Prenatal behavioral risk screening by computer in a health maintenance organization -based prenatal care clinic Sandra C. Lapham, MD, MPH,. Michael K. Kring, BSCS: and Betty Skipper, PhDC Albuquerque, New Mexico Cigarette smoking, alcohol and drug abuse, and stressful life events are significant contributors to prematurity and low birth weight in the United States. Identification and treatment of pregnant women with these risk factors require obtaining complete and accurate psychosocial histories. The purpose of this study was to determine whether a computer interview developed by our staff is appropriate for assessing behavioral risk factors for adverse pregnancy outcomes and for educating pregnant women about healthy behaviors during pregnancy. This computer interview asks about pregnant patients' perceived life stressors, diet, use of cigarettes and alcohol, and abuse of drugs. The study population consisted of 201 medically insured Hispanic and non-Hispanic white women attending a health maintenance organization-based prenatal clinic. Almost all subjects rated the computer interview favorably. Medical record reviews were conducted to compare participants' reports of cigarette, alcohol, and drug use obtained from paper-and-pencil interviews with behaviors reported during the computer interview. Although self-reported rates of smoking did not differ between the two interview techniques, a much higher percentage of women reported alcohol and drug use during the computer interview. Study participants scored significantly higher on a test measuring knowledge of the effects of stress, diet, and substances of abuse on pregnancy than did a control group. Results demonstrated the potential value of computer-interactive software programs for assessing high-risk behaviors among pregnant women in this population and educating them about healthy behaviors during pregnancy. (AM J OSSTET GVNECOL 1991 ;165:506-14.)

Key words: Computer, screening, prenatal education, substance abuse Smoking and drinking alcohol are prevalent behaviors among the United States population. 1 Although public awareness of the risks of cigarette smoking and alcohol and drug use during pregnancy has increased! many women report that these issues are not discussed as part of their prenatal care.'-5 Medical personnel also have difficulty obtaining accurate information from patients about alcohol use and substance abuse. An investigation by Morrow-Tlucak et al. 6 demonstrated underreporting of alcohol use during pregnancy by a significant proportion of women. Another study by Zuckerman et al. 7 revealed that of 202 pregnant women whose urine assays were positive for marijuana and 114 women whose urine assays were positive for cocaine, 16% and 24%, respectively, had denied having used these drugs.

From the Center for Health and Population Researcha and the Computer Facility,' Lovelace Medical Foundation, and the Department of Family and Community Medicine, University of New MexIco School of Medicine.' Supported by grants from the Lovelace Medical Foundation, the March of Dimes Birth Defects Foundation, and the University of New Mexico, General Clinical Research Program, NCRR, NIH 5 M01RR00997-14. Received for publication October 19,1990; revised February 7, 1991; accepted February 12, 1991. . Reprint requests: Sandra C. Lapham, MD, MPH, Lovelace MedIcal Foundation, 1650 University, Suite 302, Albuquerque, NM 87102.

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Patient-interactive computer interviews have demonstrated value in obtaining medical histories and educating persons about behavior-related health problems.s lO Although there are no published studies investigating the efficacy of computer-based interviews when used in pregnant populations, this technology is easily adapted for screening and health education in a prenatal care clinic setting. We have developed a personal computer-based software program to identify high-risk behaviors and to educate patients about healthy behaviors during pregnancy. This program: (1) assesses the behavioral risks of pregnant women, (2) provides educational information to patients in the form of personalized feedback, provided both on the video screen and on computer-generated printouts, (3) offers a resource directory of specialized· health care services available to assist high-risk patients, and (4) collects anonymous prevalence data regarding reported behavioral risk factors in the population under study. Topics addressed during the interview include cigarette smoking, alcohol and drug use; optimal eating habits during pregnancy; and the importance of stress management. We wish to report the results of a study conducted among medically insured Hispanic and nonHispanic white women attending a health maintenance organization-based prenatal clinic. The objectives of the study were (1) to determine whether this patient-

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interactive computer interview is well accepted in this population, (2) to determine the educational value of the program, (3) to determine the validity of selfreported information on cigarette and drug use provided during the computer interview, and (4) to compare reports of substance abuse provided during the confidential computer interview with that currently being obtained through patient self-reports of high risk behaviors on a written questionnaire. Material and methods

