Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

/tools/strategies/

Evidence Tools
Smoking

Introduction

This toolkit summarizes content from the Smoking in Pregnancy and Smoking in the Household Evidence Accelerator, and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

From the MCH Block Grant Guidance. Women who smoke during pregnancy are more likely to experience a fetal death or deliver a low birth weight baby. Adverse effects of parental smoking on children have been a clinical and public health concern for decades. Children exposed to environmental tobacco smoke have an increased frequency of ear infections; acute respiratory illnesses and related hospital admissions during infancy; severe asthma and asthma-related problems; lower respiratory tract infections; and SIDS.

Goal. To decrease the number of women who smoke during pregnancy and to decrease the number of households where someone smokes.

Note. Access other related measures in this Population Domain through the Toolkits page.

 

Overview: Read a summary of the issue related to Title V

The following trends emerged from analysis of peer- reviewed evidence. While findings might not completely align with your ESM, they can serve as ideas for future expansion.

Key Findings for Smoking in Pregnancy

Setting Intervention Type Intervention Strategy Evidence Rating
Clinic-based

Incentive

Financial incentives and vouchers to enhance smoking abstinence in a multicomponent standard smoking cessation package for pregnant women  Moderate evidence 
Counseling Enhanced adult smoking cessation program with motivational interviewing targeting pregnant women  Moderate evidence
Multicomponent psychosocial Multicomponent standard smoking cessation package for pregnant women embedded into Women, Infants, and Children (WIC) prenatal care clinic services Moderate evidence
Pharmacotherapy NRT + multicomponent standard smoking cessation package for pregnant women Moderate evidence
Health care provider training Health care provider training including maternity staff, administrators and smoking cessation counselors; or midwives  Moderate/Emerging evidence 
Automatic initiation of smoking cessation program Biochemical verification or electronic health records used to automatically opt in pregnant smokers to smoking cessation program Emerging evidence
Feedback Indoor air quality measurement feedback + multicomponent standard smoking cessation package for pregnant women  Emerging evidence
Exercise Exercise + multicomponent standard smoking cessation package for pregnant women Evidence against
Electronic Health education Standard motivational text messages added to support standard multicomponent smoking cessation program for pregnant women  Moderate evidence
Health education + Incentives Standard smoking cessation text messages specific to pregnant women + monetary incentives/gift vouchers to complete follow up at 1, 3 and 6 months Moderate/Emerging evidence
Health education + Social support Standard smoking cessation text messages with limited interaction for support to pregnant women + social support for quitting via a “quitpal”  Emerging evidence
Counseling Telephone, internet platform or text application to deliver individual counseling support for smoking cessation  Emerging evidence
Counseling + Incentives + Feedback Web-based, incentive-based contingency management program + phonedelivered cessation counseling + feedback based on breath CO results Emerging evidence
Journaling Online journaling platform to support smoking cessation for pregnant women  Emerging evidence
Community-based Multicomponent psychosocial Home visitors use smoking cessation strategies (education, motivational interviewing, referral to smoking cessation resources) during home visiting program visits Moderate evidence
Counseling Trained midwives to provide smoking cessation counseling with standard smoking cessation package to pregnant women and household members in home-based care Emerging evidence
Social support Using voluntary community members as community support workers to deliver in-person, culturally appropriate multicomponent smoking cessation package to pregnant women Emerging evidence
Population-based Policy National, state or local anti-smoking campaigns or regulations to increase smoke-free environments Mixed evidence

Key Findings for Smoking in the Household

Setting Target Audience Intervention Type Intervention Strategy Evidence Rating
Community-based Well-child  Multicomponent counseling-based intervention In-person counseling (A) + educational materials (B) + telephone counseling/ follow-up (C) + home visits (D) Moderate evidence 
In-person counseling (A) + educational materials (B) + telephone counseling/ follow-up (C) + home visits (D) + cotinine and/or SHSe (air quality) feedback Emerging evidence
In-person counseling (A) + educational materials (B) + home visits (D) + air purifiers in the home (H) Emerging evidence
Multicomponent education-based intervention In-person counseling (A) + home visits (D)  Emerging evidence
Community-based Ill-child Multicomponent counseling-based intervention In-person counseling (A) + educational materials (B) + home visits (D) Mixed evidence 
In-person counseling (A) + telephone counseling/follow-up (C) + home visits (D) + cotinine level and/or SHSe (air quality) feedback (E) + NRT and/or information/access (F)  Emerging evidence 
Clinic-based Well-child Multicomponent counseling-based intervention In-person counseling (A) + educational materials (B) Mixed evidence
In-person counseling (A) + educational materials (B) + telephone counseling/ follow-up (C) Mixed evidence
In-person counseling (A) + educational materials (B) + NRT and/or information/ access (F) + EHR prompt and referral (J) Emerging evidence
In-person counseling (no additional components) intervention In-person counseling (A) Moderate evidence/ Mixed evidence
Multicomponent education-based intervention Educational materials (B) + cotinine levels (air quality) and/or SHSe feedback (E) +/- telephone counseling/follow-up (C) Emerging evidence 
Clinic-based Ill-child Multicomponent counseling-based intervention  In-person counseling (A) + educational materials (B) + telephone counseling/ follow-up (C) Emerging evidence
In-person counseling (no additional components) In-person counseling (A)  Emerging evidence
Multicomponent education-based intervention Educational materials (B) + telephone counseling/follow-up (C) + cotinine level and/or SHSe (air quality) feedback (E) Emerging evidence/ Mixed evidence

