Ask any obstetrician what a pregnant woman should do to ensure that her baby is born healthy and that physician will be sure to mention quitting smoking. Smoking during pregnancy is dangerous for both mother and child.

Smokers inhale nicotine and carbon monoxide that reach the fetus through the placenta and prevent the fetus from getting the nutrients and oxygen needed for growth. As a result, the chances that the baby will be born pre-term (before 37 weeks of gestation) increases by about 30 percent and the likelihood of being of low birth weight (less than 5 l/2 pounds) nearly doubles. These babies are more likely to die. Indeed the United States Public Health Service estimates that if all pregnant women in the United States stopped smoking, there would be an 10 percent reduction in infant deaths. Babies of smoking moms also are at increased risk for breathing problems during the newborn period, and for asthma and other health complications later in life. Despite the evidence of these serious consequences, 13 percent of women who gave birth in 1998 smoked during pregnancy, according to the National Center for Health Statistics. Smoking during pregnancy decreased 25 percent from 1990 to 1997 for women of all ages, but smoking was up among pregnant teens, a worrisome trend because studies show that they are more likely to suffer complications during pregnancy. Women with limited education also have high rates of smoking: 48 percent of non-Hispanic white women aged 20 and older who did not graduate high school smoked while pregnant. "Pregnancy is a great time for a woman to quit because cessation benefits not only the baby but the woman too," said Cathy Melvin, director of Smoke-Free Families, a program sponsored by the Robert Wood Johnson Foundation to help women stop smoking during and after pregnancy. If a woman stops smoking, "she is less likely to suffer a miscarriage, develop placental complications that make delivery difficult or have a stillbirth. Quitting smoking also lessens her chance of developing future tobacco-related health problems such as lung and heart disease." Quitting smoking benefits the entire family, Ms. Melvin noted. The newborn starts life in a home where he or she is not exposed to the dangers of second-hand smoke. This is advantageous, because children who must breathe their parents' smoke are more likely to suffer bronchitis and other breathing conditions than those who live in smoke-free homes. To help pregnant women quit, Smoke-Free Families has developed a brief test to assess the smoking status of pregnant women. Physicians, nurse-midwives and other health providers use the exam to carefully tailor their counseling of patients with a variety of smoking patterns. The organization also has developed materials that the woman can use to cope with high-risk situations that lead her to light up, to manage cravings and to meet other challenges she faces at home and in the workplace. A lack of confidence is a major stumbling block, Ms. Melvin observed. Although many women are highly motivated to quit smoking during pregnancy, they often doubt their ability to incorporate cessation into a busy schedule of doctors' appointments and tests. Some women feel overwhelmed by the physical changes they are experiencing, and others say they are too stressed to quit. Defensiveness is another hurdle, especially for those who have made numerous attempts to quit. They don't want to risk another failure. Indeed, some expectant moms feel so defensive about smoking that they won't admit to their health care providers that they smoke. Heavy smokers often claim they are smoking fewer cigarettes "Expectant mothers who smoked during previous pregnancies will often refuse to try because they don't see any benefit since their children turned out fine," said Ms. Melvin. "Even if the woman does want to quit, the health care provider may not have the materials to help her." For these reasons, Smoke-Free Families has developed a 5 to 15 minute counseling session to determine how much the woman smokes. The woman is asked at her first prenatal visit to pick one of five statements that reflect her smoking pattern: I have never smoked or have smoked less than 100 cigarettes in my lifetime. I stopped smoking before I found out I was pregnant, and I am not smoking now. I stopped smoking after I found out I was pregnant and I am not smoking now. I smoke some now, but I cut down on the number of cigarettes I smoke since I found out I was pregnant. I smoke regularly now, about the same amount, as before I found out I was pregnant. Using this information, the health care provider will advise the patient about the impact of smoking on her health as well as the development of the fetus. Then the health provider will determine the willingness of the patient to attempt quitting during the next 30 days. "Having short-term goals is important because it makes quitting less daunting," said Ms. Melvin. The health care provider will then suggest problem-solving methods and encourage the woman to get support from family, friends and co-workers. A booklet of tips will also be provided. At subsequent appointments, the woman and health care provider will note her progress and if necessary, adapt the plan to the woman's needs. Smoke-Free Families is working with 35 organizations including the American College of Obstetricians and Gynecologists, the organization of physicians with advanced training in women's health, other professional groups of physicians and nurse-midwives, the March of Dimes and other groups concerned with maternal and child health to train providers to use the counseling session format and incorporate the self-help materials into their practices. Information on the counseling program and other materials for healthcare providers and pregnant women is available on the Smoke-Free Famalies website www.smokefreefamilies.org.

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