Description of the computer program. The Pregnancy Information Program has two important features: a flexible format, which allows programming and text changes to address specific needs of differing patient populations, and strict confidentiality protection. It is divided into eight sections: general information, stress, nutrition, cig,!:rette smoking, alcohol use, use of other drugs of abuse, program evaluation, and printouts. The program was developed with the Knowledge Man data base management system (Micro Data Base Systems, Lafayette, Ind.) and is designed for use by persons with no computer experience or typing skills. The program text consists of multiple choice questions, written at a sixth- or seventh-grade reading level, that can be answered by typing in a number. A fiberglass overlay covers the keyboard , exposing only the number keys and the return key. The subjects can answer all questions by entering one of 10 numbers and pressing the return key. The subjects' answers are checked by the Pregnancy Information Program to determine if they are in the correct range, and they are verified by the subject. Feedback is provided by the software's simple graphics in a range of screen colors. The program collects information about the patient's eating habits, life-style practices, and life situations; explains known health effects of the behaviors under investigation; provides individualized visual and printed feedbackimmediate information about how the patient's behaviors may be affecting herself and her fetus; asks the participant to rate the computer program; and generates a participant and a provider printout summarizing the assessment. The format of this interview is similar to that of the Lifestyle Assessment for general adult medical patients developed by Allen and Skinner 11 and has features similar to health risk appraisals used in community health promotion programs. However, no risk estimates are provided in the Pregnancy Information Program. Since patients may equate risk with cause and may not understand the concept of risk, the program does not use the term risk. Feedback is given in simple terms, such as "studies have shown that smoking can harm the baby" or "your baby could be healthier if you stop drinking alcoholic drinks while pregnant." When statements include the concept of risk, the wording is as

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follows: "this may increase the chance that" or "you are more likely to have a healthy baby." The feedback information is not a fear message and does not exaggerate the health effects of the behaviors discussed. Efforts were made, when possible, to use preexisting, validated questions for specific sections of the program. A description of each section follows: Section 1: Demographic information. This section requests the following : name, date of bi;th, weeks' gestation, number of previous pregnancies, number of children, years of education, ethnicity and race, number of children and adults in the household, marital status, and income. Section 2: Stress (psychosocial risk). The computer program includes questions designed to identify women experiencing symptoms of psychologic distress. Specific questions ask whether the patient is the victim of domestic violence or is living with an alcohol or drug abuser. Questions also are asked about the patient's own perception of her level of stress, anxiety, and depression; whether she has support from family members or friends; her usual methods for dealing with stress; and whether the pregnancy was wanted. Section 3: Nutrition. A complete assessment of the adequacy of dietary intake is not possible within the limitations of a brief computer program. The Pregnancy Information Program simply provides examples of foods belonging to each of the four basic food groups , defines a serving size, and asks the patient about her usual daily intakes of servings from each group. Feedback is consistent with current guidelines for optimal dietary intakes provided by the Women and Infant Care Guidelines. 12 Information provided to participants includes education about optimal weight gain during pregnancy and reinforcement that meals should be balanced according to the basic food groups. Section 4: Cigarette smoking. Questions were designed to collect accurate information on this and other sensitive topics in a nonthreatening manner. Information gathered includes whether the participant smoked during previous pregnancies, number of cigarettes smoked before becoming pregnant, number of cigarettes currently smoked daily, previous attempts to quit, the participant'S view of how smoking may affect her own health and the health of the fetus, and the smoking status of the baby's father. Some of the questions used (with permission) in this interview were developed by Roger Secker-Walker, MO, Professor of Medicine , University of Vermont, Burlington. Feedback and education stress the positive benefits of quitting smoking and effective methods to quit. 13 A special section written for smokers not only provides information about smoking during pregnancy but also attem pts to dispel some of the myths about quitting smoking. The program then provides a short self-help method for quitting. Section 5: Alcohol use. Patients were asked about the

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.I

EXAMPLE: PROVIDER SUMMARY PLEASE GIVE TltlS PRINTOUT ONL Y TO YOUR NURSE OR DOCTOR Name: OOE. JANE GENERAL TOPICS FOR DISCUSSION: AMOUNT OF TIME SPENT STANDING PHYSICAL ABUSE AND/O R SEXUAL ASSAULT WORRY ABOUT PREGNANCY OUTCOME DEPRESSION OR ANXIETY THOUGHTS OF SUICIDE

. OOET

JANE' S NUTRITION SUMMARY IS GIVEN BELOW:

