Abstract
Background: Smoking is the most important preventable cause of adverse outcomes in pregnancy;
however, most smokers who become pregnant continue to smoke and/or relapse following delivery.
The identification of patients at risk can be challenging, and the treatment options available can be
nebulous, including nonpharmacologic and pharmacologic options. The challenges of diagnosing and
treating smoking in pregnancy prompt the use of clinical practice guides (CPGs). Several have been
published to help identify at-risk patients and guide holistic management of tobacco use in pregnancy,
however, to date, there has been no comprehensive review of guideline quality or methodologic rigor.
Methods: We conducted a comprehensive search of EMBASE, MEDLINE/PubMed, SCOPUS, and grey literature sources. The quality of these guidelines was assessed by 4 reviewers using the Appraisal of Guideline for Research and Evaluation, 2nd edition (AGREE II). Domain scores were considered of acceptable quality if they scored >60%, and Interclass correlation coefficients (ICC) were calculated to assess agreement among the appraisers.
Results: Seven guidelines were assessed for evaluation. Among these, only the World Health Organization
(WHO) guidelines achieved an overall rating of “high.” Three were “average” quality, and the remaining 3
were “low” quality. The “Scope and Purpose” domain achieved the highest mean score (88.7 ± 7.6), and
the lowest was “Editorial Independence” (47.0 ± 27.6).
Conclusion: Areas of strength among the CPGs included “Scope and Purpose” and “Clarity and
Presentation,” as the guidelines were easily understood and described clear goals. The domains
requiring improvement were “Editorial Independence,” “Applicability,” and “Rigor of Development,”
indicating that not all patients or providers may benefit from these CPGs. This analysis found one strong
CPG pertaining to the management of tobacco use during pregnancy; however, several published
guidelines lack methodologic rigor and have limited applicability.
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