Preventing Alcohol and Tobacco Exposed Pregnancies: CHOICES Plus in Primary Care


      Alcohol and tobacco use are common among U.S. women, yet if used during pregnancy these substances present significant preventable risks to prenatal and perinatal health. Because use of alcohol and tobacco often continue into the first trimester and beyond, especially among women with unintended pregnancies, effective evidence-based approaches are needed to decrease these risk behaviors. This study was designed to test the efficacy of CHOICES Plus, a preconception intervention for reducing the risk of alcohol- and tobacco-exposed pregnancies (AEPs and TEPs).

      Study design

      RCT with two intervention groups: CHOICES Plus (n=131) versus Brief Advice (n=130). Data collected April 2011 to October 2013. Data analysis finalized February 2016.


      Settings were 12 primary care clinics in a large Texas public healthcare system. Participants were women who were non-sterile, non-pregnant, aged 18–44 years, drinking more than three drinks per day or more than seven drinks per week, sexually active, and not using effective contraception (N=261). Forty-five percent were smokers.


      Interventions were two CHOICES Plus sessions and a contraceptive visit or Brief Advice and referral to community resources.

      Main outcome measures

      Primary outcomes were reduced risk of AEP and TEP through 9-month follow-up.


      In intention-to-treat analyses across 9 months, the CHOICES Plus group was more likely than the Brief Advice group to reduce risk of AEP with an incidence rate ratio of 0.620 (95% CI=0.511, 0.757) and absolute risk reduction of –0.233 (95% CI=–0.239, –0.226). CHOICES Plus group members at risk for both exposures were more likely to reduce TEP risk (incidence rate ratio, 0.597; 95% CI=0.424, 0.840 and absolute risk reduction, –0.233; 95% CI=–0.019, –0.521).


      CHOICES Plus significantly reduced AEP and TEP risk. Addressing these commonly co-occurring risk factors in a single preconception program proved both feasible and efficacious in a low-income primary care population. Intervening with women before they become pregnant could shift the focus in clinical practice from treatment of substance-exposed pregnancies to prevention of a costly public health concern.