H E L P I N G S

US RECOMMENDED ~

n~~~~3 MILK

MEAT BREAD FRUIT FOOD GROUPS

RECOMMENDED DIET YOUR DIET

SMOKING: JANE CURRENTLY SMOK ES 20 C IGAR ETTES PER DA Y SMOKED DURING A PREVI OUS PREGNANCY liAS NOT TRIED '10 QUIT ALCOIIOL: liAS ADOUT 20 DRINKS/WEEK ANIJ AS MANY AS 5 AT A TIME. INIJI CATED SIIE MA Y IIA VE PRODLEM WITH ALCOHOL USE. DRUGS:

JANE CURRENTI.Y USES; MARIJUANA. II AL LUCIN ()GENS. COCAINE / CRA CK. STI MULANTS. OPIATE PAIN KILLERS. SEDATIVES. TRANQUILIZERS & INHALANI S,

Fig. 1. Example of provider sum mary. Pregnancy Information Program.

frequency and quantity of their alcohol consumption before and during this pregnancy. Questions on alcohol use and corresponding feedback were derived (with permission) from the "Ten Questions Drinking History" used at the Boston City Hospital's Fetal Alcoho l Education Program, Boston.' 1 Section 6: Use of drugs of abuse. Patients were asked specific questions about their present and prior use of marUuana, amphetamine-like drugs (including cocaine) , opiates, barbiturates (and other "downers"), tranquilizers, hallucinogens, and inhalants. The assessment questions were developed by Drs. Allen and Skinner for their Lifestyle Assessment " and were modified and adapted for the Pregnancy Information Program. Section 7: Computer program evaluation. The computer interview also queries whether the participant liked the program; learned anything new about each of the subjects covered; was honest; would have been more or less honest if interviewed in person or by a paper-andpencil interview; wou ld prefer a computer, face-to-face, or paper-and-pencil interview; and whether the program took too much time to complete. All questions are answered with a seven-point rating scale, with re-

sponses ranging from strongly agree, agree, somewhat agree, don't know, etc. , to strongly disagree. Section 8: Printouts . T he first computer printout is fo r the patient's use. It presents a summary of her individualized feedbac k and, for those who have identified a behavioral risk factor, provides educational material and a menu of options for obtaining information or assistance in changing unhealth y behaviors or situations. Included in this menu are options for specialized care availa ble to the patient at the care-giving institution, lists of community resources, and lists of self-help literature. This menu can easily be custom programmed to meet the specific needs of individual offices, clinics, or institutions. The second printout is a one-page provider summary (Fig. 1). The program encourages women to share this printout with their providers. Procedures. All pa tients who were within the first 20 weeks of pregnancy were eligible to participate. The study was conducted at the Lovelace Medical Center, Albuquerque, from January through December 1988. At the time of the study about 30 to 40 patients per week underwent their first prenatal examinations at the prenatal clinic. The study protocol was ap proved by the

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Lovelace Medical Center's Institutional Review Board. Participants were recruited by a trained project associate who explained the study to prospective subjects and asked them to provide informed consent. All participants were told that the information collected during the interview would remain strictly confidential and would not be given by the investigators to their health care providers. All women who agreed to participate received the computer program. On completion of the Pregnancy Information Program, the women were given both computer printouts. Participants had the option of giving the provider summary to their physicians. Attempts were made to enroll all eligible patients. Those who refused were asked to complete a postcard survey anonymously, containing such information as age, ethnicity, marital status, number of pregnancies, education level, and employment status, to assess possible biases introduced by patient self-selection into the study. Urine specimens were obtained from all study subjects at the time of the computer interview, to validate their reports of nonuse of cigarettes and use or nonuse of drugs of abuse. All participants received the Wide Range Reading Achievement Test (Jastak Associates, Inc., Wilmington, Del.) before completing the computer program. Most subjects received the program before their first prenatal visit. All participants participated in the standard program for prenatal care and health education offered by Lovelace Medical Center. Smoking status was determined by measuring cotinine levels in urine. Cotinine is a direct metabolite of nicotine and, unlike nicotine, has a relatively long halflife.15 Cotinine can be quantified by a radioimmunoassay technique developed by Langone et al.!6 and has been shown to be a valid indicator of tobacco smoke exposure.!7 Furthermore, cotinine levels in urine and saliva have been shown to correlate well with those in plasma.!7 Urine cotinine and creatinine ratio analyses were performed at the Clinical Research Center Laboratory, University of New Mexico School of Medicine, Albuquerque. Urine cotinine measurements >49.6 ng / ml were considered presumptive evidence of active smoking.!S Urine samples were screened by radioimmunoassay at the University of New Mexico Toxicology Laboratory for the following classifications of drugs of abuse: opiates, cocaine and other stimulants, tetrahydrocannabinoids, benzodiazepines, and barbiturates. Positive results were verfiied at the same laboratory by gas chromatography-mass spectrometry. To evaluate the educational component of the Pregnancy Information Program, a 33-item test was designed by Lovelace research staff to evaluate participants' knowledge of the four basic food groups, the definition of stress, the effects of cigarette smoking, and

