Physicians have long advocated cessation of tobacco use during pregnancy as a way to improve birth outcomes. Yet many pregnant smokers, including vulnerable Medicaid populations, may never disclose their smoking or their desire to quit when asked by providers. One nontraditional option for starting the conversation is a urine test that traces cotinine, a tobacco metabolite. This test, when administered during a prenatal visit, could open the conversation to smoking cessation. But it also runs the risk of damaging doctor-patient trust.
A new paper from Katherine Gold, M.D., M.S.W., M.S., associate professor, explored the acceptability of urine testing for tobacco use, from both patient and the providers’ perspectives. The research team conducted 19 interviews and four focus groups with 40 pregnant or postpartum women covered by Medicaid as well as interviews with 20 clinicians who provide prenatal care.
Surprisingly, the study found that patient participants generally saw the testing more positively than their clinician counterparts. Despite having some reservations, a majority of patients (89%) identified tobacco screenings as an intervention that could help them and others stop smoking.
Endorsing statements were not mutually exclusive with concerns about potential strain on the doctor-patient relationship. About a third of patient participants expressed reservations and fears. At the same time, more than 80% of clinicians raised fears that the testing could have a negative impact on the doctor-patient relationship.
One of the goals of the authors' qualitative approach was to identify patient concerns and questions regarding prenatal urine testing for tobacco use. The authors recognized that focus group participants were “more suspicious of clinicians’ motives,” despite an overall positive evaluation of testing. Patient concerns included:
Privacy, trust and confidentiality: “you are trying to act like a police officer and really figure out what if I am telling you, is it true or not...I am telling you this out of my mouth so you don’t believe me so you trying to go investigate some other stuff that really don’t concern you.” (Focus group 1)
Fear of punitive action: “There’s always somebody out there afraid that their kids are going to be taken away from them...” (Patient aged 30 years, pregnant)
Risk of judgement for positive test result: “I think just because maybe the doctor might look down on you, like you don’t care about your baby...” (Patient aged 27 years, pregnant)
Distrust of provider’s motives: “I think just be honest and explain what the motives behind the test and the study are, and if they feel that it’s coming from a helpful place...” (Patient aged 36 years, pregnant)
Provider concerns echoed many of the same ideas of patient consent, risk of provider judgement, erosion of doctor-patient trust, and how the test and its results are framed. One resident physician noted, “depending on how you frame it, it may or may not affect the relationship. If you make it so it’s like, ‘You know, you say you don’t smoke, but I’m going to make you take this test anyway because I don’t believe you,’ if you frame it like that, it’s going to damage the relationship. If you say, ‘We’re testing everybody for this so we can find out if we need to intervene and provide tips,’ I think people would be more receptive to it and not diminish the relationship.”
Although clinicians expressed overall concerned, some were hopeful that the screening would have a positive outcome. For example, a midwife who participated in the survey had a very different point of view, saying: “I think it just shows that we care really. So I can’t imagine that it would strain our relationship.”
The next steps
This work follows up on Dr. Gold’s research interests into the reduction of tobacco use during pregnancy and women’s mental health during the perinatal period. Building on her past experiences, she sees two logical future steps from this research. The first is recognizing that pregnant women are surprisingly open to being tested as long as it is an honest and transparent process. Clinicians should be leveraging that openness to help women either quit or considerably reduce their tobacco usage. She also stressed that it was clear that the women wanted to be treated in a non-judgmental way, therefore physicians need to make sure they are sensitive to their patients’ attitudes
The second step would be to reinforce tobacco’s negative effects on pregnancy in the minds of clinicians. Dr. Gold said that she was surprised that clinicians appeared to be less concerned about the effects of tobacco usage by pregnant women when compared with other perinatal issues. Given the huge amount of evidence of the negative impacts smoking has on a pregnancy, Dr. Gold said there appeared to be a disconnect between what clinicians were taught in medical school and how they apply that training in office visits with pregnant women.
The study, “Prenatal Point-of-Care Tobacco Screenings and Clinical Relationships,” was authored by Gold, Martha E. Boggs, B.S., C.C.R.C., clinical research coordinator health in the Department of Family Medicine, Aisha A. Bobb-Semple, M.D., and Alexandria F. Williams, M.D., M.P.H. Bobb-Semple is a graduate of the University of Michigan’s medical school who now practices at Mount Sinai Hospital in New York City. Williams is a practicing physician at Mt. Auburn Hospital in Cambridge, Mass. It was published in the Annals of Family Medicine in the November-December 2018 issue.
Article citation: Bobb-Semple AA, Williams AF, Boggs ME, Gold KJ. Prenatal Point-of-Care Tobacco Screening and Clinical Relationships. The Annals of Family Medicine. 2018;16(6):507-514. Doi: 10.1370/afm.2290.