Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low
birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in
high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries.
To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.
Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with
allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy.
Data collection and analysis
Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted
in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS. Main results
Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking
abstinence in late pregnancy.
In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk
ratio (RR) 1.44, 95 confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16
studies; average RR 1.35, 95 CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided
in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study;
RR 1.15, 95 CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether
interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies;
average RR 1.06, 95 CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10
studies; average RR 1.76, 95 CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95 CI 1.00 to
1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95 CI 1.23 to 3.96), but not in the longer term. In
other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were
Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95 CI 1.84
to 7.23) and an alternative intervention (one study; RR 4.05, 95 CI 1.48 to 11.11).
Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other
strategies, such as counselling (two studies; average RR 4.39, 95 CI 1.89 to 10.21), but the effect was unclear when compared with
a less intensive intervention (two studies; average RR 1.19, 95 CI 0.45 to 3.12).
The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95 CI 0.64 to 3.59) or
less intensive interventions (two studies; average RR 1.50, 95 CI 0.97 to 2.31).
Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95 CI 1.01 to 2.19), but the
effect was unclear in a single trial of support provided by partners.
Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking
in late pregnancy, and reduce low birthweight and preterm births.