Physical activity for smoking cessation in pregnancy: randomised controlled trialBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2145 (Published 14 May 2015) Cite this as: BMJ 2015;350:h2145
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We agree that in principal nicotine replacement therapy (NRT) should help pregnant smokers to stop smoking and NRT is licensed for use in pregnancy in the UK. However, randomized controlled trials have not shown NRT to be effective for smoking cessation in pregnancy.(1) This may be because of inadequate nicotine dosing due to faster nicotine metabolism during pregnancy. Besides the lack of evidence for NRT, there is also limited data on the harms of NRT for the foetus and many pregnant smokers prefer not to use NRT.(1, 2) Therefore, in our study of physical activity for smoking cessation during pregnancy (3) we wished to assess the effect of physical activity alone and not in addition to using NRT. Thus, women who indicated that they wished to use NRT at the outset were excluded. Following NICE guidelines, those women who were unable to stop smoking after their quit day, and who expressed a clear wish to receive NRT, were then prescribed it. As regards the use of combination NRT during pregnancy (e.g., patch plus lozenge), the study by Brose and colleagues (4) is promising but this is a correlational study. There is evidently a need for further trials of NRT in pregnancy, including higher dose and combination NRT.
As regards our not incorporating motivational interviewing (MI) in the intervention, there is limited evidence for the benefits of MI for smoking cessation and effects tend to be small for pregnant smokers (5). There is no evidence for an incremental benefit of MI over standard behavioural support for smoking cessation in pregnancy. Our study was a pragmatic trial implemented in NHS hospitals and both groups received the standard behavioural support provided by the NHS stop smoking services, which includes a range of cognitive and behavioural techniques but which does not focus on MI.
1. Coleman T, Chamberlain C, Davey MA, et al. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2012;9:CD010078.
2. Ussher M, West R. Interest in nicotine replacement therapy among pregnant smokers. Tob Control 2003,12:108-109.
3. Ussher M, Lewis S, Aveyard P, Manyonda I, West R, Lewis B, Marcus B, Riaz M, Taylor A, Daley A, Coleman T. Physical activity for smoking cessation in pregnancy: randomised controlled trial of. BMJ 2015;350:h2145.
4. Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug and Alcohol Dependence 2013;132:660-4.
5. Hettema JE, Hendricks PS. Motivational interviewing for smoking cessation: a meta-analytic review. J Consult Clin Psychol. 2010;6:868-84.
Competing interests: RW and PA have undertaken research and consultancy for companies that develop and manufacture smoking cessation medications in the past three years; in the last three years TC has been paid for speaking at two educational events which were part or wholly sponsored by a company that manufactures nicotine replacement therapy; RW is an unpaid trustee of the stop smoking charity, QUIT; RW is an unpaid director of the National Centre for Smoking Cessation and Training.
Smoking cessation may be the most important health intervention during pregnancy as smoking is the most preventable cause of preterm birth and other illnesses. The BMJ must be commended for publishing three randomised trials dealing with smoking during pregnancy, over 15 months and alerting readers that a mere tenth of pregnant smokers are prescribed nicotine replacement therapy (NRT).(1-4)
However we are concerned that NRT was not prescribed as warranted by evidence in any of the three trials, and particularly that patches were never combined with faster acting forms (lozenge or spray) of NRT. This ‘belt and braces’ strategy has been shown to double the odds ratio of quitting during pregnancy.(5)
Researchers and editors must ask how we can improve the implementation of evidence-based care: Why can healthcare professionals not apply simple pharmacological principles (dose effects and pharmacokinetics) to suppress craving as they would to suppress pain? The trial on financial incentives (2) would have been improved by having a control group where the healthcare professionals received financial incentives to perform motivational interviewing (a technique absent from all three trials), basic support and cognitive behavioural therapies. These effective techniques are hardly compatible with the present fixed-payment system though the benefits deserve longer consultations..
1 Ussher M, Lewis S, Aveyard P et al. Physical activity for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015;350:h2145.
2 Tappin D, Bauld L, Purves D et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015;350:h134.
3 Berlin I, Grangé G, Jacob N, Tanguy ML. Nicotine patches in pregnant smokers: randomised, placebo controlled, multicentre trial of efficacy. BMJ 2014;348:g1622.
4 O'Dowd A. Only a tenth of pregnant smokers are prescribed nicotine replacement therapy. BMJ. 2014 ;349:g5405.
5 Brose LS, McEwen A, West R. Association between nicotine replacement therapy use in pregnancy and smoking cessation. Drug and Alchohol Dependence 2013;132:660-4.
Competing interests: No competing interests