Trials on physical activity for smoking cessation in pregnancy missed a trick or two.

Smoking cessation may be the most important health intervention during pregnancy because smoking is the most preventable cause of preterm birth and other illnesses. The BMJ must be commended for publishing three randomised trials dealing with smoking during pregnancy over 15 months and alerting readers that a mere 10th of pregnant smokers are prescribed nicotine replacement therapy (NRT). However, NRT was not prescribed as warranted by evidence in any of the three trials—in particular, patches were never combined with faster acting forms (lozenge or spray) of NRT. This “belt and braces” strategy has been shown to double the odds ratio of quitting during pregnancy. Researchers and editors must ask how we can improve the implementation of evidence based care—why can’t healthcare professionals apply simple pharmacological principles (dose effects and pharmacokinetics) to suppress craving as they would to suppress pain? The trial on financial incentives would have been improved by having a control group for which the healthcare professionals received financial incentives to perform motivational interviewing (a technique absent from all three trials), basic support, and cognitive behavioural therapies.These effective techniques are hardly compatible with the present fixed payment system, although the benefits deserve longer consultations.