A content analysis of attributions for resuming smoking or maintaining abstinence in the post-partum period

Effect of an intensive tobacco cessation program on the smoker narrative: A content analysis and grounded theory

INTRODUCTION

The smoker's narrative during smoking quitting provides insight into aspects not fully explored in daily clinical practice. The aim of the study was to analyze the smoker narrative using two types of methodologies: content analysis and grounded theory, before and after smoking cessation intervention, provided to the smoker in a specialized Smoking Cessation Unit accredited by the Spanish Society of Pneumology and Thoracic Surgery.

METHODS

A prospective observational study of current smokers included in a tobacco cessation program between 2017 and 2020 was conducted at the Smoking Cessation Unit of Santiago de Compostela Health Area, Spain. Routine clinical variables and patient narrative data were collected. A descriptive analysis of the sample, the content of the textual corpus, and a grounded theory were performed in semi-structured interviews at baseline and at follow-up at 6 months.

RESULTS

A total of 116 patients were included (mean age 55.6 ± 10.6 years; 56.9% male; mean nicotine dependence score 5.7 ± 1.6). Quantitative analysis of the narrative shows that the most frequent phrases and words are associated with smoking, nicotine craving, and predisposition for smoking cessation. After the intervention, phrases related to the manifestation of abstinence, response to pharmacological treatment, and self-perception of smoking cessation were predominant. In the qualitative analysis, the most frequent categories in the smoker's textual corpus were dependence, motivation, and emotionality, which decreased after the intervention (11.4%, 21.4%, and 9.9%, respectively) accompanied by increased satisfaction (19.2%) and the manifestation of abstinence (21.5%).

CONCLUSIONS

Motivation, nicotine dependence, and sensitivity to emotions are all closely intertwined in the current smoker narrative and can be modified as a consequence of treatment.

My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy

BACKGROUND

Most women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited.

AIM

This paper aims to explore Aboriginal women's experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received.

METHODS

Qualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed.

RESULTS

Major themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation.

CONCLUSION

This qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.

Quitting Smoking before and after Pregnancy: Study Methods and Baseline Data from a Prospective Cohort Study

Smoking during pregnancy and postpartum remains an important public health problem. No known prior study has prospectively examined mutual changes in risk factors and women's smoking trajectory across pregnancy and postpartum. The objective of this study was to report methods used to implement a prospective cohort (Msgs4Moms), present participant baseline characteristics, and compare our sample characteristics to pregnant women from national birth record data. The cohort study was designed to investigate smoking patterns, variables related to tobacco use and abstinence, and tobacco treatment quality across pregnancy through 1-year postpartum. Current smokers or recent quitters were recruited from obstetrics clinics. Analyses included Chi-square and independent sample t-tests using Cohen's d. A total of 62 participants (41 smokers and 21 quitters) were enrolled. Participants were Black (45.2%), White (35.5%), and multiracial (19.3%); 46.8% had post-secondary education; and most were Medicaid-insured (64.5%). Compared with quitters, fewer smokers were employed (65.9 vs 90.5%, Cohen's d = 0.88) and more reported financial strain (61.1% vs 28.6%; Cohen's d = 0.75). Women who continue to smoke during pregnancy cope with multiple social determinants of health. Longitudinal data from this cohort provide intensive data to identify treatment gaps, critical time points, and potential psychosocial variables warranting intervention.

