“Some People Just Don’t Wanna Quit,” and Some Just Can’t

An investigation of perinatal smoking cessation and harm reduction 

As members of a research team investigating the impact of home visiting, we are inspired by the pragmatic approach these programs take in intentionally meeting families where they are. This pragmatism is not rocket science, but we should not underestimate its value. For many families, success is inextricably linked to being matched with a home visitor they connect with and working on a flexible curriculum that addresses their personal priorities.

Our most recent work, published in the August 2016 edition of BMC Public Health, focused on our investigation of home visiting effectiveness on smoking cessation. Home visiting programs represent an important primary prevention strategy for reducing adverse prenatal health behaviors and have success in reducing prenatal smoking.

Home visiting programs represent an important primary prevention strategy for reducing adverse prenatal health behaviors and have success in reducing prenatal smoking.

This mixed methods evaluation utilized client interviews and administrative data, which uniquely positioned us to provide a more complete picture of how clients are impacted by the smoking curriculum delivered by home visiting staff. Smoking curricula varies by program and includes techniques ranging from providing brochures and educational materials to motivational interviewing to referring individuals to outside smoking cessation programs.

While the medical community considers smoking cessation a clear health goal for pregnant women, we wanted to explore how this ideal works out in reality for home visiting clients. We wanted to know: 1) Whether clients getting home visitation services who start their pregnancy as smokers are better able to change that behavior than non-clients and 2) what factors complicate that behavior change?

As it turns out, clients were more likely to quit smoking than pregnant women who did not participate in home visiting services. Additionally, for those clients who did not quit completely, those that were heavier smokers in the first trimester of pregnancy were more likely to reduce smoking by the third trimester of pregnancy. For clients who didn’t quit smoking, some had family members and friends who smoke, making it difficult to quit; for others, quitting was simply not a priority.

So, when we think about how home visiting can be most effective, quitting is important, but it’s only part of the story. Harm reduction, or adjusting environmental tobacco smoke exposures, is a useful intervention approach when full and continued smoking cessation is challenging or there are other smokers in the home.

Harm reduction is a useful intervention approach when full and continued smoking cessation is challenging or there are other smokers in the home.

The impact of educating families about other behavioral changes aimed at reducing harm to children emerged as a major theme in the qualitative interviews. Clients described learning about the risks of and ways to avoid exposing children to second- and third-hand smoke. This information helped more than one-third of clients use harm reduction methods such as no longer smoking in the house, in the car or in the presence of their children. Clients also mentioned adopting the practice of wearing a smoking jacket that they would remove before coming in to the house and immediately washing their hands before interacting with their children.

Additionally, a number of clients (smokers and non-smokers) described how the program empowered them to ask friends and family members to adopt harm-reducing behaviors. For example, one non-smoker described how her home visitor taught her about smoke staying on clothing and, unexpectedly, found the information useful when a family acquaintance who smokes asked to hold her son. Similarly, non-smokers with family members who smoke described how this information impacted the behaviors of husbands/partners and grandparents to reduce the exposure of children to second-hand and third-hand smoke. Other non-smokers suggested that the knowledge they gained made them avoid public spaces where their children might be exposed.  

This work shows that investigating smoking cessation is important, but exploring other ways to reduce harm is equally valuable when you move from the ideal to the reality of many families. Given that smoking cessation is a difficult outcome to achieve, curricula of home visiting programs may be enhanced by including smoking reduction techniques to reduce the harm of smoke on young children. Additionally, home visiting programs may increase positive outcomes when collaborating with outside smoking cessation and reduction programs as an addition to the home visiting program itself. As home visiting programs continue to expand, it will be important for agencies and collaborating community or health organizations to identify effective ways to support tobacco-related harm reduction within vulnerable families.



Heather Griffis, PhD, MS, is the director of the Department of Biomedical and Health Informatics’ Healthcare Analytics Unit at Children’s Hospital of Philadelphia.