High Impact Therapy for Pregnant Smokers

Smoking during pregnancy was reported for 12% of women who gave birth in 2000, according to the Centers for Disease Control and Prevention.  Cigarette smoking while pregnant increases the risk of pregnancy complications, premature delivery, low-birth-weight infants, stillbirth, and sudden infant death syndrome (SIDS), according to the 2004 Surgeon General's Report.  Smoking rates are highest in pregnant women who are less educated and living below the poverty level.  One out of three women receiving obstetric care through publicly funded prenatal clinics is a smoker, and 60-80% of these women continue to smoke during pregnancy. Since smoking occurs in a larger interpersonal context and is just one in a constellation of interpersonal problems, pregnant smokers are particularly difficult to treat.

High Impact Therapy for Pregnant Smokers is a manualized, single 90-minute session of intensive psychotherapy followed by bi-monthly telephone calls after delivery designed to help clients recognize the links between smoking behavior and mood and relational issues.  The intervention is delivered by a mental health counselor using a Motivational Interviewing (MI) style to (1) rapidly engage the client in treatment, (2) determine the client's readiness to quit, (3) identify potential psychological or social problems that might be barriers to quitting, and (4) set a quit date.  MI is a nonconfrontational style of counseling designed to help a client explore and resolve ambivalence around changing a particular behavior, such as smoking.  Important to the intervention's success is a high degree of interpersonal engagement between therapist and client and the client's recognition that smoking can be a way of coping with emotional distress.  High-risk situations that may trigger a relapse to regular smoking, such as holidays, financial problems, family stress, and feeling fat, are discussed along with coping strategies to prevent relapse. The counseling session takes place after the client's initial prenatal clinic visit and is followed by bimonthly telephone calls from the therapist during pregnancy and monthly telephone calls for the first 6 months after delivery.  Telephone follow-up calls were made to review the client's reaction to the in-person psychotherapy session and assess the client's current adaptive functioning and smoking status. The therapist determines whether any identified comorbid conditions have improved or worsened and what positive or negative feelings the client might have for the therapist after the in-person psychotherapy session. If the client is still ambivalent about smoking cessation, the therapist attempts to reengage the client to stop smoking using the same MI approach that was used in the original psychotherapy session. 

Training: A total of 40 hours of in-service training is required for the interventionists.  This total includes 16 hours of initial group training and 24 hours of group clinical supervision focused on review of clinical cases. 

Program Implementation: Implementation requires 90 minutes for the individual face-to-face counseling session and 10-30 minutes for each follow-up telephone session. 

The intervention is targeted to smoking, pregnant women (30 weeks gestation or less) who are 18 years and older.

The intervention is suitable for implementation in either hospital- or community-based prenatal clinics.

Interventionists should be licensed professionals with at least a master's degree in any area of mental health (e.g., licensed master's-level counselor, social worker, or clinical psychologist; predoctoral clinical psychology intern under the supervision of a licensed clinical psychologist).  For information on training costs, please contact the developer.

The following materials are required: 
-- High Impact Therapy for Pregnant Smokers Treatment Manual
-- Smoking Cessation Educational handout for clients (English and Spanish versions) 
-- Counseling/Interviewing Packet

A randomized clinical study evaluated the effects on smoking abstinence which involved one-hundred-five pregnant women who smoke and were randomly assigned to one of two conditions: usual care only or usual care plus the High Impact Therapy for Pregnant Smokers interevention program.  The usual care group was given an educational booklet and a personalized quit message at every prenatal visit.  The intervention program consisted of a 90-minute face-to-face psychotherapy session with a mental health counselor and attempted bimonthly telephone follow-ups during pregnancy.  The sample was 66% Hispanic, 17% Caucasian, and 11% African American with an average age of 26.1 years (range=18-42 years) at baseline. The majority of the participants (77%) had one or more children at the time of study entry, 61% were unemployed, 54% had less than a full high school education, 71% were between 12 and 24 weeks gestation (range=8-30 weeks gestation), 60% were unmarried, and 49% reported a household income of $15,000 per year or less.

Self-reported smoking status confirmed by a carbon monoxide breath test was obtained at baseline, end of pregnancy (defined as 36 +/- 2 weeks gestation), and 6 months postpartum. Although a carbon monoxide reading of <8ppm is typically used to define a nonsmoker, none of the participants who reported smoking abstinence for the prior 7 days at the end of pregnancy or at the 6 month postpartum followup had carbon monoxide readings >4ppm, and there were no cases of reported smoking abstinence contradicted by a positive carbon monoxide breath test.

A clinical interview at baseline obtained demographic information and medical, depression, drug, and smoking history. In addition to the smoking history, participants were evaluated using the following four measurement instruments:

-- Cigarette Smoking Timeline Followback: a semistructured, calendar-based interview that asks clients to retrospectively estimate their daily cigarette smoking for the past 30 days
-- Readiness to Change: participants identify one of three statements that fit them best
-- Smoking Self-Efficacy (confidence in ability not to smoke): nine items that describe various contexts in which smoking would likely take place are rated on a confidence scale of 1 (not at all confident) to 5 (extremely confident)
-- Fagerstrom Smoking Tolerance scale: eight-item instrument from which one item was used for this study: "How soon after you wake do you smoke your first cigarette?" (within or after 30 minutes) 

There were no significant differences between conditions for any of the baseline smoking variables.  Smoking status was obtained from 100% of the sample at the end of pregnancy and from 82% at 6 months postpartum.

• Participants assigned to the intervention group had higher reported smoking abstinence rates at the end of pregnancy compared with those assigned to the usual care group only (28.3% vs. 9.6%, respectively; p=.015). The highest abstinence rates were among participants younger than 25 years of age and whose gestation was less than 18 weeks at the time of study entry (60% intervention group vs. 0% usual care group only; p=.002).

• There were no significant differences between conditions in reported smoking abstinence rates at the 6-month postpartum assessment.