Maternal Parenting Stress, Disengagement Strategies for Managing Parenting Stress, and Hazardous Alcohol Use among Mothers of Adolescents

Objective: According to the reward- stress dysregulation model of addiction and parenting, parenting stress may play a critical role in the etiology and maintenance of substance misuse. To date, limited work has examined how parenting stress may relate to hazardous alcohol use among mothers of adolescents. The present study examined if parenting stress interacted with maternal stress responses (i.e., disengagement coping, involuntary disengagement stress responses) in relation to maternal hazardous alcohol use. Method: Two hundred and fifty-three mothers (n = 147 hazardous alcohol users; 58% of the sample) of adolescents between the ages of 12 and 16 years participated in the current study. Mothers were recruited using Qualtrics panel services. Mothers reported on their parenting stress, strategies for managing parenting stress, and use of alcohol. Mothers also reported basic demographic information (Mage = 41.10 years, 86.6% identified as white, 81.1% of mothers were married). Interaction analyses were used to test hypotheses. Results: Maternal parenting stress interacted with maternal involuntary disengagement stress responses in relation to maternal hazardous alcohol use, such that at average and high levels of disengagement stress responses, parenting stress was associated with hazardous alcohol use. These results were robust to covariates (i.e., family income, maternal anxiety symptoms, maternal depressive symptoms, general levels of maternal stress, maternal cigarette use). Maternal disengagement coping strategies were not related to maternal hazardous alcohol use. Conclusion: Results suggest that parenting stress and involuntary disengagement stress responses may be associated with hazardous alcohol use among mothers of adolescents.

Mediation pathways for reduced substance use among parents in South Africa: a randomized controlled trial

BACKGROUND

Substance use is a major public health concern worldwide. Alcohol and drug use have increased during recent decades in many low- and middle-income countries, with South Africa, where this study was conducted, having among the highest rates in the world. Despite existing evidence on the effectiveness of family-based interventions in reducing substance use among parents and caregivers in low- and middle-income countries, little is known about the mechanism of change that contributes to the reduction. This study investigated mediators of change in a parenting programme (Parenting for Lifelong Health [PLH]) on reducing substance use among parents and caregivers of adolescents through three potential mediators: parental depression, parenting stress and family poverty.

METHODS

The current study used a pragmatic cluster randomized controlled trial design. The total sample comprised 552 parent and caregiver of adolescents M = 49.37(SD = 14.69) who were recruited from 40 communities in South Africa's Eastern Cape. Participants completed a structured confidential self-report questionnaire at baseline and a follow-up test 5 to 9 months after the intervention. Structural equation modeling was conducted to investigate direct and indirect effects.

RESULTS

Analyses indicated that the effect of the PLH intervention on reducing parental substance use was mediated in one indirect pathway: improvement in parental mental health (reduction in parental depression levels). No mediation pathways from the PLH intervention on parental substance use could be associated with parenting stress or family poverty.

CONCLUSIONS

The findings of the study suggest that intervention approaches targeting mental health among parents and caregivers have promise for reducing parental substance use. These findings emphasize the need to create supportive environments and systems for parents who suffer from emotional strain and mental health problems, particularly within families experiencing adversity.

TRIAL REGISTRATION

Pan-African Clinical Trials Registry PACTR201507001119966. Registered on 27 April 2015. The trial can be found by searching for the key word 'Sinovuyo' on the Pan-African Clinical Trials Registry website or via the following link: http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?_nfpb=true&_windowLabel=BasicSearchUpdateController_1&BasicSearchUpdateController_1_actionOverride=%2Fpageflows%2Ftrial%2FbasicSearchUpdate%2FviewTrail&BasicSearchUpdateController_1id=1119.

Pre- and postnatal maternal smoking and offspring smoking trajectories: Evidence from a 20-year birth cohort

