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 |
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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
- Data Resource Center for Child and Adolescent Health (DRC): A project of the Child and Adolescent Health Measurement Initiative, the DRC is a national data resource providing easy access to children’s health data on a variety of important topics, including the health and well-being of children and access to quality care.
- HRSA Federally Available Data (FAD) Document
- National Center for Health Statistics (NCHS) Data Brief. 2018.
- National Vital Statistics System
- Title V Information System (TVIS) National Performance Measure Search: This search displays the national baseline data, the State baseline data, and the objectives that the State determined for the measure. Most recent year national and state data are also available by various demographic stratifiers including race/ethnicity, income, insurance type, and urban/rural geography.
1. Accelerate with Evidence—Start 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
Evidence-Informed |
Evidence-Based |
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Mixed Evidence |
Emerging Evidence |
Expert Opinion |
Moderate Evidence |
Scientifically Rigorous |
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Smoking in the Household
Evidence-Informed |
Evidence-Based |
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Mixed Evidence |
Emerging Evidence |
Expert Opinion |
Moderate Evidence |
Scientifically Rigorous |
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Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub
Emerging:
- Text Messaging Service (OK; 2016)
- Maternal Risk Assessments (OH; 2023)
Promising:
- Comprehensive Pregnancy Health Education for Teens (AZ; 2019)
- Justice Involved Pregnant and Parenting Populations (NY; 2019)
Best:
- Counseling Services (National; 2020)
- Social Marketing Campaign (VA; 2019)
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 Tools—Lead 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:
- Intrapersonal. Theory of Planned Behavior, Health Belief Model, Stages of Change Model.
- Interpersonal. Social Cognitive Theory, Social Norms Theory.
- Community. Diffusion of Innovation, Ecological Models.
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 Tools—Move 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
- Find field-based resources focused on smoking in pregnancy and the household relevant to Title V programs in the MCH Digital Library.
- Search the Established Evidence database for peer-reviewed research articles related to strategies for reducing smoking .
- Request Technical Assistance from the MCH Evidence Center
- MCH Evidence Center Frameworks and Toolkits:
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.