7.11 Smoking cessation and pregnancy

Last updated: October 2016 

Suggested citation: Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.11 Smoking cessation and pregnancy. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-11-smoking-cessation-and-pregnancy

Tobacco use poses a significant threat to the health of pregnant women and their babies. Smoking is one of the most prevalent preventable causes of low birthweight, preterm birth, and perinatal death.1 Quitting can reduce the risk of adverse outcomes for women and for their babies; therefore it is an important and worthwhile goal. Women are more likely to quit smoking during pregnancy than at any other time of life. They also experience higher levels of social and family support for quitting and they have greater contact with the healthcare system.1,2

7.11.1 Health risks of smoking during pregnancy and the benefits of quitting

The harmful effects of smoking on the health of women and their babies are covered in Chapter 3, sections 3.7 and 3.9, Chapter 4, Section 4.11 and Chapter 9, Section 9.5. The benefits of quitting during pregnancy are outlined in Section

7.11.2 Rates of smoking during pregnancy

In 2013, 11.7% of Australian women smoked during pregnancy. Just over one in ten women (11.3%) reported smoking during the first half of their pregnancy, and 8.6% reported smoking during the second half. This reduction is mostly due to women quitting during early pregnancy, but a small proportion comprise women who took up smoking later in pregnancy. 3 A longitudinal study in NSW found that most women who smoked during their first pregnancy continued to smoke in their second, even those who experienced poor outcomes.4 Smoking during pregnancy and social disadvantage

(See also Chapter 1, Section 1.10 and Chapter 9, Section 9.5)

Smoking during pregnancy is more common among women who: have socioeconomic disadvantages; do not have partners or who have problems in their interpersonal relationships; have higher stress and poorer adaptive functioning; have depression, substance use disorders, or other psychiatric disorders; have less social support; have limited education; have prior children; live with other smokers or have a partner who smokes; and engage in other health risk behaviours.1, 5-13 Women who smoke during pregnancy are also significantly more likely to drink alcohol, compounding their risk of poor pregnancy outcomes.14 Disadvantaged women may also be more likely to take up smoking during pregnancy or in the early postpartum period,15 and be less likely to quit and more likely to start smoking in their second pregnancy.4

In 2013, almost half of Aboriginal and Torres Strait Islander mothers reported smoking during pregnancy compared with about one in 10 non-Indigenous women. Younger women are more likely to smoke during pregnancy than older women: more than one third of pregnant women under 20 reported smoking in 2013.3 Not attending prenatal classes and experiencing stressful events before or during pregnancy are associated with smoking.16

A sample of disadvantaged women in the US reported that being informed of smoking risks, maintaining goal-oriented thoughts, focusing on their concerns about the baby's health, and receiving positive social support from families and friends helped them to successfully cope with post-pregnancy cravings and relapses.17

7.11.3 Predictors of failure to quit during and post pregnancy

About 20 to 30% of women quit after they become pregnant, but about half relapse within six months after their delivery, especially if their partner smokes or they live with other smokers. Within a year after giving birth, about 70% take up smoking again.18 A 2016 systematic review examined whether women who receive cessation interventions during pregnancy are able to successfully quit and maintain long-term abstinence. Results showed that among the women who were offered some sort of smoking cessation intervention, 13% were able to quit sometime during the pregnancy and remain abstinent when they delivered. The other 87% of women either tried to quit and were unsuccessful, or did not attempt to quit. Of the 13% that did quit, almost half (43%) started smoking again by six months postpartum, highlighting the need for sustained and effective cessation support after delivery.19

There are a number of factors that consistently predict successful quitting among women in the perinatal period (i.e., the weeks immediately before and after birth), including having a good understanding of the health benefits of cessation, strong concern about the effects of smoking on their child’s health, insisting on a smokefree home and environment, strong social support, developing negative attitudes about smoking, and perceiving quitting as a lifelong change.20, 21 Women who are more highly educated and less dependent on nicotine have higher odds of quitting during pregnancy.22 Breastfeeding for at least three months also seems to promote lower rates of smoking.23 A systematic review identified four factors that acted both as barriers and facilitators to a woman's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy, and appraisal of the risk of smoking.24

