Motivational Counseling Research Articles

Client Motivation and Multicultural Counseling

This reaction article comments on the major contribution titled “Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice.” It first points out the article’s strengths, the primary of which was to move the construct of motivation to the center of focus in the discussion of counseling. In addition, the exploration of how motivation is conceptualized within each of the major theoretical schools of thought was illuminating. This reaction article also attempts to expand the discussion of motivation into the arena of multicultural counseling. One of the main efforts in multicultural counseling is to increase the utility of counseling services among racial and ethnic minorities and hence understanding the role of motivation is central. This reaction article explores the role of motivation in help-seeking behavior and offers ways in which motivation could be enhanced so that counseling services will be more frequently and better utilized.

Impact of a Health Promotion Intervention on Maternal Depressive Symptoms at 15 months Postpartum

Given that diet, physical activity, and social support are associated with depression, we examined whether a health promotion intervention designed to modify these factors in low-income, postpartum women would reduce depressive symptoms. This study used a randomized, controlled design to examine the effect of the Just for You (JFY) Program, an educational intervention promoting healthy lifestyles through home visits by nutrition paraprofessionals and motivational telephone counseling, on postpartum depressive symptoms. A total of 679 women income-eligible for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were recruited at 6-20 weeks post delivery and randomized to Usual WIC Care or JFY. Using an intention-to-treat analysis, the authors modeled depressive symptoms on the Center for Epidemiologic Studies Depression Scale (CES-D) among 403 women (59%) completing follow-up at a mean of 15 months infant age, adjusting for baseline CES-D, age, household income and randomization strata (body mass index (BMI), race/region). As a secondary analysis, the authors evaluated potential mediators related to social support and self-efficacy to change one or more health behaviors targeted by the intervention. Women randomized to JFY reported 2.5 units lower CES-D score (P = 0.046) compared with those receiving Usual WIC Care alone. This relationship was attenuated by change in self-efficacy (β = -2.3; P = 0.065), suggesting this construct may partially have mediated the effect of JFY on maternal depressive symptoms. A health promotion intervention delivered through home visits and telephone calls can reduce depressive symptoms at 15 months postpartum among low-income, ethnically diverse women.

Simplified routines in prescribing physical activity can increase the amount of prescriptions by doctors, more than economic incentives only: an observational intervention study.

BackgroundPhysical inactivity is one well-known risk factor related to disease. Physical activity on prescription (PAP) has been shown in some studies to be a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method involves motivational counselling that can be time-consuming for the prescribing doctor and might be a reason why physical activity on prescription is not used more frequently. This study might show a way to make the method of prescribing physical activity more user-friendly. The purpose is to determine whether a change in procedures increases the use of physical activity on prescription, and thus the aim of this study is to describe the methodology used.ResultsThe observational intervention study included an intervention group consisting of one Primary Health Care (PHC) clinic and a control group consisting of six PHC clinics serving 149,400 inhabitants in the County of Blekinge, Sweden.An economic incentive was introduced in both groups when prescribing physical activity on prescription. In the intervention group, a change was made to the process of prescribing physical activity, together with information and guidance to the personnel working at the clinics. Physical therapists were used in the process of carrying out the prescription, conducting the motivational interview and counselling the patient. This methodology was used to minimise the workload of the physician. The chi-2 test was used for studying differences between the two groups. PAP prescribed by doctors increased eightfold in the intervention group compared to the control group. The greatest increase of PAP was seen among physicians in the intervention group as compared to all other professionals in the control group. The economic incentive gave a significant but smaller increase of PAP by doctors.ConclusionBy simplifying and developing PAP, this study has shown a concrete way to increase the implementation of physical activity on prescription in general practice, as opposed to what can be gained by an economic bonus system alone. This study indicates that a bonus system may not be enough to implement an evidence-based method.

Telephonic screening and brief intervention for alcohol misuse among workers contacting the employee assistance program: A feasibility study