Maternal smoking is associated with increased risk of smoking in the offspring. However, it remains unclear whether this association depends on the timing of exposure to maternal smoking. We investigated the association between prenatal and/or postnatal maternal smoking and offspring smoking during adolescence. Participants (N = 1661) were from the Québec Longitudinal Study of Child Development cohort. We identified longitudinal trajectories of maternal smoking from before pregnancy to child age 12 years using group-based trajectory modeling (GBTM). Adolescent (12-19 years) smoking trajectories were also identified using GBTM. Associations between maternal smoking and offspring smoking trajectories were estimated using multinomial logistic regressions. We used propensity score inverse probability weighting (IPW) to account for the differential distribution of maternal and familial characteristics across exposure groups. We identified four distinct groups for maternal smoking: no (66.1%), decreasing (5.6%), increasing (9.5%) and persistent (18.8%) smoking, and three adolescent smoking trajectories: abstinent, early-onset (before age 15) and late-onset (after age 15). In IPW-adjusted models, youth with mothers with decreasing, increasing and persistent smoking had higher risk of being early-onset smokers compared with youth with mothers in the non-smoking group. We also found that only youth whose mothers were persistent smokers had an increased risk of late-onset smoking. Regardless of timing, offspring exposure to maternal smoking is associated with increased risk of smoking during adolescence. More research is needed on how to create effective smoking cessation campaigns that span preconception, prenatal, and postnatal periods to help prevent intergenerational transmission of smoking behaviors.

Persistent Barriers to Smoking Cessation Among Urban, Underserved Women: A Feasibility Study of Tailored Barriers Text Messages

OBJECTIVES

Despite health risks for themselves and their children, urban underserved women smoke at high rates postpartum. The postpartum period is a stressful transition time that presents unique barriers to sustained cessation. There is limited extant evidence of efficacious psychosocial programs to maintain postpartum smoking cessation.

METHODS

Guided by the Cognitive-Social Health Information Processing model, we explored the feasibility of TxT2Commit, a text-messaging intervention designed to prevent postpartum smoking relapse. Participants (n = 43) received supportive cessation-focused text messages for one month postpartum. Using a convergent mixed method design, surveys and interviews assessed changes in psychosocial factors and smoking status through a three month follow-up.

RESULTS

Participants reported satisfaction with TxT2Commit, rating text messages as helpful, understandable, supportive, and not bothersome. However, a majority of women (n = 28, 65.1%) relapsed by three months. Participants who stayed smoke free (i.e., non-relapsers) reported significantly less temptation to smoke at one and three months postpartum compared to relapsers (ps < .01). While relapsers had significantly less temptation at one month compared to baseline, temptation increased by three months (p < .01). Consistent with the quantitative results, qualitative interviews identified informational and coping needs, with continued temptation throughout the three months. Non-relapsers were able to manage temptation and reported greater support.

CONCLUSIONS FOR PRACTICE

TxT2Commit demonstrates preliminary feasibility and acceptability among urban, underserved postpartum women. However, most participants relapsed by three months postpartum. Additional research is needed to identify targeted messaging to best help women avoid temptation and bolster support to stay smoke free in this uniquely stressful period.

Depressive Symptoms Assessed Near the End of Pregnancy Predict Differential Response to Postpartum Smoking Relapse Prevention Intervention

BACKGROUND

Depressive symptoms are prevalent during pregnancy and the postpartum period and affect risk for smoking relapse. Whether and how depression affects response to postpartum interventions designed to sustain smoking abstinence is unknown.

PURPOSE

We examined end-of-pregnancy depressive symptoms as a moderator of response to two postpartum-adapted smoking relapse prevention interventions.

METHODS

Women (N = 300) who quit smoking during pregnancy were randomized to receive either a postpartum intervention focused on psychosocial factors linked to postpartum smoking (Strategies to Avoid Returning to Smoking [STARTS]) or an attention-controlled comparison intervention (SUPPORT). Women completed the Edinburgh Postnatal Depression Scale at the end of pregnancy. Smoking status was biochemically assessed at the end of pregnancy and at 12, 24, and 52 weeks postpartum.

RESULTS

End-of-pregnancy depressive symptoms moderated response to postpartum smoking relapse prevention interventions (χ2 = 10.18, p = .001). After controlling for variables previously linked to postpartum smoking relapse, women with clinically significant end-of-pregnancy depressive symptoms (20%) were more likely to sustain abstinence through 52 weeks postpartum if they received STARTS. In contrast, women with few end-of-pregnancy depressive symptoms were more likely to sustain abstinence through 52 weeks postpartum if they received SUPPORT. Changes in the psychosocial factors addressed in the STARTS intervention did not mediate this moderation effect.