Factors that predict relapse during and post pregnancy are similar to those linked to not quitting at all. These include being highly addicted, depending heavily on cigarettes to manage stress, having insufficient resources for coping with childrearing, being exposed to secondhand smoke, having easy social access to cigarettes, having low self-esteem, having a partner who smokes or living with smokers, and having smoking-related weight concerns.18, 21, 25-27 Research in NSW highlighted a number of demographic factors that predict lower rates of cessation during pregnancy, such as having a higher number of previous pregnancies, being an Aboriginal person, and being a teenage mother.28 Qualitative research with adolescent mothers found that many no longer consider their smoking to negatively affect their infants after they give birth, even if breastfeeding.29 Young women in Western Australia also cited fear of being left out as a barrier to smoking cessation.30 A large-scale study in the US found that women who experienced intimate partner violence had significantly higher rates of smoking before pregnancy and were less likely to quit during pregnancy than women who did not have such experiences.31 Motivation to stay quit can differ between pregnancy and post-birth.32, 33 For some pregnant women, quitting is a temporary suspension of habit, rather than a permanent change.34

7.11.4 Factors that must be addressed in reducing smoking during and post pregnancy

Understanding and addressing the factors that increase smoking relapse risk is critical for developing more effective interventions. Health professionals play an important role in identifying women at risk of relapse during pregnancy, at birth (hospital care) and in the early postpartum weeks (maternal and child healthcare) and providing tailored support. Part of this support includes encouraging partners to be smokefree, and supporting the establishment of smokefree homes.38 Having a partner smokes is one of the strongest predictors of continued smoking among new mothers.39 Biological, psychological, and social factors that influence a woman’s likelihood of quitting and remaining quit should be addressed as part of routine care during pregnancy and post-partum.5, 40

Addressing and managing mental health factors such as maternal mood, stressful life events, and postpartum depression can be important to the success of smoking cessation during and post pregnancy.8, 41 There is some evidence that maternal smoking during pregnancy predicts parenting stress in infancy.42 Screening and treatment of depressive symptoms during pregnancy and postpartum is one possible method of reducing continued smoking, relapse and uptake.15, 3541, 43 One study suggests that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment, both in terms of improved smoking abstinence and reduced depressive symptoms.44,

Further research is needed to develop suitable interventions for pregnant smokers with substance use disorders.12, 45 Such women often have higher rates of smoking, are heavier smokers, and are less likely to quit during pregnancy. Continued smoking is associated with depression, anxiety and lower self-worth in this group.46 Opioid-dependent pregnant women show a particularly high prevalence of smoking and are at greater risk for additional adverse health effects for themselves and their babies.47

Concern about weight gain following cessation can be a barrier to successful quitting.2748, A study in the US found that women who quit smoking during pregnancy do gain a considerable amount of gestational weight; however, the health benefits of smoking cessation to both the mother and baby outweigh the disadvantage of weight gain.49

Common myths regarding the risks of smoking during pregnancy should be addressed and corrected. For example, the argument that nicotine withdrawal during smoking cessation is more stressful to the foetus than continued smoking is not supported by evidence,50, 51 or that low birthweight babies are easier to deliver.

