few physicians and midwives are trained in treating tobacco dependence, there is an urgent need to assess the efficacy of computer-tailored smoking cessation programs in pregnant smokers. Jean-Francois ETTER, PhD, MPH. References 1) Moore L, Campbell R, Whelan A, Mills N, Lupton P, Misselbrook E, Frohlich J. Self help smoking cessation in pregnancy: cluster randomised controlled trial. BMJ 2002; 325: 1383-8. 2) Lancaster T, Stead LF. Self-help interventions for smoking cessation (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software. 3) Lumley J, Oliver S, Waters E. Interventions for promoting smoking cessation during pregnancy (Cochrane Review). In: The Cochrane Library, Issue 3, 2002. Oxford: Update Software. 4)Brug J, Steenhuis I, van Assema P, de Vries H. The impact of a computer-tailored nutrition intervention. Prev Med 1996;25:236-242. 5) Dijkstra A, De Vries H, Roijackers J, van Breukelen G. Tailoring information to enhance quitting in smokers with low motivation to quit: three basic efficacy questions. Health Psychol 1998;17:513-519. Competing interests: JF Etter developed an effective computer-tailored smoking cessation program available at no charge in 4 languages at www.Stop-Tabac.ch |
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Graham F. Cope, Honorary Senior Research Fellow and Technical Director University of Birmingham and Mermaid Diagnostics Limited, B15 2SQ
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Editor, I read the article by Moore et al with great interest(1). The results of this well executed intervention highlight both the need to re-evaluate the generalised approach to providing information to women who continue to smoke during pregnancy and the need to biochemically validate self- reported smoking in this group. We carried out a controlled intervention using a point-of-care urine test for nicotine metabolites (including cotinine), developed at the University of Birmingham. This 6-minute easy-to-use test can provide feedback about a smoker’s baseline nicotine intake, both to the healthcare professional and the smoker themselves. This provides immediate information by which to tailor the advice according to the level of smoking and a simple question can determine their readiness to change behaviour. This governs what information can be given and also the test allows the changes in behaviour to be subsequently monitored. This is important as many women report ‘cutting down’ their cigarette consumption, which is frequently accompanied by compensation - an increased efficiency of smoking to maintain the required level of nicotine. This feedback has a strong positive effect, which has been shown to increase the efficacy of behavioural change interventions (2). Our study measured nicotine metabolite levels in a cross-sectional study of women attending their first ‘booking’ hospital antenatal appointment. The women were interviewed and tested after they had seen the hospital midwife. We found a 10% previous denial rate and 38% had significantly under-reported their cigarette consumption (3). The point-of-care test was an integral part of the intervention, which increased the biochemical validated smoking cessation to 16%, and a further 33.3% significantly reducing their nicotine intake compared to the control group, in which only 8% stopped smoking and 23% reducing their intake. An additional finding showed a high proportion of the control group (42%) had significantly increased nicotine levels at 36 weeks compared to ‘booking’, which contrasts to the case group in which only 11% increased. The smoking test results at 36 weeks correlated significantly with both birth weight (p=0.006) and body length (p=0.011). References 1) Moore L, Campbell R, Whelan A, Mills N, Lupton P, Misselbrook E, Frohlich J. Self help smoking cessation in pregnancy: cluster randomised controlled trial. BMJ 2002; 325: 1383-8. 2) Di Clemente C, Marinilli A, Singh M, Bellino L. The role of feedback in the process of health behavior change. Am J Health Behavior 2001: 25: 217- 27. 3) Cope G, Nayyar P, Holder R. Measurement of nicotine intake in pregnant women – associations to changes in blood cell count. Nic Tob Res 2001; 3: 119-22. Competing interests: GF Cope invented the test for smoking whilst an employee of the Univesity of Birmingham. He is now employed by Mermaid Diagnostics Limited, a company established and partially owned by the university. |
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Aparna devi Gumma, Senior SHO in Obstetrics&Gynecology Rochdale infirmary, Ol12Opr, Dr A.Ramesh