CONCLUSION

Assessment of end-of-pregnancy depressive symptoms may help determine success following postpartum smoking relapse prevention interventions. Women with elevated end-of-pregnancy depressive symptoms benefited from postpartum relapse prevention intervention tailored to their psychosocial needs, while those with few symptoms were more successful in postpartum intervention that used standard behavioral components.

CLINICAL TRIAL REGISTRATION

NCT00757068.

Parenting stress: A novel mechanism of addiction vulnerability

Addiction remains a significant public health concern. Despite numerous public health initiatives, many parents continue to use substances during the prenatal and postpartum period. While stress has been implicated in the maintenance of substance use disorders more generally, we propose that parenting stress specifically increases vulnerability to substance use in adults caring for young children. To explore this notion, we first consider the neurobiology of the adult transition to parenthood and the value of adopting a parenting-specific approach to understanding addictive processes. Next, we consider the neurobiology of addiction and parenting before directly addressing parenting stress in the context of addiction. Finally, we describe current interventions with parents that incorporate the management of negative affect to enhance caregiving quality and decrease substance use. Taken together, this article proposes that the unique demands of caring for a developing child may be more stressful above and beyond other forms of stress. As a consequence, intervention approaches that target stress in the parenting role hold promise for decreasing parental substance abuse.

The Role of Self-Efficacy and Motivation in Postpartum Sustained Smoking Abstinence

BACKGROUND

Postpartum relapse to cigarette smoking is common and relapse prevention interventions have indicated limited efficacy. Abstinence motivations and self-efficacy are two factors that might fluctuate during the postpartum period and predict smoking abstinence. The present study was a secondary analysis that examined statistical trends in motivations and self-efficacy to sustain postpartum abstinence and evaluated their association with sustained abstinence from pregnancy through 52 weeks postpartum.

METHODS

Former smokers (N = 300) were recruited for a parent study evaluating two postpartum behavioral relapse prevention interventions. Participants completed assessments prenatally (baseline) and at 12, 24, and 52 weeks postpartum. Motivations to sustain abstinence for internal (intrinsic motivation) and external (extrinsic motivation) reasons, for the health of the baby (baby's health motivation), to maintain a healthy pregnancy (pregnancy motivation), and to avoid children becoming smokers (parenting motivation) were measured at each assessment. Confidence in maintaining abstinence, despite negative affective experiences (internal self-efficacy) and outside circumstances (external self-efficacy), was also assessed. Smoking was biochemically verified at each assessment.

RESULTS

Linear mixed models indicated decreasing intrinsic, baby's health, and parenting motivations from baseline to 12 and 24 weeks postpartum and increasing motivations from 24 to 52 weeks postpartum (ps < .03). Higher baseline internal self-efficacy was associated with lower probability of relapse at 24 weeks postpartum (odds ratio, 0.92; 95% CI, 0.87-0.98), although this effect became nonsignificant after adjustment for multiple statistical tests. Abstinence motivations and external self-efficacy were not significantly associated with relapse (ps > .10).

CONCLUSIONS

Levels of abstinence motivations fluctuated from pregnancy through postpartum. Future work should investigate more potent predictors of postpartum abstinence.

Do Psychiatric Disorders or Measures of Distress Moderate Response to Postpartum Relapse Prevention Interventions?

Introduction

Most women who quit smoking during pregnancy will relapse postpartum. Interventions for sustained postpartum abstinence can benefit from understanding prenatal characteristics associated with treatment response. Given that individuals with psychiatric disorders or elevated depressive symptoms have difficulty quitting smoking and that increases in depressive symptoms prenatally are common, we examined the relevance of psychiatric diagnoses, prenatal depressive symptoms, and stress to postpartum relapse prevention intervention response.

