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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Smoking During Pregnancy.

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Strategy. Policy (Pregnancy)

Approach. Roll out national, state, or local anti-smoking campaigns or regulations to increase smoke-free environments

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Overview. Smoke-free regulations have the potential to improve birth outcomes by decreasing smoking prevalence among pregnant women and/or reducing secondhand smoke exposure during pregnancy. However, the effectiveness of federal, statewide, and corporate policies, regulations, and programs remains unclear, due in large part to the difficulty in determining causal relationships. Population-wide activities and policies—such as smoking bans, tobacco tax increases, sales restrictions, mass media anti-smoking campaigns, and graphic health warnings on cigarette packaging—have health benefits to the general population. However, their effects on maternal smoking and neonatal outcomes seem to be limited.[1,2,3,4,5,6] Further research is needed to determine the effects of media campaigns and other policy interventions.

Evidence. Mixed Evidence. Strategies with this rating have been tested more than once with results that sometimes trend positive...

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Data on campaign implementation and reach
  • Engagement survey data on partnership collaboration
  • Data on public awareness and knowledge

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Morbidity Reduction. This strategy addresses factors that can decrease the incidence or prevalence of diseases and illnesses.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy or aligned components.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

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

  • Number of antismoking campaigns for regulations implemented at national, state, for local levels. (Measures policy and program initiation)
  • Number of smoke-free environments (e.g., workplaces, public spaces) established through regulations. (Evaluates environmental changes achieved)

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

  • Percent of antismoking campaign messages that are evidence-based. (Measures quality of content)
  • Percent of smoke-free regulations that are adequately enforced and monitored for compliance. (Assesses strength of policy implementation)

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

  • Number of partnerships formed between public health, healthcare, and community organizations to support campaigns and regulations. (Measures multisectoral collaboration)
  • Number of studies commissioned to evaluate implementation and outcomes of campaigns and regulations. (Evaluates commitment to evidence-informed policymaking)
  • Number of localities for organizations that adopt model anti smoking policies based on campaign messages and regulatory examples. (Measures diffusion and scaling of efforts)
  • Number of smoking-related illnesses and deaths prevented for reduced after implementation of campaigns and regulations. (Evaluates impact on population health burden)

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

  • Percent of campaign development process that involve representatives from a variety of communities. (Measures involvement of multiple perspectives in program design)
  • Percent of smoke-free regulations implemented in areas with high smoking prevalence and tobacco-related health challenges. (Evaluates focus of policies)
  • Percent of individuals who smoke who report motivation to quit for reduced consumption following exposure to campaigns for regulations. (Measures impact on behavior change precursors)
  • Percent of public places and spaces that are in compliance with smoke-free regulations. (Evaluates creation of health-promoting environments)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

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

References

1 Bartholomew KS, Abouk R. The effect of local smokefree regulations on birth outcomes and prenatal smoking. Maternal and Child Health Journal 2016;20:1526-38.

2 England L, Tong VT, Rockhill K, Hsia J, McAfee T, Patel D, Rupp K, Conrey EJ, Valdivieso C, Davis KC. Evaluation of a federally funded mass media campaign and smoking cessation in pregnant women: a population-based study in three states. British Medical Journal Open 2017 Dec 19;7(12):e016826. doi: 10.1136/bmjopen-2017-016826.

3 Hankins S, Tarasenko Y. Do Smoking Bans Improve Neonatal Health? Health Services Research 2016 Oct;51(5):1858-78. doi: 10.1111/1475-6773.12451. Epub 2016 Feb 3.

4 Havard A, Tran DT, Kemp-Casey A, Einarsdóttir K, Preen DB, Jorm LR. Tobacco policy reform and population-wide antismoking activities in Australia: the impact on smoking during pregnancy. Tobacco Control 2018 Sep;27(5):552-559. doi: 10.1136/tobaccocontrol-2017-053715. Epub 2017 Aug 4.

5 Hall, J., Cho, H. D., Guo, Y., Maldonado-Molina, M. M., Thompson, L. A., Shenkman, E. A., & Salloum, R. G. (2019). Association of Rates of Smoking During Pregnancy With Corporate Tobacco Sales Policies. JAMA pediatrics, 173(3), 284–286. https://doi.org/10.1001/jamapediatrics.2018.4598

6 Tennekoon V. S. B. W. (2023). Effects of Purchase Restrictions on Smoking During Pregnancy: An Analysis of U.S. Birth Records. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 25(5), 882–888. https://doi.org/10.1093/ntr/ntac220

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.