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerator:

Number of women who report smoking during pregnancy (NVSS); Number of children, ages 0 through 17, who are reported by a parent to live in a household where there is household member who smokes (NSCH)

Denominator:

Number of live births (NVSS); Number of children, ages 0 through 17 (NSCH)

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Maternal, Infant, and Child Health (MICH) Objective 10: Increase abstinence from cigarette smoking among pregnant women. (Baseline: 93.5% in 2018, Target: 95.7%); Related to Tobacco Use (TU) Objective 15: Increase smoking cessation success during pregnancy among females. (Baseline: 20.2% in 2018, Target 24.4%); Related to TU Objective 19: Reduce the proportion of children, adolescents and adults exposed to secondhand smoke. (Baseline: 25.5% in 2013-16 (age adjusted to the year 2000 standard population), Target: 17.3%)

DATA SOURCES

National Vital Statistics System (NVSS); National Survey of Children's Health (NSCH)

MCH POPULATION DOMAIN

Women/Maternal Health, Perinatal/Infant Health, Child Health, and/or Adolescent Health

MEASURE DOMAIN

Health Behavior

Data Sources: Learn more about the issue and access the data directly


1. Accelerate with EvidenceStart with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Smoking in Pregnancy

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

 

Smoking in the Household

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

 

 

 

 

 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Key Findings and Emerging Issues: Read more from the literature

KEY FINDINGS

  • There is limited rigorous evidence about effective interventions to increase dental visits during pregnancy.
  • Two studies evaluating education or counseling interventions targeting pregnant women lack sufficient evidence to assess effectiveness in increasing the receipt of dental visits.
  • Due to identifying only one study related to state policy regarding the receipt of dental visits by pregnant women, conclusions cannot be drawn regarding the effectiveness of Medicaid interventions.

IMPLICATIONS

  • Rigorous evaluations of the effectiveness of interventions to increase the receipt of dental visits during pregnancy are needed.
  • Although experts have recommended interventions targeting patients, providers, and communities or states, systematic research is needed to assess both implementation and outcomes.

EVIDENCE ANALYSIS REPORTS

  • Percent of women who smoke in pregnancy
    • Evidence Review: Brief. A summary of report methodologies, results, key findings, and implications.
    • Evidence Review: Full Report. A critical analysis and synthesis of the effectiveness of strategies that might be applied to address NPM 14 to serve as the foundation for accountability across all states and jurisdictions. The evidence review uses a structured approach to evaluate the available empirical evidence and to draw conclusions for MCH programs based on the best available evidence.
  • Percent of children, ages 0 through 17, who live in households where someone smokes
    • Evidence Review: Brief. A summary of report methodologies, results, key findings, and implications.
    • Evidence Review: Full Report. A critical analysis and synthesis of the effectiveness of strategies that might be applied to address NPM 14 to serve as the foundation for accountability across all states and jurisdictions. The evidence review uses a structured approach to evaluate the available empirical evidence and to draw conclusions for MCH programs based on the best available evidence.
  •  Read about the evidence analysis report methodology | You can also access the full set of Evidence Analysis Reports.

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

 

2. Think Upstream with Planning ToolsLead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Many of the strategies with the strongest evidence supporting them are those that are more clinical or those based in enabling services rather than those that can be easily implemented by Title V agencies. As we look to “move down the MCH Pyramid” with less emphasis on direct services (disease management) to an increased focus on public health services and systems (primary and secondary prevention and population health management), we are often challenged in identifying evidence-based/informed practices to meet the new focus of the transformed MCH Block Grant.1 

Where possible, we try to align evidence-based strategies (“what works”) to activities that can be adopted by Title V agencies (“what we can do”). However, there is often the need for adaptation and innovation.2 Sometimes it’s difficult to identify the role a Title V agency could take in implementing and/or adopting such evidence-based/informed strategies.

