MATERNAL SMOKING CESSATION INTERVENTION: TARGETING WOMEN AND THEIR PARTNERS BEFORE PREGNANCY

Pollack recently analyzed the relationship between maternal smoking and sudden infant death syndrome (SIDS) and the costeffectiveness of smoking cessation programs.1 We fully agree that smoking cessation interventions should remain an important policy goal, but we wish to emphasize that such programs should especially be targeted at women before conception in order to protect the developing embryo from tobacco exposure during organogenesis and to minimize other risks.2–4

We carried out a study on preconception care in the Netherlands in which we evaluated the impact of smoking cessation advice given before pregnancy on smoking behavior of both women and their partners. Two limitations of Pollack's study, self-reported maternal smoking and lack of data on smoking by other household members,1 were accounted for in our study design: we confirmed smoking by serum cotinine assay and also assessed paternal smoking behavior.

Our findings were similar to previous findings of maternal underreporting of smoking.5,6 In our cohort of 111 women followed over a 1-year time period, 16 women reported smoking, whereas 24 were identified as smokers (serum cotinine > 5 μg/L, 33% underreporting). Moreover, we found a similar trend in men who were questioned on smoking habits; only 20 admitted tobacco use vs 36 men identified as smokers via serum cotinine assay (44% underreporting). Using a linear model for repeated measurements to analyze data collected up to 12 months after counseling, we found that the estimated mean serum cotinine concentration of smoking women decreased significantly after intervention (from 214 μg/L to 99 μg/L; P = 0.016). Although none of the women stopped smoking, 75% of cotinine-validated smokers and 88% of self-reported smokers reduced smoking after the preconception counseling intervention. The men, however, neither reduced nor stopped smoking.

In contrast to Pollack's study population, our small sample of smokers did not allow further analyses of pregnancy outcome. Our findings emphasize the significant underreporting of smoking by both sexes, however, and underscore the great difficulty in changing smoking habits. A single preconceptional intervention is not enough to stimulate couples planning pregnancy to stop smoking. We found a more prominent post-intervention decrease in cotinine levels of self-reported smokers than in cotinine-validated smokers, which may indicate that prevaricators are more resistant to changing smoking habits. Influencing prevaricators and their partners to give up smoking will pose a continuing challenge for obstetricians and other health care workers seeking to reduce the occurrence of SIDS and other adverse pregnancy outcomes.