Preventing postpartum smoking relapse among diverse low-income women: a randomized clinical trial

Relapse prevention interventions for smoking cessation

BACKGROUND

A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Several interventions have been proposed to help prevent relapse.

OBJECTIVES

To assess whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in May 2013 for studies mentioning relapse prevention or maintenance in title, abstracts or keywords.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of relapse prevention interventions with a minimum follow-up of six months. We included smokers who quit on their own, were undergoing enforced abstinence, or were participating in treatment programmes. We included trials that compared relapse prevention interventions with a no intervention control, or that compared a cessation programme with additional relapse prevention components with a cessation programme alone.

DATA COLLECTION AND ANALYSIS

Studies were screened and data extracted by one review author, and checked by a second. Disagreements were resolved by discussion or by referral to a third review author.

MAIN RESULTS

Sixty-three studies met inclusion criteria but were heterogeneous in terms of populations and interventions. We considered 41 studies that randomly assigned abstainers separately from studies that randomly assigned participants before their quit date.Upon looking at studies of behavioural interventions that randomly assigned abstainers, we detected no benefit of brief and 'skills-based' relapse prevention methods for women who had quit smoking because of pregnancy, or for smokers undergoing a period of enforced abstinence during hospitalisation or military training. We also failed to detect significant effects of behavioural interventions in trials in unselected groups of smokers who had quit on their own or through a formal programme. Amongst trials randomly assigning smokers before their quit date and evaluating the effects of additional relapse prevention components, we found no evidence of benefit of behavioural interventions or combined behavioural and pharmacotherapeutic interventions in any subgroup. Overall, providing training in skills thought to be needed for relapse avoidance did not reduce relapse, but most studies did not use experimental designs best suited to the task and had limited power to detect expected small differences between interventions. For pharmacological interventions, extended treatment with varenicline significantly reduced relapse in one trial (risk ratio (RR) 1.18, 95% confidence interval (CI) 1.03 to 1.36). Pooling of six studies of extended treatment with bupropion failed to detect a significant effect (RR 1.15, 95% CI 0.98 to 1.35). Two small trials of oral nicotine replacement treatment (NRT) failed to detect an effect, but treatment compliance was low, and in two other trials of oral NRT in which short-term abstainers were randomly assigned, a significant effect of intervention was noted.

AUTHORS' CONCLUSIONS

At the moment, there is insufficient evidence to support the use of any specific behavioural intervention to help smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focused on identifying and resolving tempting situations, as most studies were concerned with these. Little research is available regarding other behavioural approaches.Extended treatment with varenicline may prevent relapse. Extended treatment with bupropion is unlikely to have a clinically important effect. Studies of extended treatment with nicotine replacement are needed.

Changes in smoking patterns during pregnancy

This study examined trajectories of smoking during pregnancy among low-income smokers and differences on demographics, psychopathology, and smoking outcome expectancies among women with different smoking trajectories. The sample consisted of 215 urban pregnant smokers living in the United States. Results indicated four trajectories of smoking and significant changes over time within each trajectory. Persistent smokers had the highest demographic and mental health risks, reported higher craving compared to light smokers, and were more likely to endorse smoking to reduce negative affect, for state enhancement motives. Implications for intervention are discussed. The study was funded by the National Institute on Drug Abuse.

Pathways linking socioeconomic status and postpartum smoking relapse

BACKGROUND

Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth.

PURPOSE

This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy.

METHODS

Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach.

RESULTS

Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models.

CONCLUSIONS

Findings have implications for future interventions that aim to reduce postpartum relapse.

Design of a randomized controlled trial for multiple cancer risk behaviors among Spanish-speaking Mexican-origin smokers

BACKGROUND

Smoking, poor diet, and physical inactivity account for as much as 60% of cancer risk. Latinos experience profound disparities in health behaviors, as well as the cancers associated with them. Currently, there is a dearth of controlled trials addressing these health behaviors among Latinos. Further, to the best of our knowledge, no studies address all three behaviors simultaneously, are culturally sensitive, and are guided by formative work with the target population. Latinos represent 14% of the U.S. population and are the fastest growing minority group in the country. Efforts to intervene on these important lifestyle factors among Latinos may accelerate the elimination of cancer-related health disparities.