Substantial empirical support exists for alcohol screening, brief intervention, and referral to treatment (SBIRT) in medical, but not non-medical settings such as the workplace. Workplace settings remain underutilised for delivering evidenced-based health services. This research aims to translate medical research into behavioural health-care practice in a telephonic call centre acting as a point of entry into an Employee Assistance Program (EAP). The goal of the study is to examine the feasibility of implementing routine telephonic alcohol SBIRT in an EAP call centre and assess whether routine SBIRT results in increased identification of workers who misuse alcohol. The design was pretest-posttest, one-group, pre-experimental. An alcohol SBIRT program developed based on World Health Organization recommendations was implemented in one EAP call centre serving one large employer. Workers were offered screening using the Alcohol Use Disorder Identification Test (AUDIT) during intake, brief counselling using motivational interviewing, referral to counselling, and follow-up. At 5 months, 93% of workers contacting the EAP completed the AUDIT-C: 40% prescreened positive and 52% went on to screen at moderate or high risk for an alcohol problem. Overall identification rate (18%) approached general US population estimates. Most agreed to follow-up and three-quarters set an appointment for face-to-face counselling. Integration of routine alcohol SBIRT into EAP practice is feasible in telephonic delivery systems and increases identification and opportunity for brief motivational counselling. When SBIRT is seamlessly integrated workers are willing to answer questions about alcohol and participate in follow-up.[McPherson TL, Goplerud E, Derr D, Mickenberg J, Courtemanche S. Telephonic screening and brief intervention for alcohol misuse among workers contacting the employee assistance program: A feasibility study.

First steps for mommy and me: a pilot intervention to improve nutrition and physical activity behaviors of postpartum mothers and their infants.

To assess the feasibility of a pediatric primary care based intervention to promote healthful behaviors among 0-6 month old infants and their mothers. We enrolled two intervention practices (60 mother-infant pairs) and one usual care control practice (24 pairs) in a non-randomized controlled trial. We completed visits and interviews with 80 (95%) pairs at birth and 6 months. The intervention included (1) brief focused negotiation by pediatricians, (2) motivational counseling by a health educator, and (3) group parenting workshops. We evaluated the intervention effects on infant feeding, sleep duration, TV viewing, and mothers' responsiveness to satiety cues. Maternal behavioral targets included postpartum diet, physical activity, TV and sleep. At 6 months, fewer intervention than control infants had been introduced to solid foods (57% vs. 82%; P=0.04), and intervention infants viewed less TV (mean 1.2 vs. 1.5 h/d; P=0.07). Compared to control infants, intervention infants had larger increases in their nocturnal sleep duration from baseline to follow up (mean increase 1.9 vs. 1.3 h/d; P=0.05); larger reductions in settling time (mean reduction -0.70 vs. -0.10 h/d; P=0.02); and larger reductions in hours/day of nighttime wakefulness (mean reduction -2.9 vs. -1.5 h/d; P=0.08). There were no differences in breastfeeding, response to satiety cues, or maternal health behaviors. A program of brief focused negotiation by pediatricians, individual coaching by health educators using motivational interviewing, and group parenting workshops tended to improve infant feeding, sleep and media exposure, but had less impact on mothers' own health-related behaviors.

Study protocol: The Adherence and Intensification of Medications (AIM) study - a cluster randomized controlled effectiveness study

BackgroundMany patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen.MethodsIn this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates.DiscussionIntegration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care.Trial RegistrationThe ClinicalTrials.gov registration number is NCT00495794.

Motivation and Participation in a Phase III Cardiac Rehabilitation Programme: An Application of the Health Action Process Approach

This longitudinal study extends the previous research on low participation rates and high dropout rates in phase III cardiac rehabilitation (CR) exercise programmes. It examines the correlates of motivation and participation 6 months after inpatient phase II CR (T1) and the predictors of dropout 6 months later (T2) using the health action process approach (HAPA). Risk perception, outcome expectancies, self-efficacy, intention (at T1), and participation (at T1 and T2) in relation to phase III CR programmes was assessed in 456 patients. Based on intention and participation at T1, patients were classified as nonintenders (56%), intenders (13%), or actors (31%). Group differences were confirmed in outcome expectancies and self-efficacy. By T2, 21% of T1 actors had dropped out. Dropouts and maintainers differed in intention and self-efficacy (at T1). Results are in line with the HAPA and suggest a perspective for tailoring motivational counselling to improve participation in phase III CR programmes.

Motivational interviewing for smoking cessation in college students: A group randomized controlled trial

Objective To examine the efficacy of four individually-delivered Motivational Interviewing counseling sessions for smoking cessation versus a matched intensity comparison condition. Method From 2006–2009, students attending college in the Midwest smoking at least 1 of 30 days were recruited regardless of their interest in quitting. 30 fraternities and sororities were randomized, resulting in 452 participants. Results No significant differences were found for 30-day cessation between treatment and comparison at end of treatment (31.4% vs 28%, OR = 1.20, 95% CI 0.72,1.99) or at follow-up (20.4% vs 24.6%, OR = 0.78, 95% CI 0.50,1.22). Predictors of cessation at follow-up, regardless of condition, included more sessions attended (OR 1.2, 95% CI 1.1,1.8) and more cigarettes smoked in 30 days at baseline (OR 4.7, 95% CI 2.5,8.9). The odds of making at least one quit attempt were significantly greater for those in the smoking group at end of treatment (OR 1.75, 95% CI 1.11,2.74) and follow-up (OR 1.66, 95% CI 1.11,2.47). Modeling showed reduction in days smoked for both groups. At end of treatment, more frequent smokers in the treatment condition had greater reductions in days smoked. Conclusion Motivational Interviewing for smoking cessation is effective for increasing cessation attempts and reducing days smoked in the short run.

