The research team, led by Bibiana Barrera and colleagues at the Leibniz Institute for Prevention Research and Epidemiology in Bremen, Germany, searched five major databases through October 2023 and applied rigorous methodology consistent with the Joanna Briggs Institute framework and PRISMA 2020 reporting standards. Their protocol was prospectively registered on the Open Science Framework. The scope was deliberately restricted to behavioral and psychosocial interventions, excluding purely pharmacological approaches, which have been comprehensively addressed in separate Cochrane reviews. This choice allowed the investigators to focus on the sociocultural and relational dimensions of cessation support that pharmacological trials rarely capture.

The stakes could hardly be higher. Tobacco smoke contains carbon monoxide, which impairs fetal oxygen supply, alongside carcinogens such as polycyclic aromatic hydrocarbons and tobacco-specific nitrosamines that readily cross the placenta. Maternal smoking is causally linked to ectopic pregnancy, placental abruption, miscarriage, preterm birth, low birth weight, and congenital anomalies. Children exposed prenatally face elevated risks of asthma, wheezing, and neurodevelopmental challenges including attention-deficit/hyperactivity disorder. After birth, second-hand smoke exposure is causally associated with sudden infant death syndrome, middle ear disease, and lower respiratory tract infections, while thirdhand smoke deposits on indoor surfaces pose additional hazards. Children of smoking parents are also more likely to become smokers themselves, perpetuating tobacco dependence across generations.

Despite these well-documented dangers, cessation rates during pregnancy remain suboptimal. Approximately 25 to 50 percent of pregnant women who smoke manage to quit during gestation, but the proportion who do not is markedly higher among those experiencing socioeconomic disadvantage. Factors associated with continued smoking include low educational attainment, poor mental health, high stress levels, limited social support, and living with a partner who also smokes. The inequalities are stark: in Europe, smoking prevalence during pregnancy is roughly five times higher among women with lower educational attainment compared with their more highly educated counterparts. These disparities establish early pathways for tobacco-associated disease burden in already disadvantaged populations.

The meta-analysis confirmed that behavioral interventions are broadly effective across all delivery formats examined, from individual counseling and group sessions to telephone support, home visits, written materials, and technology-mediated approaches. Individual counseling emerged as the most effective format for maternal cessation, with an odds ratio of 1.66 and a 95 percent confidence interval of 1.39 to 1.99. Effect sizes across other formats ranged from 1.39 to 1.66, and the high statistical heterogeneity observed reflects the diversity of populations and implementation contexts rather than fundamental inconsistency of effect. These findings align with the existing Cochrane evidence base while extending it in important new directions.

The review’s central analytical innovation lay in systematically characterizing five distinct approaches to addressing sociocultural vulnerability among pregnant smokers. These included language and education adaptation, socioeconomic inclusiveness, specialized provider training, mental health and emotional support integration, and community and cultural involvement. At the overall level, interventions reporting any vulnerability approach showed similar pooled effectiveness to those without explicit vulnerability strategies, with odds ratios of 1.55 versus 1.51. However, this apparent equivalence concealed clinically important differentiation across the five approaches.

Socioeconomic inclusiveness yielded by far the largest subgroup effect at an odds ratio of 2.51, driven by interventions that reduced material barriers through financial incentives, practical assistance, and extended resource provision. Examples included trials offering up to £400 in financial vouchers to pregnant women from deprived communities in the United Kingdom and providing cell phones with unlimited texting to low-income Latina participants. Mental health and emotional support integration showed the second-largest effect at an odds ratio of 2.01, consistent with the high co-occurrence of depression, anxiety, and social isolation among disadvantaged pregnant smokers. Specialized training for vulnerability showed a smaller but statistically significant benefit at an odds ratio of 1.29. In contrast, language and education considerations, despite being the most frequently implemented approach, showed no statistically significant benefit at an odds ratio of 1.13, suggesting that linguistic and literacy adjustments alone are insufficient to drive cessation outcomes without accompanying structural or psychological support.

The findings on father involvement require careful reframing. Across 22 studies that involved expectant fathers in some capacity, the meta-analysis found no statistically significant overall benefit for maternal smoking cessation, with an odds ratio of 1.12. Active involvement showed a positive but non-significant trend at an odds ratio of 1.20, while passive involvement showed essentially no benefit at 1.05. Notably, interventions that did not involve fathers showed a larger and statistically significant effect on maternal cessation at an odds ratio of 1.85, a pattern most likely attributable to higher intervention intensity rather than a beneficial effect of excluding fathers per se. The mismatch between the intervention target and the outcome measure explains this apparent paradox: including a father in a maternal cessation program does not straightforwardly translate into better maternal outcomes when the father’s own smoking behavior is not directly addressed.

The review’s most important finding in this domain emerged from four studies that evaluated father-directed interventions with paternal cessation as the primary outcome. These included brief advice with nicotine replacement therapy sampling and active referral, a video-based intervention focusing on maternal and child health, a randomized trial directed specifically at expectant fathers, and a partner-assisted cessation program. The pooled effect was an odds ratio of 2.18 with a 95 percent confidence interval of 1.67 to 2.83 and zero heterogeneity across studies. This represents the highest-certainty finding in the entire review, rated as high certainty under the GRADE framework, reflecting low and consistent heterogeneity, low overall risk of bias, and a narrow confidence interval. The pregnancy period represents a well-documented window of heightened cessation motivation for men, and father-directed interventions act on this motivation directly, reducing household second-hand smoke exposure and creating a smoke-free environment that protects both mother and child.

The implications for antenatal care are substantial. For programs targeting pregnant women from disadvantaged backgrounds, adding financial incentives and practical support alongside cessation counseling was associated with substantially larger pooled effects and merits consideration as an equity strategy, although the low certainty of the subgroup evidence means such approaches should be introduced with concurrent evaluation. Similarly, integrating mental health and emotional support into cessation programs addresses the psychological comorbidities that disproportionately burden the most disadvantaged pregnant smokers. Training midwives, nurses, and community health workers in vulnerability-sensitive communication is a scalable and cost-effective investment with measurable benefit. Regarding expectant fathers, brief father-directed cessation support delivered at routine antenatal contact points was highly effective in the available trials and could be considered for integration into antenatal care pathways. Because this evidence derives from only four trials, implementation should be accompanied by ongoing evaluation. The concentration of evidence in high-income countries also constrains transferability, and future research should prioritize co-produced, culturally grounded interventions in low- and middle-income settings where the global burden of smoking during pregnancy is greatest.

Subject of Research: Smoking cessation in pregnancy: a systematic review and meta-analysis of vulnerability approaches and expectant father involvement

Article Title: Smoking cessation in pregnancy: a systematic review and meta-analysis of vulnerability approaches and expectant father involvement

Article References: Barrera, B., Ahmed, F., Brand, T., & Zeeb, H. (2026). Smoking cessation in pregnancy: a systematic review and meta-analysis of vulnerability approaches and expectant father involvement. Public Health Reviews, 47, Article 1609825. https://doi.org/10.3389/phrs.2026.1609825

Image Credits: AI Generated

DOI: 10.3389/phrs.2026.1609825

Keywords: Smoking, cessation, pregnancy, systematic, review, meta-analysis, vulnerability, approaches, expectant, father, involvement, scientific research