METHODS/DESIGN

The proposed study will evaluate the efficacy of an evidence-based and theoretically-driven Motivation And Problem Solving (MAPS) intervention, adapted and culturally-tailored for reducing cancer risk related to smoking, poor diet, and physical inactivity among high-risk Mexican-origin smokers who are overweight/obese (n = 400). Participants will be randomly assigned to one of two groups: Health Education (HE) or MAPS (HE + up to 18 MAPS counseling calls over 18 months). Primary outcomes are smoking status, servings of fruits and vegetables, and both self-reported and objectively measured physical activity. Outcome assessments will occur at baseline, 6 months, 12 months, and 18 months.

DISCUSSION

The current study will contribute to a very limited evidence base on multiple risk factor intervention studies on Mexican-origin individuals and has the potential to inform both future research and practice related to reducing cancer risk disparities. An effective program targeting multiple cancer risk behaviors modeled after chronic care programs has the potential to make a large public health impact because of the dearth of evidence-based interventions for Latinos and the extended period of support that is provided in such a program.

TRIAL REGISTRATION

National Institutes of Health Clinical Trials Registry # NCT01504919.

Self-help booklets for preventing postpartum smoking relapse: a randomized trial

OBJECTIVES

We tested a series of self-help booklets designed to prevent postpartum smoking relapse.

METHODS

We recruited 700 women in months 4 through 8 of pregnancy, who quit smoking for their pregnancy. We randomized the women to receive either (1) 10 Forever Free for Baby and Me (FFB) relapse prevention booklets, mailed until 8 months postpartum, or (2) 2 existing smoking cessation materials, as a usual care control (UCC). Assessments were completed at baseline and at 1, 8, and 12 months postpartum.

RESULTS

We received baseline questionnaires from 504 women meeting inclusion criteria. We found a main effect for treatment at 8 months, with FFB yielding higher abstinence rates (69.6%) than UCC (58.5%). Treatment effect was moderated by annual household income and age. Among lower income women (< $30 000), treatment effects were found at 8 and 12 months postpartum, with respective abstinence rates of 72.2% and 72.1% for FFB and 53.6% and 50.5% for UCC. No effects were found for higher income women.

CONCLUSIONS

Self-help booklets appeared to be efficacious and offered a low-cost modality for providing relapse-prevention assistance to low-income pregnant and postpartum women.

Smoking cessation intervention for pregnant women: a call for extension to the postpartum period

The association between smoking during pregnancy and adverse maternal/neonatal health outcomes is widely acknowledged, and recent health care reform has filled a much-needed gap by extending prenatal smoking cessation intervention coverage to all pregnant women on Medicaid. While more extensive coverage will improve quit rates during pregnancy, there continues to be a need to address high relapse rates in the postpartum period for both the insured and the uninsured. Smoking during the postpartum period exposes infants directly and indirectly to negative health effects, and has additional costs to mothers and society. Approximately 80% of women who quit smoking during pregnancy relapse in the first year postpartum, highlighting a need for effective continuing care that supports them through the challenging postpartum period when stress is high and motivations to stay quit may change. Existing relapse prevention interventions, typically delivered during pregnancy, have been found to be of little benefit during the postpartum period, suggesting the need for a more formal continuing care approach. Phone-based protocols are promising because they address the need for flexible access, and are known to be effective at increasing quit rates and sustained cessation.

Efficacy of smoking-cessation interventions for young adults: a meta-analysis

CONTEXT

Approximately 22% of U.S. young adults (aged 18-24 years) are smokers. Young adults typically display an interest in quitting, but it is unknown whether the evidence-based cessation programs designed for adults will be equally effective for young adults. This meta-analysis investigated the efficacy of smoking-cessation programs for this population.