Motivational interviewing versus prescriptive advice for smokers who are not ready to quit

Objective Smokers who are not ready to quit are a very difficult group to treat. Physicians, nurses, and nurse practitioners are in a unique position to encourage patients to quit smoking. However, the best approach to do so is not clear. Methods A two-group randomized controlled trial with 218 pack-a-day precontemplative and contemplative smokers recruited from the community. The laboratory-based study was designed to simulate outpatient visits to general practitioners. Participants were randomized to a 15-min intervention to compare the effectiveness of brief motivational or prescriptive counseling by a health professional. Thirteen outcome variables included intentions to quit and verbal reports at 1 and 6 months with biological verification. A composite outcome measure was constructed to provide greater power to detect study differences. Results Approximately 33% of the sample reported at least one 24-h quit period during the 6 months they were followed after the trial. Results suggest that while neither treatment was superior, there were subgroup differences. Participants in the motivational condition were also more likely to respond to follow-up calls. Conclusions and practice implications Motivational interviewing and prescriptive advice were equally effective for precontemplative and contemplative smokers. Practitioners should use the method that appeals to them.

Applying test operating characteristics to measures of exercise motivation: A primer

Physical activity programmes that include a motivational counselling component can be effective at increasing exercise participation. Reliable screening procedures could provide a cost effective method of identifying and channelling those 'at risk' for non-participation into a motivational counselling intervention and increase participation and long-term adherence. Traditional statistical methods have played an important step in developing measures that are good predictors of future exercise behaviour. Test operating characteristics (TOCs), a set of clinical outcome statistics, could be used to evaluate the accuracy of these measures as screening tools in identifying those 'at risk' for non-participation and those 'not at risk' for use in applied settings, such as physical activity programmes. This paper will provide a primer on the use of TOCs, particularly as they apply to the evaluation of measures of exercise motivation. Also provided is an example application using eight measures of exercise motivation previously used in research.

Impact of spirometry feedback and brief motivational counseling on long-term smoking outcomes: A comparison of smokers with and without lung impairment

Objective We compared long-term outcomes among smokers with and without impaired lung functioning who received brief counseling highlighting their spirometric test results. Methods Participants in this analysis all received a brief motivational intervention for smoking cessation including spirometric testing and feedback (∼20 min), were advised to quit smoking, offered free access to a phone-based smoking cessation program, and followed for one year. Outcomes were analyzed for smokers with ( n = 99) and without ( n = 168) impaired lung function. Results Participants with lung impairment reported greater use of self-help cessation materials at 6 months, greater use of non-study-provided counseling services at 6 and 12 months, higher 7-day PPA rates at 6 months, and were more likely to talk with their doctor about their spirometry results. Conclusion Further research is warranted to determine if spirometry feedback has a differential treatment effect among smokers with and without lung impairment. Practice implications It is premature to make practice recommendations based on these data.

Exercise on prescription: changes in physical activity and health-related quality of life in five Danish programmes

Exercise prescribed by the general practitioner may be an important health-improving intervention for inactive individuals with lifestyle diseases. The objective was to analyse changes in physical activity and health-related quality of life among participants in five similar 'Exercise on Prescription' (EoP) programmes. The analysis was based on self-reported information in a follow-up design without a control group. The intervention comprised group training twice weekly in the first 2 months and once weekly in the following 2 months (24 sessions in all) combined with four to five sessions of motivational counselling. Self-report questionnaires were administered at the first contact and again after 4, 10 and 16 months. Outcome measures were changes in self-reported activity levels converted to metabolic equivalents and health-related quality of life measured by standard instruments (SF-12v2 and EQ-5D). 449 individuals (59% women, mean age 57 years) agreed to participate in the study. Dropout was considerable [123 (27%); 231 (52%) 297 (66%) after 4, 10 and 16 months]. Participants increased their physical activity level and health-related quality of life from baseline to 4 months and maintained improvement throughout the observation period. One in three to six participants increased their physical activity level and one in 4-10 achieved improvements in health-related quality of life. Exercise on prescription can contribute to improvements in physical activity level and health-related quality of life in physically inactive patients with or at increased risk of developing lifestyle diseases. An acceptable number of participants achieved and maintained improvements in physical activity level and health-related quality of life.

Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial

Chronic pain patients who show aberrant drug-related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain. The purpose of this study was to conduct a randomized trial in patients who were prescribed opioids for noncancer back pain and who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids. Forty-two patients meeting criteria for high-risk for opioid misuse were randomized to either standard control (High-Risk Control; N = 21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental; N = 21). Twenty patients who met criteria indicating low potential for misuse were recruited to a low-risk control group (Low-Risk Control). Patients were followed for 6 months and completed pre- and post-study questionnaires and monthly electronic diaries. Outcomes consisted of the percent with a positive Drug Misuse Index (DMI), which was a composite score of self-reported drug misuse (Prescription Drug Use Questionnaire), physician-reported abuse behavior (Addiction Behavior Checklist), and abnormal urine toxicology results. Significant differences were found between groups with 73.7% of the High-Risk Control patients demonstrating positive scores on the DMI compared with 26.3% from the High-Risk Experimental group and 25.0% from the Low-Risk Controls ( p < 0.05). The results of this study demonstrate support for the benefits of a brief behavioral intervention in the management of opioid compliance among chronic back pain patient at high-risk for prescription opioid misuse.

Effects of an intensive depression-focused intervention for smoking cessation in pregnancy.

The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. Mean age was 25 years (SD = 5.9), and women averaged 19.5 weeks (SD = 8.5) gestation at study entry. We measured symptoms of depression using the Center for Epidemiological Studies-Depression Scale (Radloff, 1977). At 6 months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.

How do we manage patients who become unemployed?

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social "vitamins" of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

The alliance in motivational enhancement therapy and counseling as usual for substance use problems.

Data from a community-based multicenter study of motivational enhancement therapy (MET) and counseling as usual (CAU) for outpatient substance users were used to examine questions about the role of the alliance in MET and CAU. Most (94%) of the sample met diagnostic criteria for abuse or dependence (primarily alcohol and/or cocaine). Sixteen therapists for CAU and 14 for MET participated. No reliable differences in patient ratings (n = 319) on the Helping Alliance Questionnaire-II (HAq-II) were evident for MET compared to CAU, but significant differences between therapists were found within each condition in mean patient-rated HAq-II scores. Overall, average levels of alliance were high. The between-therapists component of the alliance, but not the within-therapist component, was significantly associated with self-reported days of primary substance use during the follow-up period from Week 4 to Week 16 (Cohen's d = 0 .39; n = 257). Therapists with either low or very high alliances had relatively poorer average outcomes (quadratic effect, d = 0.44). For therapists in both MET and CAU, increased use of MET fundamental techniques and MET advanced techniques during treatment sessions was associated with higher levels of alliance. Implications of the findings for conceptualization of the alliance and for training of therapists are discussed.

Motivation and patch treatment for HIV+ smokers: a randomized controlled trial

To test the efficacy of two smoking cessation interventions in a HIV positive (HIV+) sample: standard care (SC) treatment plus nicotine replacement therapy (NRT) versus more intensive motivationally enhanced (ME) treatment plus NRT. Randomized controlled trial. HIV+ smoker referrals from eight immunology clinics in the northeastern United States. A total of 444 participants enrolled in the study (mean age = 42.07 years; 63.28% male; 51.80% European American; mean cigarettes/day = 18.27). SC participants received two brief sessions with a health educator. Those setting a quit date received self-help quitting materials and NRT. ME participants received four sessions of motivational counseling and a quit-day counseling call. All ME intervention materials were tailored to the needs of HIV+ individuals. Biochemically verified 7-day abstinence rates at 2-month, 4-month and 6-month follow-ups. Intent-to-treat (ITT) abstinence rates at 2-month, 4-month and 6-month follow-ups were 12%, 9% and 9%, respectively, in the ME condition, and 13%, 10% and 10%, respectively, in the SC condition, indicating no between-group differences. Among 412 participants with treatment utilization data, 6-month ITT abstinence rates were associated positively with low nicotine dependence (P = 0.02), high motivation to quit (P = 0.04) and Hispanic American race/ethnicity (P = 0.02). Adjusting for these variables, each additional NRT contact improved the odds of smoking abstinence by a third (odds ratio = 1.32, 95% confidence interval = 0.99-1.75). Motivationally enhanced treatment plus NRT did not improve cessation rates over and above standard care treatment plus NRT in this HIV+ sample of smokers. Providers offering brief support and encouraging use of nicotine replacement may be able to help HIV+ patients to quit smoking.