7.11.5 Interventions for reducing smoking during and post pregnancy

In 2013, the fifth update of a Cochrane review was published, which assessed the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. Findings showed that psychosocial interventions increased the proportion of women who stopped smoking in late pregnancy and reduced the number of low birthweight and preterm births. No adverse effects from the interventions were found, and in fact a small number of studies noted an improvement in women’s psychological wellbeing.52 The US Preventive Services Task Force (USPSTF) released its final recommendation statement in 2015, and similarly concluded that for pregnant women, behavioural treatments improve smoking cessation rates, improve infant birth weight, and reduce preterm birth.53

The Cochrane review found that the most effective intervention appeared to be providing incentives in an intensive format. Counselling, when combined with other strategies, was also effective. Feedback also appeared to help women quit, but only when compared with usual care and combined with other strategies. The effectiveness of health education alone was unclear, and the evidence for social support was mixed. Increasing the frequency and duration of the interventions did not appear to increase the effectiveness.52

The interventions appeared to be equally effective for women of low socioeconomic backgrounds, but there was insufficient evidence regarding their use with Indigenous or culturally diverse women. Almost all studies were conducted in high-income countries, limiting the broader generalisability of the findings. Studies in which the interventions became part of routine pregnancy care did not appear to help more women to quit, which the authors suggest indicates that there may be barriers to translating the evidence into practice.52

Since the Cochrane review, several other studies have supported the efficacy of financial incentives. A randomised controlled trial in the UK found that women who received routine care plus up to £400 of shopping vouchers for attending appointments and maintaining abstinence were significantly more likely to quit than those who received routine care alone.54 Another study in the UK that considered whether women might falsely report their smoking in order to obtain the incentives found that only a very small number (4%) of those enrolled lied on one or more occasions to gain vouchers.55 Research in the US also found that financial incentives contingent on smoking status increased abstinence rates, but changing the schedule to make higher values available early in the quit attempt did not lead to different rates of quitting. The usual schedule also increased foetal growth above the control condition, while the revised schedule did not.56 Another US study found that successful participation in an incentive-based cessation program for pregnant women was associated with significantly reduced odds of having a low birth weight infant.57 Incentives also appear to be effective for depression-prone pregnant and newly postpartum women in terms of achieving abstinence, and may also reduce the severity of postpartum depression.58 A 2015 review concluded that concluded that incentives combined with behavioural therapy appear to show the greatest promise for promoting cessation among pregnant women,59 and such incentives appear to be highly cost-effective.60 Public opinion about providing financial incentives during pregnancy is mixed, but tends to be more negative among women, which may be problematic for uptake.61,62

A number of other interventions for pregnant women have also been investigated. In Australia, quitlines provide support tailored for pregnant women through a free callback service. The support is available during pregnancy and postpartum. A 2013 Cochrane review concluded that, despite some encouraging findings, there was insufficient evidence to recommend routine telephone support for women accessing maternity services. Limited benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction.63 More recently, a randomised controlled trial in the US found that embedding a pregnancy-specific counselling protocol in a Quitline was effective in helping pregnant smokers quit and maintain abstinence postpartum.64 Pregnant and postpartum women are less likely to use telephone support if they have to initiate the contact.65

An approach that warrants further investigation involves applying a pre-conception counselling model, designed to reduce the risk of alcohol-exposed pregnancy, to smokers. Pharmacotherapy can be provided safely at this time.66 Although a study in Canada found that a bout of exercise is associated with a reduction in cravings and withdrawal among pregnant smokers,67 a large randomised controlled trial in England found that adding a physical activity intervention to behavioural smoking cessation support for pregnant women did not increase cessation rates at end of pregnancy.68 Text messaging 69 and internet-based interventions for pregnant smokers have shown promise in improving cessation outcomes.70 ‘Opt-out’ referral systems, whereby pregnant women who are smokers are automatically referred by healthcare professionals for cessation support, may be more effective than the traditional ‘opt-in’ method.71 There is increasing interest in, but limited trials of, interventions focusing on the partners of pregnant women.72

Along with individual-level strategies, government tobacco control policies can also prompt cessation among pregnant women. Research in the US found that low-educated pregnant women had the highest rates of smoking and were the most responsive to cigarette tax increases; therefore such taxes may be an effective population-level intervention to decrease disparities in smoking during pregnancy.73