      Trial registration

      This study is registered at NCT01032772.
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        • Tan C.H.
        • Denney C.H.
        • Cheal N.E.
        • Sniezek J.E.
        • Kanny D.
        Alcohol use and binge drinking among women of childbearing age – United States, 2011-2013.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 1042-1062
        • Jamal A.
        • Homa D.M.
        • O’Connor E.
        • et al.
        Current cigarette smoking among adults - United States, 2005-2014.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 1233-1240
        • Jacobson J.L.
        • Jacobson S.W.
        Drinking moderately and pregnancy. Effects on child development.
        Alcohol Res Health. 1999; 23: 25-30
        • Sood B.
        • Delaney-Black V.
        • Covington C.
        • et al.
        Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. dose-response effect.
        Pediatrics. 2001; 108: E34
        • CDC
        Trends in smoking before, during, and after pregnancy – Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000-2010.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 1-19
        • Castles A.
        • Adams E.K.
        • Melvin C.L.
        • Kelsch C.
        • Boulton M.L.
        Effects of smoking during pregnancy. Five meta-analyses.
        Am J Prev Med. 1999; 16: 208-215
        • Salihu H.M.
        • Aliyu M.H.
        • Pierre-Louis B.J.
        • Alexander G.R.
        Levels of excess infant deaths attributable to maternal smoking during pregnancy in the United States.
        Matern Child Health J. 2003; 7: 219-227
        • Dietz P.M.
        • England L.J.
        • Shapiro-Mendoza C.K.
        • Tong V.T.
        • Farr S.L.
        • Callaghan W.M.
        Infant morbidity and mortality attributable to prenatal smoking in the United States.
        Obstet Gynecol Surv. 2010; 65: 601-602
        • Odendaal H.J.
        • Steyn D.W.
        • Elliott A.
        • Burd L.
        Combined effects of cigarette smoking and alcohol consumption on perinatal outcome.
        Gynecol Obstet Invest. 2009; 67: 1-8
        • Finer L.B.
        • Zolna M.R.
        Shifts in intended and unintended pregnancies in the United States, 2001–2008.
        Am J Public Health. 2014; 104: S44-S48
        • Naimi T.S.
        • Brewer R.D.
        • Mokdad A.
        • Denny C.
        • Serdula M.K.
        • Marks J.S.
        Binge drinking among U.S. adults.
        JAMA. 2003; 289: 70-75
        • Stotts A.L.
        • Green C.
        • Northrup T.F.
        • et al.
        Feasibility and efficacy of an intervention to reduce secondhand smoke exposure among infants discharged from a neonatal intensive care unit.
        J Perinatol. 2013; 33: 811-816
        • Floyd R.L.
        • Sobell M.
        • Velasquez M.M.
        • et al.
        Preventing alcohol-exposed pregnancies: a randomized controlled trial.
        Am J Prev Med. 2007; 32: 1-10
        • Kanny D.
        • Liu Y.
        • Brewer R.D.
        • et al.
        Vital signs: binge drinking among women and high school girls — United States, 2011.
        MMWR Morb Mort Wkly Rep. 2013; 62: 9-13
        • Institute of Medicine Committee to Study the Prevention of Low Birthweight
        Preventing Low Birthweight.
        National Academies Press, Washington, DC1985
      1. Stratton K. Howe C. Battaglia F. Institute of Medicine Committee to Study Fetal Alcohol Syndrome. Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. National Academies Press, Washington, DC1996
        • Johnson K.
        • Posner S.F.
        • Biermann J.
        • et al.
        Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
        MMWR Recomm Rep. 2006; 55: 1-23
      2. Office of the Surgeon General. Advisory on alcohol use in pregnancy. Published February 21, 2005. Accessed July 14, 2015.

      3. NIH Fact Sheets: Fetal alcohol spectrum disorders. NIH. Updated March 29, 2013. Accessed July 15, 2015.

      4. Healthy People 2020. Maternal, infant and child health: objectives. U.S. DHHS, Office of Disease Prevention and Health Promotion. Accessed July 13, 2015.

        • Stade B.C.
        • Bailey C.
        • Dzendoletas D.
        • Sgro M.
        • Dowswell T.
        • Bennett D.
        Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy.
        Cochrane Database Syst Rev. 2009; 2: CD004228
        • Chang G.
        • Wilkins-Haug L.
        • Berman S.
        • Goetz M.A.
        Brief intervention for alcohol use in pregnancy: a randomized trial.
        Addiction. 1999; 94: 1499-1508
        • O’Connor M.J.
        • Whaley S.E.
        Brief intervention for alcohol use by pregnant women.
        Am J Public Health. 2007; 97: 252-258
        • Olson H.C.
        • Jirikowic T.
        • Kartin D.
        • Astley S.
        Responding to the challenge of early intervention for fetal alcohol spectrum disorders.
        Infants Young Child. 2007; 20: 172-189
        • Velasquez M.M.
        • Ingersoll K.
        • Sobell M.
        • Sobell L.C.
        Women and Drinking: Preventing Alcohol-Exposed Pregnancies.
        Hogrefe Press, New York, NY2015
        • Parrish D.E.
        • von Sternberg K.
        • Velasquez M.M.
        • Cochran J.
        • Sampson M.
        • Mullen P.D.
        Characteristics and factors associated with the risk of a nicotine exposed pregnancy: expanding the CHOICES preconception counseling model to tobacco.
        Matern Child Health J. 2012; 16: 1224-1231
        • Velasquez M.M.
        • von Sternberg K.
        • Kowalchuk A.
        • et al.
        Preventing alcohol and tobacco-exposed pregnancies in primary care setting: results of a randomized controlled trial.
        (June 20-25) Symposium presented at: Research Society on Alcoholism 37th Annual Scientific Meeting, Bellevue, WA2014
        • Miller W.R.
        • Rollnick S.
        Motivational Interviewing: Helping People Change. 3rd ed. The Guilford Press, New York, NY2013
        • Institute of Medicine Committee on Treatment of Alcohol Problems
        Broadening the Base of Treatment for Alcohol Problems.
        National Academies Press, Washington, DC1990
        • Madras B.K.
        • Compton W.M.
        • Avula D.
        • Stegbauer T.
        • Stein J.B.
        • Clark H.W.
        Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later.
        Drug Alcohol Depend. 2009; 99: 280-295
      5. National Institute of Alcohol Abuse and Alcoholism. Rethinking Drinking. NIH Publication No. 15-3770. Revised December 2015. Accessed March 7, 2017.

