Question:

A 32-year-old woman, gravida 2 para 0 aborta 1, at 7 weeks gestation comes to the office to initiate prenatal care. Her first pregnancy 2 years ago ended in a first-trimester spontaneous abortion. She has smoked 2 packs of cigarettes daily for the past 14 years. She does not use alcohol or recreational drugs. Vital signs are within normal limits. BMI is 27 kg/m². Pelvic examination is normal. Ultrasound reveals a 7-week intrauterine gestation with a normal heartbeat. When asked about quitting smoking cigarettes, she says, "I know smoking is bad for my baby. I have tried quitting several times on my own and could not do it." Which of the following is the most appropriate next statement to this patient?

"If you are ready to quit, I recommend complete nicotine cessation as replacement therapy can be harmful to your pregnancy."

"Quitting can be hard; when you are ready, we can discuss treatment options that can increase your chances of success."

"Smoking cessation is difficult; would you be willing to try cognitive-behavioral therapy?"

"What are some of the barriers you foresee in your future that may make it difficult to quit?"

"You are right, smoking during pregnancy can be bad for your baby. You should quit now or you are going to have pregnancy complications."

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Motivational interviewing: components
Engaging	Start a nonjudgmental, open-ended conversation Collaborate to set the agenda Elicit patient strengths
Focusing	Ask the patient to identify 1 or 2 behavior targets
Evoking	Elicit change talk to get the patient's: Commitment Reasons to change
Planning	Guide the patient toward: Identifying specific next steps Anticipating obstacles Deciding how to measure success

Tobacco use is associated with multiple pregnancy-related complications, including spontaneous abortion, congenital anomalies, abruptio placentae, preterm delivery, and low birth weight. It also is associated with long-term complications in the infant, including sudden infant death syndrome and increased risk for diabetes mellitus, asthma, and obesity. Smoking cessation during pregnancy decreases these risks. Therefore, pregnant patients are asked about tobacco use, and cessation is encouraged in those who smoke.

Smoking-cessation interventions initiated by physicians are generally successful in helping patients quit. A nonjudgmental, open-ended conversation is the most effective approach. The first step is to assess the patient's readiness to quit. Physicians should also encourage patients to reflect on their motivations for change (eliciting change talk to increase self-motivation) and guide patients toward identifying specific next steps if they are ready to quit.

Patients who have attempted to quit previously should be asked to anticipate potential obstacles (eg, "What are some of the barriers you foresee?"). Risk factors for continued cigarette use during pregnancy include heavy tobacco use (more than half a pack a day) and the presence of another smoker in the home.

(Choice A) Abrupt and complete ("cold turkey") nicotine cessation is less effective than use of adjunctive pharmacotherapy (eg, nicotine replacement therapy, bupropion, varenicline). In addition, nicotine replacement therapy and bupropion are safe for use in pregnancy; varenicline is not used due to lack of safety information in pregnancy.

(Choice B) Rather than waiting for patient readiness, providers should provide education and initiate smoking-cessation interventions as early in pregnancy as possible to minimize obstetric and fetal complications.

(Choice C) All pregnant smokers are recommended to enroll in a behavioral counseling program for tobacco cessation. However, this patient requires a readiness assessment and education on the available cessation strategies prior to initiating a specific therapy (eg, cognitive-behavioral therapy).

(Choice E) Stating that "you should quit now or you are going to have pregnancy complications" does not guide the patient toward identifying specific next steps or help her anticipate obstacles to quitting tobacco use. In addition, she has already acknowledged that smoking is bad for her baby.

Educational objective:
Tobacco use is associated with multiple adverse pregnancy complications. Physician-initiated smoking-cessation interventions are successful in helping patients quit. Initial steps include determining patient readiness and addressing barriers to smoking cessation.