Stress- and SmokeFree Start of Life

This project aims to reduce smoking among pregnant women, via a personalized e-health application that targets both stress and smoking in women with low socio-economic status (SES). An important element that has been missing in previous smoking cessation programs, that have been mostly unsuccessful in women with low SES, is stress-coping management. Stress is a common maintaining factor among smokers, particularly for women who live in disadvantaged circumstances, and smoking is often used as a way to alleviate feelings of tension. Chronic daily stress also makes it difficult to change lifestyle habits. Despite this observed co-occurrence of smoking with high levels of stress among low SES pregnant women, we still lack an intervention that also supports pregnant women in learning new stress-coping skills. It is essential that a smoking cessation program, especially those targeting low SES women, also includes effective stress-coping techniques. For our study, we will adapt and personalize an existing smoking cessation online intervention (www.mijnkoersroken.nl), developed by Trimbos institute, to our targeted population of women with low SES to gain optimal compliance and efficacy. Importantly, we will add stress-management techniques to our intervention that consist of a combined approach of targeting both the physiological stress system, by training with HRV-biofeedback, and stimulating active problem solving on a behavioral level. HRV-biofeedback entails a method of paced breathing with visual feedback, is easy to learn and to maintain in daily life, and requires little cognitive efforts. HRV-biofeedback training could therefore be very appropriate for pregnant smoking women with low SES. With the problem solving techniques that are also part of our application, women can address their own stated stressful situations that could yield stress and evoke smoking habits, in a stepwise approach, with guidance from the e-health application and an e-coach. The customization of the content of both the smoking cessation element and the stress reduction element in our application, will be achieved by co-creating processes with focus groups of women from low SES who were themselves either successful or struggled with quitting smoking during pregnancy. In our project, we will evaluate the effectiveness of our e-health application in reducing smoking rates and reducing stress among women in pregnancy and the first months following childbirth. As a randomized-controlled trial (RCT) provides critical support for evidence-based practice using interventions, we will compare our application in a 2-arm RCT with an experimental condition, consisting of our e-health application with a 8-weeks program that targets both smoking cessation and stress reduction, and a control condition, consisting of single online psycho-education module on smoking during pregnancy. Each arm will include 80 participants. Our design includes four measurement waves: pre-intervention or baseline (T0), post-intervention (T1), two weeks following birth (T2) and three months after birth (T3). Primary outcomes include smoking cessation and stress reduction, secondary outcomes include self-efficacy in dealing with stress and pregnancy, more optimal birth outcomes, and less difficult infant behavior at three months of age. We intend to deliver an effective e-health application, as end-product of our study for midwives, gynecologists, primary health caretakers for parents of young children (the Parent-Child Centers) and or general practitioners, which they can promote among their smoking clients. We will actively discuss the potential and possibilities for its implementation in clinical practice with involved stakeholders, including the Eerstelijns Verloskundigen Amsterdam Amstelland (midwives) and Netwerk Geboortezorg Noordwest Nederland. Moreover, workshop and presentations will be given on the application and program at national annual meetings and conferences for health care takers, during regional meetings of birth networks in the Netherlands, and during meetings of local cooperating obstetrics practices to disseminate the study findings to health care workers involved with pregnant smoking women.