Telephone Intervention for Pregnant Smokers

A Randomized Controlled Trial


      Pregnant smokers are advised to quit; however, many struggle to do so. Behavioral counseling can increase quitting success, but the efficacy of telephone counseling for pregnant smokers has not been established. This study tests the efficacy of pregnancy-specific counseling, embedded in the ongoing operations of a state quitline.


      In this two-group RCT, participants were randomly assigned to the intervention (telephone counseling plus self-help materials, n=584) or the control group (self-help materials only, n=589).


      Participants were pregnant smokers (N=1,173) in the first 27 weeks of gestation who called a state quitline between September 2000 and May 2003 for help with quitting.


      The primary component of the intervention was telephone counseling using a semi-structured protocol developed specifically for pregnant smokers. It drew its basic structure and clinical content from a previously tested counseling protocol for adult quitline callers, while including pregnancy-specific content and additional counseling sessions (nine rather than the standard five).

      Main outcome measures

      Subjects were evaluated on prolonged abstinence at the third trimester (about 29 weeks’ gestation) and at 2 and 6 months postpartum. Data were analyzed in 2015.


      Abstinence was higher for the intervention than the control group at the end of pregnancy (30-day abstinence, 29.6% vs 20.1%; p<0.001); 2 months postpartum (90-day abstinence, 22.1% vs 14.8%; p<0.001); and 6 months postpartum (180-day abstinence, 14.4% vs 8.2%; p<0.001). Cotinine-corrected (≤13 ng/mL) 7-day abstinence rates at the end of pregnancy supported the intervention effect (35.8% vs 22.5%, p<0.001).


      A pregnancy-specific counseling protocol, embedded in a state quitline, was effective in helping pregnant smokers quit and stay quit postpartum. Wide adoption of this intervention could help reduce the rate of maternal smoking and prevent its devastating health consequences.

      Trial Registration

      This study is registered at NCT02144883.
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        • Department of Veteran Affairs, Department of Defense
        VA/DoD Clinical Practice Guideline for Management of Pregnancy. Department of Veterans Affairs, Department of Defense, Washington, DC2009
        • Wong S.
        • Ordean A.
        • Kahan M.
        • et al.
        Substance use in pregnancy.
        J Obstet Gynaecol Can. 2011; 33: 367-384
      1. U.S. Office of the Surgeon General, Office on Smoking and Health. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: CDC; 2004. Accessed December 3, 2015.

        • Solomon L.J.
        • Quinn V.P.
        Spontaneous quitting: self-initiated smoking cessation in early pregnancy.
        Nicotine Tob Res. 2004; 6: S203-S216
        • Tong V.T.
        • Jones J.R.
        • Dietz P.M.
        • D’Angelo D.
        • Bombard J.M.
        CDC. Trends in smoking before, during, and after pregnancy—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 31 sites, 2000-2005.
        MMWR Surveill Summ. 2009; 58: 1-29
        • Chamberlain C.
        • O’Mara-Eves A.
        • Oliver S.
        • et al.
        Psychosocial interventions for supporting women to stop smoking in pregnancy.
        Cochrane Database Syst Rev. 2013; 10: CD001055
        • Lumley J.
        • Chamberlain C.
        • Dowswell T.
        • Oliver S.
        • Oakley L.
        • Watson L.
        Interventions for promoting smoking cessation during pregnancy.
        Cochrane Database Syst Rev. 2009; 3: CD001055
        • Benowitz N.L.
        • Dempsey D.A.
        Pharmacotherapy for smoking cessation during pregnancy.
        Nicotine Tob Res. 2004; 6: S189-S202
        • Pollak K.I.
        • Oncken C.A.
        • Lipkus I.M.
        • et al.
        Nicotine replacement and behavioral therapy for smoking cessation in pregnancy.
        Am J Prev Med. 2007; 33: 297-305
        • Brose L.S.
        • McEwen A.
        • West R.
        Association between nicotine replacement therapy use in pregnancy and smoking cessation.
        Drug Alcohol Depend. 2013; 132: 660-664
        • Dempsey D.
        • Jacob P.
        • Benowitz N.L.
        Accelerated metabolism of nicotine and cotinine in pregnant smokers.
        J Pharmacol Exp Ther. 2002; 301: 594-598
        • Bruin J.E.
        • Gerstein H.C.
        • Holloway A.C.
        Long-term consequences of fetal and neonatal nicotine exposure: a critical review.
        Toxicol Sci. 2010; 116: 364-374
        • Coleman T.
        • Chamberlain C.
        • Davey M.-A.
        • Cooper S.E.
        • Leonardi-Bee J.
        Pharmacological interventions for promoting smoking cessation during pregnancy.
        Cochrane Database Syst Rev. 2012; 9: CD010078
        • Schroeder D.R.
        • Ogburn P.L.
        • Hurt R.D.
        • et al.
        Nicotine patch use in pregnant smokers: smoking abstinence and delivery outcomes.
        J Matern Fetal Neonatal Med. 2002; 11: 100-107
        • Slotkin T.A.
        If nicotine is a developmental neurotoxicant in animal studies, dare we recommend nicotine replacement therapy in pregnant women and adolescents?.
        Neurotoxicol Teratol. 2008; 30: 1-19
        • Berlin I.
        • Grangé G.
        • Jacob N.
        • Tanguy M.-L.
        Nicotine patches in pregnant smokers: randomised, placebo controlled, multicentre trial of efficacy.
        BMJ. 2014; 348: g1622
        • Nowicki P.
        • Gintzig L.
        • Hebel J.R.
        • Latham R.
        • Miller V.
        • Sexton M.
        Effective smoking intervention during pregnancy.
        Birth. 1984; 11: 217-224
        • Dornelas E.A.
        • Magnavita J.
        • Beazoglou T.
        • et al.
        Efficacy and cost-effectiveness of a clinic-based counseling intervention tested in an ethnically diverse sample of pregnant smokers.
        Patient Educ Couns. 2006; 64: 342-349
        • Lichtenstein E.
        • Zhu S.-H.
        • Tedeschi G.J.
        Smoking cessation quitlines: an underrecognized intervention success story.
        Am Psychol. 2010; 65: 252-261
        • Stead L.F.
        • Perera R.
        • Bullen C.
        • et al.
        Nicotine replacement therapy for smoking cessation.
        Cochrane Database Syst Rev. 2012; 11: CD000146
        • Melvin C.L.
        • Gaffney C.A.
        Treating nicotine use and dependence of pregnant and parenting smokers: an update.
        Nicotine Tob Res. 2004; 6: S107-S124
        • Bombard J.M.
        • Farr S.L.
        • Dietz P.M.
        • Tong V.T.
        • Zhang L.
        • Rabius V.
        Telephone smoking cessation quitline use among pregnant and non-pregnant women.
        Matern Child Health J. 2013; 17: 989-995
        • Al-Sahab B.
        • Saqib M.
        • Hauser G.
        • Tamim H.
        Prevalence of smoking during pregnancy and associated risk factors among Canadian women: a national survey.
        BMC Pregnancy Childbirth. 2010; 10: 24
      2. Saul J, Davis R, North American Quitline Consortium. Results from the 2012 NAQC annual survey of quitlines. Published September 2013. Accessed June 8, 2015.