Relapse prevention interventions during pregnancy and in the postpartum period are extremely important for the continued protection of maternal and child health. One study found that in neonatal intensive care settings, interventions that support mother-infant bonding during a newborn’s hospitalisation are associated with reduced rates of smoking relapse and prolonged duration of breastfeeding during the first eight weeks postpartum.74 Cognitive behavioural strategies, such as positive ‘self-talk’ and avoiding being around other smokers, may be helpful in preventing lapses.75 As discussed previously, smokefree homes are important in supporting cessation.76 There is a short-term increase in the proportion of smokefree homes following birth77 but such changes may be temporary. There is limited evidence on interventions that increase smokefree homes among new families. A systematic review concluded that comprehensive interventions that emphasise the effects of secondhand smoke on the family and encourage smokefree home environments, and that increase the motivation and confidence of family members to stay quit, could reduce relapse rates.25 Another review concluded that there is limited evidence regarding the success of interventions to reduce environmental tobacco smoke, and called for further research.78 A randomised trial in the US found that a behavioural counselling approach with under-served maternal smokers to help them achieve smokefree homes reduced children's tobacco smoke exposure and increased quit rates.79

Although pregnant women are advised to abruptly quit smoking to minimise health risks, cutting down on cigarette consumption is a commonly reported practice.80 Australian research found that more than two-thirds of women smokers in maternity hospitals preferred to stop smoking gradually.81 Women who are pregnant often receive mixed messages from health professionals about the benefits of cutting down as opposed to quitting smoking altogether.82 There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight83 and reduce preterm birth.84 Qualitative research in the UK explored the perspectives of women who chose to cut down during pregnancy. Reducing consumption was used as both a method of quitting and, for persistent smokers, a method of harm reduction. The women perceived cutting down as a positive behaviour change in often-difficult circumstances, but felt that health professionals condoned it. The authors suggest that cutting down in pregnancy, as an aid and an alternative to quitting, should receive greater recognition if healthcare and tobacco control policies are to be sensitive to the perspectives and circumstances of pregnant smokers.80 However, Australian85 and UK82 guidelines state that health professionals should be recommending complete abstinence to pregnant women in order to maximise health benefits. Role of pharmacotherapies

Research in Australian maternity hospitals found that almost half of women smokers cited medications, particularly nicotine replacement therapy (NRT) as their preferred method of quitting.81 NRT can be used by pregnant and breastfeeding mothers, however the risks and benefits should be explained by those providing the product and the clinician supervising the pregnancy should be consulted.86-88 Behavioural interventions among pregnant women benefit cessation and perinatal health, and are recommended as first-line treatments.89 NRT may be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking. If NRT use is recommended, intermittent-use forms (such as gum or spray) are preferred over continuous-delivery nicotine (patches) for pregnant or breastfeeding women, as outlined in the official ‘product information’ approved by the TGA.3890 This helps to avoid high levels of nicotine in the foetal circulation.59

A 2015 Cochrane review investigated the effectiveness of pharmacological interventions for smoking cessation during pregnancy. The authors concluded that there is weak evidence to suggest that using NRT with behavioural support for smoking cessation in pregnancy is effective; however, the authors note that findings should be interpreted with caution, due to the risk of bias in some of the studies. The review also concluded that there is no evidence that NRT has either a positive or negative impact on health outcomes for the mother or child.91

There is evidence that pregnant women are reluctant to use NRT1 although one trial found they were happy to be offered NRT as part of cessation advice.92 Healthcare providers may also be reluctant to provide NRT to pregnant women, despite known harms of continued smoking during pregnancy.93 One study has suggested that NRT patches deliver an inadequate dose of nicotine to aid smoking cessation during pregnancy.94 A large randomised controlled trial in France found that use of nicotine patches did not increase either smoking cessation rates or birth weights, even when the doses of nicotine were adjusted to match levels attained when smoking, and when higher than usual doses were used.95 Further research is also needed as to whether the use of NRT during pregnancy is a cost effective strategy.96