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the effects of use of drugs of abuse during pregnancy. * This test was validated among patients at the Lovelace Medical Center clinic; then it was administered to 169 subjects who had received the Pregnancy Information Program from 12 to 20 weeks earlier in their pregnancies and, finally, to a comparison group consisting of 66 patients in the third trimester of pregnancy who were receiving prenatal care at Lovelace Medical Center and who had not been offered the computer program. After each participant gave birth, a trained abstractor, who did not know the purpose of the study and had no information regarding the responses given by participants to the computer interview, reviewed each of the medical records. Chart reviews were conducted for 196 (97%) of the 201 subjects. Five medical records were missing or unavailable, and five additional records contained incomplete information. Information abstracted from the medical record included participant responses to a written questionnaire that queried the patient'S use of cigarettes, alcohol, and drugs of abuse. This questionnaire was administered to participants in a group setting as part of a prenatal education class. Women completed this questionnaire 1 day to 4 weeks before they received the computer interview. Data from the computer-assisted program were stored on the personal computer's hard drive and on floppy diskettes. Data were then transmitted by floppy diskette to a minicomputer for storage and subsequent data analysis. Pregnancy Information Program information, laboratory results, results of the reading tests, and information collected from the medical records were entered directly into a computer file. All data collected for each subject were expanded into single sequential records. Records were processed and analyzed statistically by a series of SAS (Statistical Analysis Systems Institute, Raleigh, N.C.) programs. Results Participation rate and characteristics of participants. Of the 229 eligible women who were asked to participate in the study, 201 (88%) agreed to participate. One woman agreed to take the program but refused to provide a urine specimen. The most commonly used reason for non participation among the 28 nonparticipants was "not enough time" (54%), followed by "not interested in the study" (25%). One woman expressed a dislike of computers, and one woman felt her reading skills were too poor. Characteristics of participants and nonparticipants were similar. The study population was almost equally divided between Hispanic (48%) and non-Hispanic (49%) white women. Ages of participants ranged from *Copies of this questionnaire are available from the authors on request.

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Table 1. Participant ratings of computer interview Response (%) (N = 201) Topic and statement

Acceptability I like this interview I found this interview easy to read and understand I would rather be interviewed by a person than a computer I would prefer a paper-and-pencil questionnaire to a computer interview Educational value I learned new information about: Stress Nutrition during pregnancy Smoking during pregnancy Alcohol and drug use during pregnancy Perceived value as a motivator of behavior change I will change my life-style habits because of this interview Validity I confidentiality I was totally honest during this computer interview I would be less honest if my answers were given to my doctor and added to my medical chart I will give my doctor the report of my life-style habits I was more honest in this interview than I would be in a personal or paper-and-pencil interview

Strongly disagree

Strongly agree

3 or 4 days before sampling. Exceptio ns includ e marijuana (detectable for as long as 30 days for a heavy marijua na user, 7 to 10 days for a moderate user, and 3 to 5 days for a light u ser), phe-