        • Roese N.J.
        • Jamieson D.W.
        Twenty years of bogus pipeline research: a critical review and meta-analysis.
        Psychol Bull. 1993; 114: 363-375
        • Hegaard H.K.
        • Kjærgaard H.
        • Møller L.F.
        • Wachmann H.
        • Ottesen B.
        Determination of a saliva cotinine cut-off to distinguish pregnant smokers from pregnant non-smokers.
        Acta Obstet Gynecol Scand. 2007; 86: 401-406
        • Cummins S.E.
        • Tedeschi G.J.
        • Anderson C.M.
        • Quinlan-Downs R.
        • Harris P.
        • Zhu S.-H.
        Telephone counselling for pregnant smokers: essential elements.
        J Smok Cessat. 2007; 2: 36-46
        • Zhu S.-H.
        • Tedeschi G.J.
        • Anderson C.M.
        • Pierce J.P.
        Telephone counseling for smoking cessation: what’s in a call?.
        J Couns Dev. 1996; 75: 93-102
        • Zhu S.-H.
        • Stretch V.
        • Balabanis M.
        • Rosbrook B.
        • Sadler G.
        • Pierce J.P.
        Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions.
        J Consult Clin Psychol. 1996; 64: 202-211
        • Zhu S.-H.
        • Anderson C.M.
        • Tedeschi G.J.
        • et al.
        Evidence of real-world effectiveness of a telephone quitline for smokers.
        N Engl J Med. 2002; 347: 1087-1093
        • Fiore M.C.
        • Jaén C.R.
        • Baker T.B.
        • et al.
        Treating Tobacco Use and Dependence: 2008 Update.
        U.S. DHHS, Rockville, MD2008: 1-257
        • Hughes J.R.
        • Keely J.P.
        • Niaura R.S.
        • Ossip-Klein D.J.
        • Richmond R.L.
        • Swan G.E.
        Measures of abstinence in clinical trials: issues and recommendations.
        Nicotine Tob Res. 2003; 5: 13-25
        • Agresti A.
        An Introduction to Categorical Data Analysis. 2nd ed. John Wiley & Sons, New York, NY2007
        • Hollis S.
        • Campbell F.
        What is meant by intention to treat analysis? Survey of published randomised controlled trials.
        BMJ. 1999; 319: 670-674
        • Simmons V.N.
        • Sutton S.K.
        • Quinn G.P.
        • Meade C.D.
        • Brandon T.H.
        Prepartum and postpartum predictors of smoking.
        Nicotine Tob Res. 2014; 16: 461-468
        • Rigotti N.A.
        • Park E.R.
        • Regan S.
        • et al.
        Efficacy of telephone counseling for pregnant smokers: a randomized controlled trial.
        Obstet Gynecol. 2006; 108: 83-92