EVIDENCE ACQUISITION

In 2009-2011, studies published between 2004 and 2008 that investigated smoking cessation were first found through the DHHS Clinical Practice Guidelines for Treating Tobacco Use and Dependence as well as a PubMed search (2009-2010) and were then subjected to a rigorous inclusion process. Authors were contacted to glean raw data for young adults. Fourteen studies provided data that were coded for descriptive information and aggregated using the Comprehensive Meta-Analysis, version 2.0.

EVIDENCE SYNTHESIS

Among young adults, any type of intervention was more effective in producing successful smoking cessation than the control. This was the case for intent-to-treat analyses as well as complete cases. When interventions were effective for the larger adult sample, they were also effective for the younger adult sample.

CONCLUSIONS

Although young adults tend to underutilize evidence-based cessation treatments, the current meta-analysis showed that these treatments should be as effective for young adults as they are for the general adult population. Thus, it may be useful to focus on motivating young adults to seek cessation treatment to increase utilization.

Tobacco cessation intervention during pregnancy among Alaska Native women

This paper describes a community-based participatory research program with Alaska Native people addressing a community need to reduce tobacco use among pregnant women and children. Tobacco use during pregnancy among Alaska Native women is described along with development of a community partnership, findings from a pilot tobacco cessation intervention, current work, and future directions. Among Alaska Native women residing in the Yukon Kuskokwim Delta region of western Alaska, the prevalence of tobacco use (cigarette smoking and/or use of smokeless tobacco) during pregnancy is 79%. Results from a pilot intervention study targeting pregnant women indicated low rates of participation and less than optimal tobacco abstinence outcomes. Developing alternative strategies to reach pregnant women and to enhance the efficacy of interventions is a community priority, and future directions are offered.

Smoking cessation and relapse among pregnant African-American smokers in Washington, DC

Smoking is the single most preventable cause of perinatal morbidity. This study examines smoking behaviors during pregnancy in a high risk population of African Americans. The study also examines risk factors associated with smoking behaviors and cessation in response to a cognitive behavioral therapy (CBT) intervention. This study is a secondary analysis of data from a randomized controlled trial addressing multiple risks during pregnancy. Five hundred African-American Washington, DC residents who reported smoking in the 6 months preceding pregnancy were randomized to a CBT intervention. Psycho-social and behavioral data were collected. Self-reported smoking and salivary cotinine levels were measured prenatally and postpartum to assess changes in smoking behavior. Comparisons were made between active smokers and those abstaining at baseline and follow-up in pregnancy and postpartum. Sixty percent of participants reported quitting spontaneously during pregnancy. In regression models, smoking at baseline was associated with older age, <a high school education and illicit drug use. At follow-up closest to delivery, smoking was associated with lower education, smoking and cotinine level at baseline and depression. At postpartum, there was a relapse of 34%. Smokers postpartum were significantly more likely to smoke at baseline and use illicit drugs in pregnancy. Mothers in the CBT intervention were less likely to relapse. African-American women had a high spontaneous quit rate and no response to a CBT intervention during pregnancy. Postpartum mothers' resolve to maintain a quit status seems to wane despite their prolonged period of cessation. CBT reduced postpartum relapse rates.

Mediators of the association of major depressive syndrome and anxiety syndrome with postpartum smoking relapse

OBJECTIVE

Based on conceptual models of addiction and affect regulation, this study examined the mechanisms linking current major depressive syndrome (MDS) and anxiety syndrome (AS) to postpartum smoking relapse.

METHOD

Data were collected in a randomized clinical trial from 251 women who quit smoking during pregnancy. Simple and multiple mediation models of the relations of MDS and AS with postpartum relapse were examined using linear regression, continuation ratio logit models, and a bootstrapping procedure to test the indirect effects.