A 2014 review of human and animal studies concluded that there is insufficient evidence to recommend the use of varenicline and/or bupropion for smoking cessation during pregnancy,97 and a 2015 review concluded that the safety and efficacy of pharmacotherapy for use among pregnant women remains unclear.40 Similarly, the 2015 Cochrane review concluded that there was insufficient evidence regarding the use of bupropion, varenicline, or e-cigarettes to recommend their use during pregnancy.91 US research found that few women filled any prescription for a smoking-cessation pharmacotherapy during pregnancy or postpartum, but this increased with pregnancy complications and substance use.98 Role of treating health professionals

Health professionals and healthcare settings are in an excellent position to promote cessation among pregnant women, who are often highly motivated to quit. A Cochrane review of interventions for promoting smoking cessation during pregnancy states that ‘attention to smoking behaviour together with support for smoking cessation and relapse prevention needs to be as routine a part of antenatal care as the measurement of blood pressure’.7 This continues to be a key recommendation of guidelines for treating tobacco use and dependence among pregnant women.38,99 If possible, cessation interventions should be also be integrated into existing services that deal with sexual, reproductive, and child health.38

Early pregnancy represents an important time for first promoting cessation, as many women begin their contact with a variety of health professionals who will monitor their health during the perinatal period. However, pregnant smokers with high levels of social disadvantage can often be late to access antenatal care. Health professionals involved with pregnant women and their families at any stage of pregnancy and postpartum should ask about tobacco use, provide education about the risks of smoking and secondhand smoke, and encourage and support their efforts to stop smoking. 

However, opportunities to intervene with pregnant women are often underutilised. Although most pregnant women are asked about their smoking, appropriate advice, intervention, and follow-up can be lacking.78 Research suggests that the proportion of pregnant women being advised of the risks of smoking and given advice to stop by antenatal health professionals ranges from 40–60%.100 Less than half of smokers in two large Australian maternity hospitals reported that their health professionals discouraged smoking during pregnancy.81 Similarly, surveys carried out before and after the implementation of cessation guidelines in Australia found that, despite an increase over time, half of smokers still failed to receive the full complement of advice and support.101 A large survey in the US in 2012 found that, compared with 1998, ob-gyns were less likely to adhere to the 5As smoking cessation guidelines.102 Midwives tend to deliver interventions at a higher rate than doctors,103 and training midwives to deliver the 5As can promote higher reduction and cessation rates among pregnant women.104  

While asking about smoking status during consultations and encouraging and supporting quitting is part of national guidelines in a number of countries, including Australia,38 some health professionals continue to find discussion of smoking behaviour with pregnant women difficult.78 Pregnant women are often not routinely asked about their smoking by each of their health professionals, due to concerns about damaging the relationship, time constraints, and differences between professional groups.78 A study in the US found that time constraints and documentation issues were major barriers to implementing the 5As with pregnant and post-partum women.105 Implementing clinic systems designed to increase the assessment and documentation of tobacco use almost doubles the rate at which clinicians intervene with their patients who smoke and results in higher rates of smoking cessation.106 Other barriers can include self-perceptions of limited skills and knowledge about smoking cessation; lack of staffing and educational materials; and pessimism about the effectiveness of what they do provide.78 Health professionals also cite the association between maternal smoking and social disadvantage as a considerable barrier to addressing and supporting cessation.107

Pregnant women report some dissatisfaction with the content and clarity of the advice provided to them. The advice and recommendations given by health professionals often varies regarding the provision of cessation counselling, self-help materials, information about NRT, and referral to other specialist services. Some advice is contradictory, particularly regarding the recommendation of quitting smoking versus cutting down (see Section 7.11.5). The manner in which information is provided is important and may affect a woman’s willingness to consider stopping smoking.78 Interviews with a small number of socially disadvantaged pregnant women in Australia revealed that they often felt that advice and support to quit from health professionals was overly didactic and superficial.108 New Zealand research found that compared with informational approaches, cessation messages that evoke strong affective responses (e.g., that depict unwell or distressed children) capitalise on the dissonance many women feel when smoking while pregnant and stimulate stronger consideration of quitting.109  

