PROMISE Protocol Delivered by Midwives Increased Discussions About Smoking Cessation

This trial was conducted at 20 midwifery practices and 3 hospital obstetric departments in the Netherlands in 2017.

A stepped-wedge cluster randomized controlled trial found that a smoking cessation program administered by midwives was successful at facilitating more conversation with pregnant women about quitting. These findings were published in the journal Midwifery.

This trial was conducted at 20 midwifery practices and 3 hospital obstetric departments in the Netherlands in 2017. Midwives and obstetrics and gynecology (OB-GYN) specialists were administering an existing smoking cessation protocol called V-MIS. During the study, practitioners were randomized to receive face-to-face training about the PROMISE protocol after which time they crossed over to using the PROMISE program in practice. The practitioners responded to 6 questionnaires throughout the study about the proportion of patients and amount of time they spent discussing smoking cessation with patients during the V-MIS or PROMISE programs.

The V-MIS program comprised 6 steps in which the midwife or OB-GYN discussed smoking behavior and motivations to quit and provided self-help materials and support. The PROMISE program complemented the V-MIS protocol with the addition of more referral options and distribution of educational leaflets and a carbon monoxide meter.

A total of 106 midwifes or OB-GYNs were recruited for this study, 85 received the PROMISE training, and 81 completed both experimental phases and filled out 1 or more experimental surveys. The practitioners who completed the study were 89.6% women, they were aged mean 40.3 SD, 10.3) years, and 81.8% were midwives.

During the V-MIS and PROMISE phases of the experiment, the average number of clients seen in the previous month was 69.8 and 55.7, among whom 7.4 and 4.1 were smokers, respectively.

During the PROMISE protocol, the proportion of patients whom the practitioners discussed smoking cessation strategies with increased from 51.7% to 56.8%, indicating that switching strategies resulted in a significant increase in facilitating cessation discussions (β, -0.43; P =.031).

Similarly, the proportion of smoking clients with whom the practitioners discussed smoking in general increased from 66.0% to 72.0% (β, -0.45; P =.006).

Despite the increased discussion rate about smoking cessation, no significant increase in time spent conducting the intake interview (mean, 6.0 vs 7.2 min; β, -2.55; P =.148) or during consolation (mean, 3.3 vs 3.8 min; β, -0.36; P =.690) were observed.

Trends were similar between the intention to treat and per protocol populations.

The major limitation of this study was the large number of midwives and OB-GYNs lost to follow-up, likely in part due to the stepped wedge design, which placed a high burden on the practitioners.

The study authors concluded, “The PROMISE smoking cessation counselling protocol significantly improved the provision of smoking cessation support for pregnant women in the participating midwifery practices and obstetrics hospitals departments. Midwives and OB-GYNs are recommended to implement this protocol and its accessory materials in daily practice.”


Bommelé J, Springvloet L, Abouri N, Djoyoadhiningrat-Hol K, van Laar M, Blankers M. The effectiveness of PROMISE minimal smoking cessation intervention strategy to improve the adherence to smoking cessation counselling during pregnancy: A stepped-wedge cluster randomized controlled trial. Midwifery. 2022;111:103364. doi:10.1016/j.midw.2022.103364