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nobarbital (detectable for 2 to 3 weeks), methaqualone (detectable for 2 weeks), and phencyclidine (detectable for 8 days)!l In addition, urine tests are not 100% sensitive and specific. They were performed on a relatively small cohort and were obtained at one time point. Therefore some participants may have been misclassified as being truthful (false negative) or untruthful (false positive). Subjects were informed that the urine specimens provided may be tested for cotinine and drugs of abuse. Some of the participants could have been more honest in reporting smoking and drug use because they did not want their test results to belie their answers to these questions. Finally, testing did not include a screen for recent alcohol use. Previous studies have found that computers may obtain more accurate information than that obtained in a face-to-face interview!2,23 Skinner and Allen 24 found that people were equally honest with computer-based interviews as with face-to-face or paper-and-pencil questionnaires in reporting use of alcohol, tobacco, caffeine, and drugs. The fourth objective of the study was to compare responses to the Pregnancy Information Program with self-reported use of cigarettes, alcohol, and drugs of abuse obtained by a written questionnaire, completed as part of routine care in this prenatal clinic. Study participants did report significantly more drug and alcohol use during the computer interview; there was no difference in the rate of reported smoking. In the majority of instances, the discrepancy occurred because the participant denied the behavior during the written questionnaire and reported the behavior in the computer interview. However, there were a small number of exceptions, where a subject reported the behavior in the written questionnaire and denied it during the computer interview. There are several possible explanations for the discrepancies between reports obtained from the two questionnaire modalities. The most likely explanation is that the women were more honest in reporting their behaviors during the computer interview. Conceivably women who were not smoking, drinking alcohol, or using drugs at the time they attended the prental class initiated these behaviors in the period between taking the written questionnaire and the computer interview. However, this seems unlikely. Available evidence indicates that a high percentage of women abstain from or reduce smoking and drinking alcohol soon after discovering they are pregnant. 25 , 26 Some of the participants may have reduced their high-risk behaviors as a result of the information provided during the educational class before receiving the computer program. This could account for the small number of persons who reported the behavior initially during the written questionnaire and failed to report

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the behavior during the computer interview. Some participants also may have misread or misunderstood the questions in either questionnaire, thus accounting for discrepancies. The computer interview was offered in a setting of anonymity. Information provided during the computer interview was not made available to the patients' physicians; however, included in the on-screen information for the participants was a statement urging them to give the computer printout entitled "Provider Summary" to their physicians. An informal survey of providers conducted after this study was completed revealed that few printouts were actually received by providers. This is in contradistinction to the high percentage of women who stated they would give the report to their providers. In a recent study of pregnant women 6 the authors found that those with a history of alcohol-related problems, determined by an elevated score on the Michigan Alcoholism Screening Test, were most likely to underreport alcohol consumption. In this study a large number of participants did not wish to disclose the results of their interviews to their physicians. The persons who were least willing to share their life-style information with their physicians were current drug and alcohol users. This finding supports the conclusion that the observed increased reporting of alcohol and drug use during the computer interview was attributable to its confidential nature. Routine use of institution-specific computer software programs, such as described here, could provide personalized health risk information to all patients, including those women who do not report their behavior accurately to their health care providers. The software could be programmed to direct patients to an appropriate referral source and could optimize the use of existing services within the institution. The providers administering the interview would obtain prevalence data, which could be used to guide medical staff in making informed decisions about resource allocations. In addition, anonymous patient-interactive computer programs have demonstrated value in increasing dialogue between patients and their physicians in a general medical practice. Skinner et al. B found that patients were more likely to discuss life-style issues with their physicians if they received a computerized life-style assessment before seeing their physicians. If the Pregnancy Information Program were used as part of routine care, the provider summaries, when patients chose to share them, could serve as a focus for discussions regarding high risk for adverse pregnancy outcomes. This study demonstrated that a confidential, computerized, patient-interactive assessment was valid in this patient population. Its use in prenatal clinics could enhance prenatal education programs and provide in-