When deciding how best to implement a strategy that seems outside the typical role of Title V, it may be helpful to consider activities that support the strategy while aligning with activities that Title V is charged with,3 such as:

  • Assessing ongoing community needs: Title V can use data collected by programs, evaluations, or more formal needs assessment findings to see if the strategy could address identified service gaps or build equity in access and positive health outcomes.
  • Informing and educating the public: Title V can provide educational/outreach materials to families/consumers to advance the strategy through training and peer support.
  • Engaging community partners and families: Title V can serve as the convener for those groups/organizations that can implement the strategy.
  • Integrating systems of public health. Title V can help ensure access, sharing of resources, and coordination of services to assure maximum impact of the strategy (coordinating the public health approach, health care, and related community services).
  • Educating the MCH workforce (building capacity): Title V can partner with groups actually conducting this strategy in order to train MCH and healthcare professionals in strategy implementation.
  • Developing public health policies and plans: Title V can support adoption of the strategy at a state level.
  • Ensuring quality improvement and promoting applied research: Title V can collect data and evaluate programs in the state/jurisdiction that are implementing this strategy to build the evidence base and promote rapid innovation.

SDOH and Health Equity Considerations: Identify ways to advance health for all

Not all strategies are effective for all population groups, and the evidence is often lacking in terms of using specific strategies to advance health equity.

Once the evidence has been considered for what works generally, it is important to understand if a specific strategy will work for targeted populations, especially those most affected by health disparities. Implementation science helps to translate the science into programs and policies that impact health outcomes in light of multiple social determinants. In finding strategies to meet needs, we have the ability to adopt and/or adapt what works.

ADOPT Strategies to Meet Needs

In choosing to adopt an existing strategy based on existing science and practice, we should consider:2

Is the study sample or population similar to our target audience?

  • ​Geography
  • Demographic characteristics
  • Culture, values, and preference
  • Health status
  • Other characteristics of interest 

Do we have the resources needed to implement?

  • ​Workforce capacity
  • Money
  • Time
  • Leadership 

Does our organization and the broader environment support the strategy? ​

  • Political support
  • Financial and legal support
  • Champions for intervention
  • Community norms and partnerships
  • Title V priority and jurisdiction
  • Favorable environment for change​​

Special Considerations: Tease out ways to zoom in on populations of focus

Adapt Strategies to Meet Needs

Not all strategies are effective for all populations. To adapt strategies to meet needs, we should consider:5

What about the existing strategy works? If we understand the key ingredients of a strategy, we can replicate and/or adapt the effective components. Looking at a strategy through a health behavior theory identifies key ingredients. Here are several to consider:

How does it work? Being specific about the underlying mechanisms can help us increase the impact. Developing a logic model with program actions, targets, outcomes, and moderators allows you track the process from action to outcome.

For whom does it work, and for whom does it not work? When we know who is and is not responding, we can make targeted adaptations to improve outcomes. Think about the program life cycle:

  • Precision. Understand what a strategy entails so you can go beyond “does it work,” to “what about it works” and “for whom does it work.”
  • Fast-cycle iteration. Incorporate new ideas as you go – what is working and what is not working.
  • Shared learning. Create a mechanism to share learning about success and failures.
  • Co-creation. Bring together multiple parties to create a mutually valued outcome.

In what contexts does it work? By evaluating the context in which a strategy is implemented, we can adapt it for other settings. The best way to ensure that a strategy is effective is to conduct a robust evaluation. The MCH Navigator’s Evaluation Spotlight provides trainings and resources related to the steps and standards for effective program evaluation.

3. Work Together with Implementation ToolsMove from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Implementation Resources: Use these field-generated resources to affect change

  • NPM 14 Transformation Tools (MCH Navigator and National MCH Workforce Development Center). Learning resources, implementation strategies, and links to the evidence base for the competencies needed to carry out NPM 14 activities.

References

Introductory References: From the MCH Block Grant Guidance

1National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2014.

Toolkit References: From the Evidence Accelerator

1,3 Brownson RC, Fielding JE, Green LW. Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research. Annual Review of Public Health 2018 39:1, 27-53.
2 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of State and Community Health. Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report
4,5 Adapted from IDEAS Impact Framework, Center on the Developing Child, Harvard University.
6 Hayden J. Introduction to Health Behavior Theory, Second Edition. Burlington, MA: Jones & Bartlett Learning. 2014.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.