Given the time and resource constraints on most health professionals and antenatal services, the brief intervention ‘5As’ approach discussed in Section 7.10 is a workable, minimal approach for these settings.38 This approach has been implemented in a number of antenatal services locally and statewide.110-114 It includes integrating a record of 5As interventions into medical records of pregnancy as part of routine practice, training health workers, raising the issues in early consultations, providing printed information on smoking and pregnancy, reviewing quitting intentions, and discussing action at each subsequent consultation.111, 113, 114 In the antenatal setting, there is opportunity for following up with women who were initially unsure about quitting or not ready. Ongoing follow-up can also help to identify women who may have previously concealed their smoking.115  

Intervention should provide positive, non-judgemental encouragement to quit that addresses women’s concerns about stopping smoking, and include referral to the Quitline or other services able to provide tailored support for pregnant women.7, 111, 113  Referral to services that address common predictors of relapse (such as treatment for depression, relationship counselling, etc.) may also be warranted. Support and interventions with smoking partners should also form part of routine care.116 Specialist smoking cessation services for pregnant women

There is limited research on the use of specialist smoking cessation services and courses (apart from quitline services) for pregnant women. A specialised service or course may be more likely to understand the needs of pregnant women who continue to smoke, but referral to such services from antenatal health professionals can be lacking. Major barriers to pregnant women accessing such services and courses can include problems with transport and childcare for other children, lack of time, and a disbelief that they would help.78 Offering flexible home visits and providing intensive multisession treatment delivered by well-trained staff may help to overcome these barriers and promote greater rates of cessation.117 Electronic resources

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Recent news and research

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1. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, 2009; (3):CD001055. Available from: http://dx.doi.org/10.1002/14651858.CD001055.pub3

2. Orleans CT, Barker DC, Kaufman NJ, and Marx JF. Helping pregnant smokers quit: Meeting the challenge in the next decade. Tobacco Control, 2000; 9(suppl. 3):iii6–11. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/9/suppl_3/iii6

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4. Tran D, Roberts C, Jorm L, Seeho S, and Havard A. Change in smoking status during two consecutive pregnancies: A population-based cohort study. BJOG, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24735217

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17. Wen KY, Miller SM, Roussi P, Belton TD, Baman J, et al. A content analysis of self-reported barriers and facilitators to preventing postpartum smoking relapse among a sample of current and former smokers in an underserved population. Health Education Research, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25099776

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19. Jones M, Lewis S, Parrott S, Wormall S, and Coleman T. Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: A systematic review. Addiction, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26990248

20. Ashford K, Hahn E, Hall L, Peden A, and Rayens M. Postpartum smoking abstinence and smoke-free environments. Health Promotion Practice, 2010; 12(1):126–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20720096

21. Ripley-Moffitt CE, Goldstein AO, Fang WL, Butzen AY, Walker S, et al. Safe babies: A qualitative analysis of the determinants of postpartum smoke-free and relapse states. Nicotine & Tobacco Research, 2008; 10(8):1355–64. Available from: http://www.informaworld.com/smpp/content~content=a901415349~db=all~order=page

22. Vaz LR, Leonardi-Bee J, Aveyard P, Cooper S, Grainge M, et al. Factors associated with smoking cessation in early and late pregnancy in the smoking, nicotine, and pregnancy trial: A trial of nicotine replacement therapy. Nicotine & Tobacco Research, 2014; 16(4):381–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24127265

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29. Constantine NA, Slater JK, Carroll JA, and Antin TM. Smoking cessation, maintenance, and relapse experiences among pregnant and postpartum adolescents: A qualitative analysis. The Journal of Adolescent Health, 2014; 55(2):216–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24566100

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32. Lopez E, Simmons V, Quinn G, Meade C, Chirikos T, et al. Clinical trials and tribulations: Lessons learned from recruiting pregnant ex-smokers for relapse prevention. Nicotine & Tobacco Research, 2008; 10(1):87–96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18188749

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