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Strengthen the Evidence for Maternal and Child Health Programs

New: MCHbest strategies database for sample ESMs

Evidence Tools
MCHbest. NPM 14.1: Smoking in Pregnancy

MCHbest Logo paper cutout people holding a used cigarette

Strategy. Counseling

Approach. Provide counseling to reduce smoking during pregnancy.

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Overview. Research indicates that interventions using in-person or telephone-based counseling can be effective in reducing smoking during pregnancy. Counseling interventions are those which provide motivation to quit, support to increase problem solving skills, and may incorporate “transtheoretical” models of change. This includes interventions such as motivational interviewing, cognitive behavior therapy, other psychotherapies, relaxation, problem-solving facilitation, and other strategies.1

The Five A's of Smoking Cessation is considered the gold standard in cessation counseling: Ask - Advise - Assess - Assist - Arrange. The Five A;s is a brief counseling-based intervention, it can be combined wiht motivational strategies in a step-by-step process.2

Evidence. Emerging evidence. Initial research shows primarily positive results for this strategy, but further research is needed to confirm effects. The strategy of using counseling to reduce smoking during pregnancy has been tested more than once and results trend positive overall. Access the peer-reviewed evidence through the MCH Digital Library. (Read more about understanding evidence ratings).

Target Audience. Pregnant women/health care providers.

Outcome. Smoking cessation during pregnancy. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link above and read the "Intervention Results" for each study.

Examples from the Field. Access descriptions of current ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

North Carolina is collecting data on the number of women who receive tobacco cessation counseling by a care manager and/or home visitor. Texas is tracking the number of health care professionals trained on tobacco prevention and cessation interventions as it relates to the risks associated with maternal and infant exposure to tobacco.

The Role of Title V. Title V agencies can support cessation counseling for pregnant women by:

For suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies.

Sample ESMs. Using the approach “Provide counseling to reduce smoking during pregnancy,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework:

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of pregnant women who receive counseling during prenatal clinic visits and/or home visits to quit smoking.
  • Number of pregnant women who receive individualized, motivational text messages to quit smoking.
  • Number of providers/educators/home visitors trained to deliver tobacco cessation counseling to pregnant women.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percent of pregnant women who report high levels of satisfaction with the counseling received.
  • Percent of providers referring pregnant women for tobacco cessation counseling services .

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of pregnant women who received counseling and report increased knowledge of the adverse effects of smoking during pregnancy.
  • Number of pregnant women who received counseling and report new or positive attitudes about quitting smoking due to the support received.
  • Number of pregnant women who received counseling and report a readiness to quit smoking because of counseling.
  • Number of pregnant women who received counseling and report using a referral for additional tobacco cessation services.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percent of pregnant women who received counseling and quit or reduce smoking.
  • Percent of women who received counseling and remain smoke-free into the postpartum period.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4).

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


1 Chamberlain C, O-Mara-Eves A, Porter J, Coleman T, Perlen SM, Thomas J, McKenzie JE. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews 2017, Issue 2. Art No.: CD001055.

2 Fiore MC, Jaen CR, Baker TB, Bailey WC, BenowitzNL, Curry SJ, et al. Treating tobacco use and dependence: 2008 Update. Clinical Practice Guidelines. 2008. U.S. Department of Health and Human Services, Public Health Service. Rockville, MD.

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.