Group-randomized trial of a proactive, personalized telephone counseling intervention for adolescent smoking cessation.

The Hutchinson Study of High School Smoking randomized trial was designed to rigorously evaluate a proactive, personalized telephone counseling intervention for adolescent smoking cessation. Fifty randomly selected Washington State high schools were randomized to the experimental or control condition. High school junior smokers were proactively identified (N = 2151). Trained counselors delivered the motivational interviewing plus cognitive behavioral skills training telephone intervention to smokers in experimental schools during their senior year of high school. Participants were followed up, with 88.8% participation, to outcome ascertainment more than 1 year after random assignment. The main outcome was 6-months prolonged abstinence from smoking. All statistical tests were two-sided. The intervention increased the percentage who achieved 6-month prolonged smoking abstinence among all smokers (21.8% in the experimental condition vs 17.7% in the control condition, difference = 4.0%, 95% confidence interval [CI] = -0.2 to 8.1, P = .06) and in particular among daily smokers (10.1% vs 5.9%, difference = 4.1%, 95% CI = 0.8 to 7.1, P = .02). There was also generally strong evidence of intervention impact for 3-month, 1-month, and 7-day abstinence and duration since last cigarette (P = .09, .015, .01, and .03, respectively). The intervention effect was strongest among male daily smokers and among female less-than-daily smokers. Proactive identification and recruitment of adolescents via public high schools can produce a high level of intervention reach; a personalized motivational interviewing plus cognitive behavioral skills training counseling intervention delivered by counselor-initiated telephone calls is effective in increasing teen smoking cessation; and both daily and less-than-daily teen smokers participate in and benefit from telephone-based smoking cessation intervention.

Brief and intensive behavioral interventions to promote sexual risk reduction among STD clinic patients: results from a randomized controlled trial.

The purpose of this study was to evaluate the separate and combined effectiveness of brief and intensive interventions for sexual risk reduction among patients at a sexually transmitted disease (STD) clinic. Patients (N =1483; 54% men; 64% African-American; M = 29.2 years old) were recruited from a publicly funded, walk-in STD clinic. Patients completed a baseline assessment, and then were randomized to one of six intervention arms; each arm combined a brief intervention with an intensive intervention. The interventions provided different levels of information, motivational counseling, and behavioral skills training, guided by theory, formative research, and empiric precedent. Follow-up assessments, including STD screening, occurred at 3, 6, and 12 months post-intervention. The results showed that infection rates declined from 18.1% at baseline to 4.5% at 12 months. At a 3-month follow-up, patients reported fewer sexual partners, fewer episodes of unprotected sex, and a lower percentage of unprotected sexual events; they strengthened sexual health knowledge, safer sex attitudes and intentions, and self-efficacy beliefs. No consistent pattern of differential risk reduction was observed among the six intervention conditions, nor was any evidence of decay from 3 to 12-month follow-ups obtained. We conclude that implementing behavioral interventions in a STD clinic was associated with significant reduction of sexual risk behavior and risk antecedents.

Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy.

Cigarette smoking during pregnancy is associated with poor maternal and child health outcomes. Effective interventions to increase smoking cessation rates are needed particularly for pregnant women unable to quit in their first trimester. Real-time ultrasound feedback focused on potential effects of smoking on the fetus may be an effective treatment adjunct, improving smoking outcomes. A prospective randomized trial was conducted to evaluate the efficacy of a smoking cessation intervention consisting of personalized feedback during ultrasound plus motivational interviewing-based counseling sessions. Pregnant smokers (N = 360) between 16 and 26 weeks of gestation were randomly assigned to one of three groups: Best Practice (BP) only, Best Practice plus ultrasound feedback (BP+US), or Motivational Interviewing-based counseling plus ultrasound feedback (MI+US). Assessments were conducted at baseline and end of pregnancy (EOP). Analyses of cotinine-verified self-reported smoking status at EOP indicated that 10.8% of the BP group was not smoking at EOP; 14.2% in the BP+US condition and 18.3% who received MI+US were abstinent, but differences were not statistically significant. Intervention effects were found conditional upon level of baseline smoking, however. Nearly 34% of light smokers (< or =10 cigarettes/day) in the MI+US condition were abstinent at EOP, followed by 25.8% and 15.6% in the BP+US and BP conditions, respectively. Heavy smokers (>10 cigarettes/day) were notably unaffected by the intervention. Future research should confirm benefit of motivational interviewing plus ultrasound feedback for pregnant light smokers and explore mechanisms of action. Innovative interventions for pregnant women smoking at high levels are sorely needed.