      6. Resources for Women and Patients. Birth control (contraception): resource overview. American Congress of Obstetricians and Gynecologists. Accessed December 17, 2015.

      7. Moyers TB, Martin T, Manuel JK, Miller WR, Ernst D. Revised global scales: motivational interviewing treatment integrity 3.1.1. Revised January 22, 2010. Accessed July 8, 2015.

        • Allen J.P.
        • Litten R.Z.
        • Fertig J.B.
        • Babor T.
        A review of research on the Alcohol Use Disorders Identification Test (AUDIT).
        Alcohol Clin Exp Res. 1997; 21: 613-619
        • Derogatis L.R.
        BSI Brief Symptom Inventory: Administration, Scoring, and Procedure Manual. 4th ed. National Computer Systems, Minneapolis, MN1993
        • DiClemente C.C.
        • Hughes S.O.
        Stages of change profiles in outpatient alcoholism treatment.
        J Subst Abuse. 1990; 2: 217-235
        • Janis I.L.
        • Mann L.
        Decision Making: A Psychological Analysis of Conflict, Choice, and Commitment.
        Free Press, New York, NY1997
        • Prochaska J.O.
        • Velicer W.F.
        • Rossi J.S.
        • et al.
        Stages of change and decisional balance for 12 problem behaviors.
        Health Psychol. 1994; 13: 39-46
        • DiClemente C.C.
        • Carbonari J.P.
        • Addy R.C.
        • Velasquez M.M.
        Alternate short forms of a Processes of Change Scale for alcoholism treatment.
        Washington, DC, Poster presented at: 4th International Congress of Behavioral MedicineNovember 1996
        • Annis H.
        • Davis C.S.
        Self-efficacy and the prevention of alcoholic relapse: initial findings from a treatment trial.
        in: Baker T.B. Cannon D.S. Assessment and Treatment of Addictive Disorders. Praeger Publishers, New York, NY1988: 88-112
        • Breslin F.C.
        • Sobell L.C.
        • Sobell M.B.
        • Agrawal S.
        A comparison of a brief and long version of the Situational Confidence Questionnaire.
        Behav Res Ther. 2000; 38: 1211-1220
        • DiClemente C.
        • Prochaska J.
        • Gibertini M.
        Self-efficacy and the stages of self-change of smoking.
        Cognit Ther Res. 1985; 9: 181-200
        • Sobell L.C.
        • Sobell M.B.
        Timeline follow-back: a technique for assessing self-reported ethanol consumption.
        in: Allen J. Litten R.Z. Measuring Alcohol Consumption: Psychosocial and Biological Methods. Humana Press, Totowa, NJ1992: 41-72
        • Patrick D.L.
        • Cheadle A.
        • Thompson D.C.
        • Diehr P.
        • Koepsell T.
        • Kinne S.
        The validity of self-reported smoking: a review and meta-analysis.
        Am J Public Health. 1994; 84: 1086-1093
        • Murray R.P.
        • Connett J.E.
        • Lauger G.G.
        • Voelker H.T.
        Error in smoking measures: effects of intervention on relations of cotinine and carbon monoxide to self-reported smoking.
        Am J Public Health. 1993; 83 (The Lung Health Study Research Group): 1251-1257
        • Jarvis M.J.
        • Tunstall-Pedoe H.
        • Feyerabend C.
        • Vesey C.
        • Saloojee Y.
        Comparison of tests used to distinguish smokers from nonsmokers.
        Am J Public Health. 1987; 77: 1435-1438
        • Etter J.F.
        • Vu Duc T.
        • Perneger T.V.
        Saliva cotinine levels in smokers and nonsmokers.
        Am J Epidemiol. 2000; 151: 251-258
        • Rochon J.
        Application of GEE procedures for sample size calculations in repeated measures experiments.
        Stat Med. 1998; 17: 1643-1658<1643::AID-SIM869>3.0.CO;2-3
      8. A clinical practice guideline for treating tobacco use and dependence: 2008 update.
        Am J Prev Med. 2008; 35: 158-176
        • Zou G.
        A modified Poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Liublinska V.
        • Rubin D.B.
        Sensitivity analysis for a partially missing binary outcome in a two-arm randomized clinical trial.
        Stat Med. 2014; 33: 4170-4185
        • Babor T.F.
        • Higgins-Biddle J.C.
        • Saunders B.
        • Monteiro M.G.
        AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary care. 2nd ed. WHO, WHO/MSD/MSB/01.6a. Geneva, Switzerland2001
        • Saitz R.
        • Palfai T.P.A.
        • Cheng D.M.
        • et al.
        Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.
        JAMA. 2014; 312: 502-513
      9. Final Update Summary: Drug Use, Illicit: Screening. U.S. Preventive Services Task Force. July 2015.