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formation useful for institutional planning and resource allocation. We thank Clay Burchell, MD,Jan Ross, RN, andJane Grubbs, RN, the staff of the Lovelace Department of Obstetrics and Gynecology, and the participants for their support of this study. We thank Gayle Sovereign for administering the program to participants; Harvey Skinner, PhD, David Paperny, MD, Diana Koster, MD, Marcia Messer, RN, and Pamela Palmer, PhD, for their contributions to the development of the Pregnancy Information Program; and Gary Simpson, MD, PhD, for his review of this manuscript. REFERENCES I. Fox SH, Brown C, Koontz AM, Kessel SS. Perceptions of risks of smoking and heavy drinking during pregnancy: 1985 NHIS findings. Public Health Rep 1987;102:73-9. 2. Marks ]S, Hogelin GC, Gentry EM, et al. The behavioral risk factor surveys: I. State-specific prevalence estimates of behavioral risk factors. Am] Prev Med 1985; 1: 1-8. 3. Dalton ER, Hughes CA, Cogswell]J. Cigarette smoking in pregnancy: a health education problem. Public Health (Lond) 1981;95:207-54. 4. Prager K, Malin H, Spiegler D, Van Natta P, Placek PJ. Smoking and drinking behavior before and during pregnancy of married mothers of live-born infants and stillborn infants. Public Health Rep 1984;99:117-27. 5. Minor M], Van Dort B. Prevention research on the teratogenic effects of alcohol. Prev Med 1982; 11 :346-59. 6. Morrow-Tlucak M, Emhart CB, Sokol RJ, MariterS, Ager J. Under-reporting of alcohol use in pregnancy: relationship to alcohol problem history. Alcoholism Clin Exp Res 1989; 13:399-40 I. 7. Zuckerman B, Frank DA, Hingson R, et al. Effects of maternal marijuana and cocaine use on fetal growth. N Engl] Med 1989;32:762-768. 8. Skinner HA, Allen BA, McIntosh MC, Palmer WHo Lifestyle assessment:just being asked makes a difference. BMJ 1985;290:214-6. 9. Bernadt MW, Daniels OJ, Blizard RA, Murray RM. Can a computer reliably elicit an alcohol history? Br J Addiction 1989;84:405-11. 10. Paperny DM, Lehman RM, Hammar SL. Computerassisted detection and intervention in adolescent high-risk health behaviors. Am J Dis Child 1986; 140:293. II. Allen BA, Skinner HA, Lifestyle assessment using microcomputers. In: Butcher IN, ed. Computer psychology assessment. New York: Basic Books, 1987: 108-23.

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12. State of New Mexico policy manual for program operations, fiscal year 1986: special supplemental food program for women, infants, and children. Santa Fe: New Mexico WIC Program, Health and Environment Program, Health Services Division, 1986. 13. Hogue CJR, Zahnise SC, Dalmat ME. You can help your OB patients stop smoking. Contemp Ob/Gyn Aug 1987: 130-43. 14. Rosett HL, Weiner L, Edelin KC. Strategies for prevention of fetal alcohol effects. Obstet Gynecol 1981 ;57: 1-7. 15. Kyerematen GA, Damiano MD, Dvorchik BH, Vesell ES. Smoking-induced changes in nicotine disposition: application of a new HPLC assay for nicotine and its metabolites. Clin Pharmacol Ther 1982;32:769-80. 16. Langone], Gjika HB, Van Vunakis H. Nicotine and its metabolites: radioimmunoassay for nicotine and cotinine. Biochemistry 1973;12:5025-30. 17. Sepkovic DW, Haley NJ. Biomedical applications of cotinine quantitation in smoking related research. AmJ Public Health 1985;75:663-5. 18. Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Vesey C, Saloojee Y. Comparison of tests used to distinguish smokers from nonsmokers. Am] Public Health 1987;77: 1435-8. 19. Erdman HP, Klein MH, Greist ]H. Direct patient computer interviewing.] Consult Clin Psychol 1985;53:76073. 20. Paperny DM, Starn JR. Adolescent pregnancy prevention by health education computer games: computer-assisted instruction of knowledge and attitudes. Pediatrics 1989;83:742-52. 21. Bassett RC. Disposition of toxic drugs and chemicals in man. 2nd ed. Davis, California: PSG, 1982. 22. Greist JH, Klein MH. Computer programs for patients, clinicians, and researchers in psychiatry. In: SidowskiJB, Johnson JH, Williams TA, eds. Technology in mental health care delivery systems. Norwood, New Jersey, Ablex, 1980:161-82. 23. Lucas RW, Mullin P], Luna CBX, McInroy DC. Psychiatrists and acomputer as interrogators of patients with alcohol-related illnesses: a comparison. Br ] Psychiatry 1977;131:160-7. 24. Skinner HA, Allen BA. Does the computer make a difference? Computerized versus face-to-face versus selfreport assessment of alcohol and drug and tobacco use. ] Consult Clin Psychol 1983;51:267-75. 25. Kruse J, Lefevre M, Zweig S. Changes in smoking and alcohol consumption during pregnancy-a populationbased study in a rural area. Obstet Gynecol 1986;67:62733. 26. Condon JT, Hilton CA. A comparison of smoking and drinking behaviors in pregnant women: who abstains and why? MedJ Aust 1988;148:381-5.