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Dear sir This study by Moore and colleagues showed the ineffectiveness of selfhelp approach by offering booklets to quit smoking in pregnancy. Randomized controlled trial of a midwife-delivered brief smoking cessation intervention in pregnancy as one-off approach sessions are not very effective to reduce this rates as shown by Hajek P etal. Smoking has multitude of health problems including risk of low birthweight, preterm labour, spontaneous abortion and perinatal death and also genotoxicity. Sociodemographic factors has to be considered to design effective intervention programmes like Midwifery Smoking counsellors, computer tailored programmes , partner&family involvement.Novelty approaches like text messsaging, using nicotine pathces should be tried. During pregnancy midwives and doctors have a unique opportunity to influence and help women who smoke to give up smoking. References: 1. Moore L, Campbell R, Whelan A, Mills N, Lupton P, Misselbrook E, Frohlich J. Self help smoking cessation in pregnancy: cluster randomised controlled trial. BMJ 2002; 325: 1383-8. 2.Randomized controlled trial of a midwife-delivered brief smoking cessation intervention in pregnancy. Hajek P, West R, Lee A, Foulds J, Owen L, Eiser JR, Main N 3.Effectiveness of a pregnancy smoking cessation program. O'Connor AM, Davies BL, Dulberg CS, Buhler PL, Nadon C, McBride BH, Benzie RJ. Competing interests: None declared |
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TRACEY A BATTERSBY, MIDWIFE SPECIALIST DONCASTER SMOKEFREE PREGNANCY HPDC ST CATHERINES HOSPITAL DONCASTER DN48QN, CAROLE POUGHER LISA FENDALL
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We were interested to read your article,demonstrating that'self help' strategies do not work with pregnant women. This is indeed the case.Pregnant women require sophisiticated,tailor made packages to meet their individual needs.The care they recieve needs to be delivered by highly trained Specialist Midwives.The midwives who deliver antenatal and postnatal care to pregnant and postnatal women and their families need to be trained to raise the issue of smoking with that client group and refer to the specialist service as necessary. Doncaster has a history of working with pregnant women who want to give up smoking,and were part of the initial pilot with QUIT to develop and implement a Smoking and Pregnancy Helpline.Building on the success from the pilot, Doncaster launched its own service,SmokeFree Pregnancy.This Service encompasses all of the elements recommended for a successful service. Two specially trained , highly motivated midwives , have been employed to offer flexible support to pre conceptual, pregnant and postnatal women and their families.They also negotiate, with the G P, the use of Nicotine Replcement Therapy. All midwives in Doncaster are trained to raise the issue of smoking, and in the last year 150 pregnant women have successfully stopped smoking as a result of the interventions they recieved. The success in Doncaster with regard to this type of specifically tailored service is reflected in the percentage quit rate ,which is one of the highest in the country,and is seen as an example of good practice. Competing interests: None declared |
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David Michael Tappin, Clinical Senior Lecturer, Department of Child Health, Glasgow University. Paediatric Epidemiology & Community Health Unit, Royal Hospital for Sick Children, Glasgow, G3 8SJ., Evelyn Mohammed
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The study of a self help approach to smoking cessation in pregnancy (1) suffers from the common misconception that the process of intervention is less important than the outcome. This simple intervention aimed to include at least 5 minutes explanation by a midwife specially trained to introduce the first self help smoking cessation booklet at the first antenatal appointment, followed by 4 further booklets posted at intervals during pregnancy. None of the intervention women subsequently interviewed could recall the midwife taking them through the first booklet at the first antenatal appointment. Interviewed midwives admitted that time spent at maternity booking was variable. The most worrying issue is that we have no idea how many women had 5 minutes, how many had more than 5 minutes and how many had less than 5 minutes explanation at maternity booking. We are therefore left with 2 questions which should have been answered by this study. 1. Did the intervention take place as planned? 2. If it did not, would it have worked if it had? 1. Moore L, Campbell R, Whelan A, Mills N, Lupton P, Misselbrook E, Frohlich J. Self help smoking cessation in pregnancy: cluster randomised controlled trial. BMJ 2002; 325: 1383-6. Competing interests: None declared |
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