        • Miech R.
        • Koester S.
        Trends in U.S. past-year marijuana use from 1985 to 2009: an age–period–cohort analysis.
        Drug Alcohol Depend. 2012; 124: 259-267
        • Hurd Y.L.
        • Wang X.
        • Anderson V.
        • Beck O.
        • Minkoff H.
        • Dow-Edwards D.
        Marijuana impairs growth in mid-gestation fetuses.
        Neurotoxicol Teratol. 2005; 27: 221-229
        • Goldschmidt L.
        • Richardson G.A.
        • Cornelius M.D.
        • Day N.L.
        Prenatal marijuana and alcohol exposure and academic achievement at age 10.
        Neurotoxicol Teratol. 2004; 26: 521-532
        • Wu C.S.
        • Jew C.P.
        • Lu H.C.
        Lasting impacts of prenatal cannabis exposure and the role of endogenous cannabinoids in the developing brain.
        Future Neurol. 2011; 6: 459-480
        • Day N.L.
        • Leech S.L.
        • Goldschmidt L.
        The effects of prenatal marijuana exposure on delinquent behaviors are mediated by measures of neurocognitive functioning.
        Neurotoxicol Teratol. 2011; 33: 129-136
        • Varner M.W.
        • Silver R.M.
        • Rowland Hogue C.J.
        • et al.
        Association between stillbirth and illicit drug use and smoking during pregnancy.
        Obstet Gynecol. 2014; 123: 113-125
      10. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Substance Abuse and Mental Health Services Administration. Published September 2013. Accessed July 14, 2015.

        • Gioia C.J.
        • Sobell L.C.
        • Sobell M.B.
        • Simco E.R.
        Shorter and proximal Timeline Followback windows are representative of longer posttreatment functioning.
        Psychol Addict Behav. 2012; 26: 880-887
        • Vakili S.
        • Sobell L.C.
        • Sobell M.B.
        • Simco E.R.
        • Agrawal S.
        Using the Timeline Followback to determine time windows representative of annual alcohol consumption with problem drinkers.
        Addict Behav. 2008; 33: 1123-1130
        • Witkiewitz K.
        • Finney J.W.
        • Harris A.H.S.
        • Kivlahan D.R.
        • Kranzler H.R.
        Guidelines for the reporting of treatment trials for alcohol use disorders.
        Alcohol Clin Exp Res. 2015; 39: 1571-1581