RESULTS

Both MDS and AS significantly predicted postpartum smoking relapse. After adjusting for MDS, AS significantly predicted relapse. However, after adjusting for AS, MDS no longer predicted relapse. Situationally based self-efficacy, expectancies of controlling negative affect by means other than smoking, and various dimensions of primary and secondary tobacco dependence individually mediated the effect of both MDS and AS on relapse. In multiple mediation models, self-efficacy in negative/affective situations significantly mediated the effect of MDS and AS on relapse.

CONCLUSIONS

The findings underscore the negative impact of depression and anxiety on postpartum smoking relapse and suggest that the effects of MDS on postpartum relapse may be largely explained by comorbid AS. The current investigation provided mixed support for affect regulation models of addiction. Cognitive and tobacco dependence-related aspects of negative and positive reinforcement significantly mediated the relationship of depression and anxiety with relapse, whereas affect and stress did not. The findings emphasize the unique role of low agency with respect to abstaining from smoking in negative affective situations as a key predictor of postpartum smoking relapse.

The role of negative affect management in postpartum relapse to smoking

The aim of this study was to explore the role of affect management in postpartum relapse to smoking. Between January and October 2005, 65 women who smoked prior to pregnancy but not during the last month of pregnancy were recruited from Brigham and Women's Hospital in Boston, MA, and followed for 24 weeks. Surveys administered at baseline, 2, 6, 12, and 24 weeks postpartum assessed smoking status and symptoms of depression (Beck Depression Inventory, BDI) and anxiety (Beck Anxiety Inventory, BAI). Qualitative interviews were conducted when women relapsed or achieved an elevated BDI or BAI score. Elevated BDI or BAI scores did not predict relapse, suggesting that symptoms that make women vulnerable to relapse may not be fully captured by these instruments. Women described feelings of anger or frustration as part of the relapse experience. Women with elevated BDI or BAI scores who did not relapse were more likely to normalize their mood symptoms as part of the postpartum experience and described more adaptive and active coping strategies. Interventions designed to prevent postpartum relapse to smoking may need to target a broader range of negative affect and mood management strategies to increase the likelihood of efficacy.

Race/ethnicity moderates the effect of prepartum menthol cigarette use on postpartum smoking abstinence

INTRODUCTION

Little is known about the influence of prepartum menthol cigarette use on postpartum smoking abstinence or how race/ethnicity might moderate this relationship. The current study addressed that gap by testing these relationships among racially/ethnically diverse women who quit smoking during pregnancy (N = 244; 33% African American, 31% Latina, 36% White).

METHODS

Continuation ratio logit models were used to examine the effects of prepartum menthol cigarette use on biochemically confirmed, continuous abstinence through 26 weeks postpartum using an intent-to-treat approach. Analyses controlled for age, race/ethnicity, partner status, income, education, treatment, number of prequit cigarettes smoked per day, time to the first cigarette of the day, and time (Week 8 or 26 data collection timepoint). An additional model tested the moderating effects of race/ethnicity by including an interaction term.

RESULTS

Prepartum menthol cigarette use was not significantly associated with postpartum smoking abstinence in the overall sample. However, the interaction between menthol use and race/ethnicity was significant (p = .02). Among White women, menthol use was associated with significantly lower odds of maintaining postpartum smoking abstinence (p = .03; odds ratio = .19 [.04-.89]), and the effect approached significance among African American women (p = .08).

CONCLUSIONS

This study provides the first evidence that prepartum menthol cigarette use may increase the risk of postpartum smoking relapse among White, and possibly African American, women who quit smoking during or immediately before pregnancy. Results suggest that White and African American prepartum menthol users may require different or more intensive cessation services to aid in the maintenance of postpartum smoking abstinence. Replication with larger samples, and a focus on understanding the mechanisms that underlie these relationships, are warranted.

Anger, hostility, and aggression as predictors of persistent smoking during pregnancy

OBJECTIVE

We examined the role of anger, hostility, and aggression, in addition to depression and stress, in predicting persistent smoking during pregnancy in a low-income sample.

