Key messages:
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Advice and guidance on how to quit smoking with counseling and rewards/payments (financial rewards) for staying smoke-free probably increase the number of women who stop smoking during pregnancy; and health education, social support, and feedback programs may increase the number who stop smoking.
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Psychological and social support programs may reduce the number of babies being born too small (< 2500 g), result in heavier, and usually healthier, babies, and reduce the number of babies under one-month-old who need hospital care.
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We do not know if these findings apply to women from ethnic minority or indigenous communities because very few studies looked at their results specifically in these groups.
What is the issue?
Tobacco smoke toxins can affect a baby's growth and development before birth. Smoking during pregnancy can result in babies being born too small and increases the risk of complications for the mother.
What are psychological and social support programs?
Many women who smoke during pregnancy want to stop but find it difficult and need support. Programs designed to help women stop smoking without using medication are known as psychological and social (psychosocial) support programs. These may include:
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Advice and guidance on how to quit smoking (counseling);
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Information on why stopping is important (health education);
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Rewards for staying smoke-free (financial incentives);
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Feedback about the baby's health, such as through an ultrasound (a medical tool that uses sound waves to create images of the inside of your body) or levels of harmful chemicals in the body, such as through a urine test (feedback);
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Emotional and practical support from others (social support); or
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Programs that encourage regular physical activity (exercise).
What did we want to find out?
We wanted to find out how successful different psychological and social support programs are in helping pregnant women who smoke, or who have recently quit, to stop smoking and stay smoke-free. We also wanted to look at whether these programs improve babies' health.
What did we do?
We searched for studies that had looked at different psychological and social support programs to help pregnant women stop smoking.
What did we find?
We found 127 studies with 47,361 pregnant women who smoked or had recently quit. The largest study included 3571 women and the smallest had 17. Most women were healthy and over 16 years old. About half of the studies included women from lower-income backgrounds, with 11 studies involving ethnic minority groups and four involving indigenous communities. All studies were funded by independent research bodies, and none were supported by organizations that might influence the results.
The support programs included: counseling (60), health education (21), feedback (8), financial incentives (17), social support (7), and exercise programs (1). Women in the comparison groups usually received standard care (66), which mainly included information about the risks of smoking and advice to quit smoking. Some studies compared the intervention with a less intensive program (50), and a smaller number compared it with a different type of program (11).
Stopping smoking in late pregnancy (around 36 weeks' pregnant or later)
Counseling and programs that offer financial rewards for not smoking probably increase the number of women who stop smoking during late pregnancy. Health education, feedback, and social support programs may increase the number of women who stop smoking during late pregnancy. Exercise probably makes little to no difference in the number of women who stop smoking during late pregnancy. In one study, the same counseling program was used in both groups, but the way it was provided to clinics differed. One group of clinicians only received written information about the program, while the other group received more support, such as training, regular contact, and feedback. However, it is unclear whether this affected smoking quit rates.
Babies health at birth
Overall, psychosocial interventions may reduce the number of babies being born too small (< 2500 g); result in heavier, and usually healthier, babies; and reduce the number of babies under one-month-old who need specialist intensive care. These programs probably make little or no difference to the number of stillbirths, and it is unclear whether they affect the number of babies born preterm (< 37 weeks).
Do these interventions work for everyone?
Very few studies looked at whether psychological and social support programs worked differently for women from disadvantaged backgrounds or minority populations, so we have limited information on how to better meet the needs of women who are most affected by smoking during pregnancy.
What are the limitations of the evidence?
Some studies did not provide all the information we needed and left out important details which could have affected their findings. Some studies were too small for us to be completely certain of exactly how much the interventions helped women to stop smoking. There were also not many studies on women from ethnic minority and indigenous communities, and when these women were included, the results were often not reported separately for different groups.
How up to date is this evidence?
The evidence is current to November 2025.
Read the full abstract
Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.
Objectives
To assess the effects of psychosocial interventions provided to support pregnant women who are currently smoking or have recently quit, on smoking abstinence, continued postpartum abstinence, and infant outcomes.
Search strategy
We searched Embase, MEDLINE, PsycINFO, four other databases and two trial registers, together with reference checking, citation searching, and contact with study authors to identify studies that are included in the review. The latest search date was November 2025.
Selection criteria
Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.
Data collection and analysis
Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.
Main results
The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.
In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.
Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.
There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).
High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).
High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.
The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).
Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.
The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.
Authors' conclusions
Counseling and financial incentives probably support women to stop smoking, while health education, feedback, and social support may support women to stop smoking in late pregnancy, by an amount likely to be important. Psychosocial interventions may also reduce the proportion of infants born with low birthweight, increase mean birthweight, and reduce the number of infants admitted to NICU. These findings were not evident in ethnic minority or Indigenous populations.
Funding
This Cochrane review was funded (partly) by the 2021 MRFF Maternal Health and Healthy Lifestyles (2022138), NHMRC Leadership Fellowship (GNT2025437), and NHMRC Investigator Grant (GNT2009612).
Registration
Protocol (1998) https://doi.org/10.1002/14651858.CD001055
Original review (1999) DOI: 10.1002/14651858.CD001055 (this first version of the review is not available in the Cochrane Library)
Review update (2004) https://doi.org/10.1002/14651858.CD001055.pub2
Review update (2009) https://doi.org/10.1002/14651858.CD001055.pub3
Review update (2013) https://doi.org/10.1002/14651858.CD001055.pub4
Review update (2017) https://doi.org/10.1002/14651858.CD001055.pub5
