Counselling for smoking cessation during pregnancy reduces tobacco-specific nitrosamine (NNAL) concentrations: A randomized controlled trial
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General Oncology Hospital of Kifissia “Agioi Anargyroi”
George D Behrakis Research Lab, Hellenic Cancer Society, Athens, Greece
Institute of Public Health, American College of Greece, Athens, Greece
General Maternity Hospital Helena Venizelou, Athens, Greece
School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
Maternity Unit, Attikon Hospital, Athens, Greece
Laboratory of Toxicology, School of Medicine, University of Crete, Heraklion, Greece
Environmental Chemical Processes Laboratory (ECPL), Department of Chemistry, University of Crete, Greece
Integrative Systems Medicine and Digestive Disease, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Exhibition Road, London, SW7 2AZ, United Kingdom
Andriani N. Loukopoulou   

George D. Behrakis Research Lab, Hellenic Cancer Society, 17b Ipitou street, Athens 105 57, Greece
Submission date: 2018-08-21
Acceptance date: 2018-11-03
Publication date: 2018-11-14
Eur J Midwifery 2018;2(November):14
Smoking cessation during pregnancy is beneficial to both the mother and child. Our objective was to assess if an intensive smoking cessation intervention for pregnant women increases: a) rates of smoking cessation, and b) reduces exposure to tobacco-specific carcinogens during pregnancy.

A two-group single-blinded parallel randomized controlled trial (RCT) was conducted involving 84 pregnant smokers in either a high intensity (n=42) or minimal contact control group (n=42). Women assigned to the high intensity smoking cessation intervention group received a single 30-minute behavioural counselling session and a tailored self-help booklet. The primary outcome measures were: 7-day point prevalence abstinence measured by selfreport and urine cotinine levels, and maternal tobacco specific carcinogens nitrosamine (NNAL) urine concentrations assessed at 32 weeks of gestation.

A significantly greater percentage of pregnant smokers quit smoking in the high intensity group compared to the low intensity control group (45.2% vs 21.4%; p=0.001). A significant decrease in urine cotinine concentrations was documented in the experimental group (-140.74 ± 361.70 ng/mL; p=0.004), with no significant decrease documented in the control group. A significant decrease in NNAL levels was also documented in the experimental group (158.17 ± 145.03 pg/mL before, 86.43 ± 112.54 pg/mL after; p=0.032) with no significant changes in the control group.

The high intensity intervention tested resulted in significantly greater cessation rates. Intensive smoking cessation interventions can be effective in reducing fetal exposure to NNAL. This is the first trial to report on NNAL tobacco-specific carcinogen concentrations before and after an intervention for smoking cessation during pregnancy.