METHOD

The sample consisted of 270 pregnant women (189 smokers, 81 nonsmokers) recruited into a prospective study of prenatal cigarette exposure in the first trimester. Persistent pregnancy smoking was defined as self-reporting daily smoking in at least two trimesters, a positive salivary cotinine level in at least two trimesters, or infant meconium positive for nicotine and/ or its metabolites.

RESULTS

Persistent smokers reported higher prenatal stress and negative affect symptoms (depression, anger, hostility, aggression) than nonpersistent smokers or nonsmokers. However, in the context of model testing, maternal anger, hostility, and aggression each accounted for unique variance in persistent smoking, whereas symptoms of depression and stress did not.

CONCLUSIONS

To date, interventions for pregnant low-income smokers have been largely ineffective. The current results suggest that anger management interventions may be particularly effective for low-income persistent pregnant smokers and may be more likely to prevent relapse than depression-focused interventions.

The role of prepartum motivation in the maintenance of postpartum smoking abstinence

OBJECTIVE

Motivation plays an important role in a variety of behaviors, including smoking cessation, and is integral to theory and treatment of smoking. For many women, pregnancy offers a motivational shift that helps them stop smoking and maintain abstinence during pregnancy. However, women's motivation to maintain smoking abstinence postpartum is not well-understood and may play a role in high postpartum relapse rates. The current study utilized multiple measures of prepartum motivation to maintain smoking abstinence to predict postpartum smoking abstinence.

METHODS

As part of a randomized clinical trial on postpartum smoking relapse prevention, pregnant women who quit smoking during pregnancy reported their motivation to continue smoking abstinence at a prepartum baseline session. Biochemically verified continued smoking abstinence was assessed at 8 and 26 weeks postpartum.

RESULTS

Direct relationships among multiple measures of motivation were significant, and ranged in strength from weak to moderate. All motivation measures individually predicted continuous smoking abstinence, after controlling for treatment group, demographics, and prequit tobacco use. When tested simultaneously, a global motivation measure and parenthood motives for quitting remained significant predictors of abstinence. Backward selection modeling procedures resulted in a reduced model of prepartum predictors of postpartum abstinence including global motivation, parenthood motives, and stage of change.

CONCLUSIONS

Global motivation for smoking abstinence and parenthood motives for quitting are particularly important motivational constructs for pregnant women's continued smoking abstinence.

Breast feeding is associated with postpartum smoking abstinence among women who quit smoking due to pregnancy

INTRODUCTION

The purpose of this study was to characterize the relationship between breast feeding and postpartum smoking abstinence among women who quit smoking due to pregnancy and who were participating in a randomized clinical trial of an intervention designed to prevent postpartum relapse.

METHODS

A total of 251 women were enrolled in the intervention between 30 and 33 weeks postpartum and were followed through 26 weeks postpartum. Participant characteristics were assessed at the prepartum baseline visit, any breast feeding was assessed at 8 weeks postpartum, and smoking abstinence was assessed at 8 and 26 weeks postpartum.

RESULTS

Although 79.1% of participants intended to breast feed, only 40.2% reported breast feeding at 8 weeks postpartum. Characteristics associated with breast feeding at 8 weeks postpartum included Caucasian race/ethnicity, greater education, higher household income, and being married/living with a significant other. Logistic regression analysis indicated that breast feeding at 8 weeks postpartum was significantly associated with smoking abstinence at 8 weeks postpartum, odds ratio (OR) = 7.27 (95% CI = 3.27, 16.13), p < .001. Breast feeding at 8 weeks postpartum was also associated with abstinence at 26 weeks postpartum after controlling for smoking status at 8 weeks postpartum, OR = 2.64 (95% CI = 1.14, 6.10), p = .02.

DISCUSSION

Encouraging breast feeding among women who quit smoking due to pregnancy may facilitate postpartum smoking abstinence while increasing adherence to current infant feeding guidelines.