Kleinman J, Pierre M, Madans J, Land G, Schramm W. The effects of maternal smoking on fetal and infant mortality. American Journal of Epidemiology. 1988;127(2):274-282. doi: 10.1093/oxfordjournals.aje.a114803
Ventura SJ, Martin JA, Taffel SM, Mathews TJ, Clarke SC. Advance report of final natality statistics, 1993. Monthly Vital Stat Rep. 1995;44 (suppl):1-88.
U.S. Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General. Rockville; 2001.
Vivilaki VG, Diamanti A, Tzeli M, et al. Exposure to active and passive smoking among Greek pregnant women. Tobacco Induced Diseases. 2016;14(1). doi:10.1186/s12971-016-0077-8
Florek E, Piekoszewski W, Basior A, et al. Effect of maternal tobacco smoking or exposure to second-hand smoke on the levels of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) in urine of mother and the first urine of newborn. Journal of Physiology and Pharmacology. 2011;62(3):377-383.
Lackman GM, Salzberger U, Tollner U, Chen M, Carmella SG, Hecht SS. Metabolites of a tobacco-specific carcinogen in urine from newborns. J Natl Cancer Inst. 1999;91(5):459-65. doi:10.1093/jnci/91.5.459
Lumley J, Oliver SS, Chamberlain C, Oakley L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2004;8(4):CD001055. doi:10.1002/14651858.cd001055.pub2
Centers for Disease Control and Prevention. Cigarette Smoking-Attributable Mortality and Years of Potential Life Lost—United States. Morbidity and Mortality Weekly Report 1993;42(33):645–649. Accessed November 10, 2008.
US Department of Health and Human Services. The Health Benefits of Smoking Cessation. A report of the Surgeon General. Atlanta, Georgia: Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. Accessed November 10, 2008.
Vardavas CI, Chatzi L, Patelarou E, et al. Smoking and smoking cessation during early pregnancy and its effect on adverse pregnancy outcomes and fetal growth. Eur J Pediatr. 2010;169(6):741-748. doi:10.1007/s00431-009-1107-9
Solomon LJ, Quinn VP. Spontaneous quitting: Self-initiated smoking cessation in early pregnancy. Nicotine Tob. Res. 2004;6(Suppl 2):203–216. doi:10.1080/14622200410001669132
Berg CJ, Park ER, Chang Y, Rigotti NA. Is concern about post cessation weight gain a barrier to smoking cessation among pregnant women? Nicotine Tob Res. 2008;10(7):1159–63. doi:10.1080/14622200802163068
Xu X, Rao Y, Wang L, Li, S, Guo JJ, Sharma M, Zhao Y. Smoking in pregnancy: a cross-sectional study in China. Tobacco Induced Diseases. 2017;15(1):35. doi:10.1186/s12971-017-0140-0
McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res. 2003;18(2):156-70. doi:10.1093/her/18.2.156
Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg. RL Recommended cessation counselling for pregnant woman who smoke: a review of the evidence. Tobacco Control. 2000;9(Sup III):iii80-iii84. doi:10.1136/tc.9.suppl_3.iii80
Chamberlain C, O'Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2(14Feb):CD001055. doi: 10.1002/14651858.CD001055.pub5
Loukopoulou AN, Vardavas CI, Farmakides G, et al. Design and study protocol of the Maternal Smoking Cessation during Pregnancy study, (M-SCOPE). BMC Public Health. 2011;11:903. doi: 10.1186/1471-2458-11-903
Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV). American Psychiatric Association: Washington D.C.; 1994.
Goldberg DP. General Health Questionnaire. Windsor: NFER-Nelson England; 1978.
Garyallos G, Karastergiou A, Adamopoulou A, Moutzoukis C, Alagiozidou E, Mala D, Garyfallos A. Greek version of General Health Questionnaire: accuracy of translation and validity. Acta Psychiatrica Scandinavica. 1991;84(4):371-378. doi:10.1111/j.1600-0447.1991.tb03162.x
Miller EI, Norrisa HK, Rollins DE, Tiffany T, Wilkins DG. A novel validated procedure for the determination of nicotine, eight nicotine metabolites and two minor tobacco alkaloids in human plasma or urine by solid-phase extraction coupled with liquid chromatography-electrospray ionization-tandem mass spectrometry. J Chromatogr B. 2010; 878(9-10);725–737. doi:10.1016/j.jchromb.2009.12.018
Nakajima M, Fukami T, Yamanaka EH, et al. Comprehensive evaluation of variability in nicotine metabolism and CYP2A6 polymorphic alleles in four ethnic populations. Clin Pharmacol Ther. 2006;80(Suppl 3):282–297. doi:10.1016/j.clpt.2006.05.012
Spierto FW, Hannon WH, Kendrick JS, Bernert JT, Pirkle J, Gargiullo P. Urinary cotinine levels in women enrolled in a smoking cessation study during and after pregnancy. Journal of Smoking-Related Disorders. 1994;5(2): 65-76. doi:10.2105/ajph.85.2.217
Glynn TJ, Manley MW, Pechacek TF. Physician-initiated smoking cessation program: The National Cancer Institute trials. Prog Clin Biol Res.1990;339:11-25.
Vardavas C, Karabela M, Agaku I, et ail. Secondhand smoke exposure within semi-open-air cafes and tobacco specific 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) concentrations among nonsmoking employees. International journal of occupational medicine and environmental health. 2014q 27(5):875-881. doi:10.2478/s13382-014-0294-4
Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. U.S. Department of Health and Human Services, A Public Health Service Report 2000. Accessed August 21, 2018.
SPSS Inc. PASW STATISTICS 18.0 Command Syntax Reference. SPSS Inc., Chicago, 2009.
Schneider S, Huy C, Schütz J, Diehl K. Smoking cessation during pregnancy: a systematic literature review. Drug Alcohol Rev. 2010;29(1):81-90. doi:10.1111/j.1465-3362.2009.00098.x
Vardavas CI, Fthenou E, Patelarou E, et al. Exposure to different sources of secondhand smoke during pregnancy and its effect on urinary cotinine and tobacco-specific nitrosamine (NNAL) concentrations. Tobacco Control. 2013;22(3):194-200. doi:10.1136/tobaccocontrol-2011-050144
Kavvadias D, Scherer G, Cheung F, Errington G, Shepperd J, McEwan M. Determination of tobacco-specific N-nitrosamines in urine of smokers and non-smokers. Biomarkers. 2009;14(8):547-53. doi:10.3109/13547500903242883
Xia Y, Bernert JT, Jain RB, Ashley DL, Pirkle JL. Tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) in smokers in the United States: NHANES 2007-2008. Biomarkers. 2011;16 2:112-119. doi:10.3109/1354750x.2010.533288
Yu S, Park C, Schwalberg R. Factors associated with smoking cessation among U.S. pregnant women. Matern Child Health J. 2002;6:89–9.