Methods

Pregnant women (N = 300) who quit smoking during pregnancy received intervention (with specialized focus on mood, weight, and stress [STARTS] or a comparison [SUPPORT]) to prevent postpartum relapse. As previously published, nearly one-third and one-quarter of women achieved biochemically-confirmed sustained abstinence at 24- and 52-weeks postpartum, with no difference in abstinence rates between the interventions. Women completed psychiatric interviews and questionnaires during pregnancy. Smoking was assessed in pregnancy, and 24- and 52-weeks postpartum.

Results

Psychiatric disorders did not predict sustained abstinence or treatment response. However, treatment response was moderated by end-of-pregnancy depressive symptoms (χ2 = 9.98, p = .002) and stress (χ2 = 6.90, p = .01) at 24- and 52-weeks postpartum and remained significant after including covariates. Women with low distress achieved higher abstinence rates in SUPPORT than in STARTS (37% vs. 19% for depressive symptoms; 36% vs. 19% for stress), with no difference for women with high symptoms.

Conclusions

Prenatal depressive symptoms and stress predicted differential treatment efficacy in women with low symptoms, not in women with high symptoms. Diagnostic history did not predict treatment differences. Future research to address prenatal distress may help tailor postpartum relapse prevention interventions.

Implications

We examined prenatal history of psychiatric disorders and psychiatric distress as moderators of response to postpartum smoking relapse prevention intervention that either included or did not include added content on mood, stress, and weight concerns. For women with lower psychiatric distress, the added focus is not necessary, as these women achieved greater sustained abstinence in the less-intensive treatment. Understanding which women need which level of care to sustain abstinence can help allocate resources for all postpartum former smokers. These findings underscore the importance of perinatal symptom monitoring and promoting behavioral health more broadly in pregnant and postpartum women.

Review of the Relationships Among Psychosocial Stress, Secondhand Smoke, and Perinatal Smoking

OBJECTIVE

To summarize and evaluate the recently published literature in which the relationships among psychosocial stress, smoking, and exposure to secondhand smoke during the perinatal period are examined, and to describe the characteristics and demographics of the samples.

DATA SOURCES

Electronic databases MEDLINE, Academic Search Complete, CINAHL, Psychology and Behavioral Sciences Collection, and PsychINFO. In addition, hand searches of reference lists supplemented the electronic search.

STUDY SELECTION

English language, peer-reviewed studies published between 2010 and 2015 on the relationships of self-reported or perceived stress, smoking, and secondhand smoke exposure during pregnancy and postpartum were included. Twenty-four studies met the inclusion criteria.

DATA EXTRACTION

Data that specified the relationships among smoking, stress, and secondhand smoke exposure during pregnancy and postpartum were extracted from the studies. A table matrix, available as supplemental material, to summarize the literature and sample characteristics and demographics was created.

DATA SYNTHESIS

Evidence from the included studies supported an association between psychosocial stress specific to pregnancy or from other sources and smoking or smoking relapse during pregnancy or in the postpartum period. In the studies in which it was included, exposure to secondhand smoke was cited as a barrier to abstinence.

CONCLUSION

It is probable that women who persistently smoke in pregnancy experience elevated stress. Further research with longitudinal designs and inclusion of secondhand smoke as a variable are needed.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Postpartum smoking relapse--a thematic synthesis of qualitative studies

BACKGROUND AND AIMS

Many women quit smoking during pregnancy, but relapse after the baby is born. To understand why and identify ways of preventing this, this study reviewed the qualitative literature on women's experience of postpartum smoking relapse.

METHODS

A systematic review of qualitative studies and process evaluations of trials. We undertook a thematic synthesis of published qualitative data.

RESULTS

We screened 1336 papers. Twenty-two papers reporting on 16 studies were included, reporting on the views of 1031 postpartum women. Factors affecting relapse and barriers and facilitators to relapse prevention were identified around the key themes of beliefs, social influences, motivation, physiological factors and identity. Women's beliefs about smoking as a means of coping with stress and the need for social support, especially from a partner, emerged as important. Extrinsic motivation to quit during the pregnancy (for the health of the fetus) appeared to be a factor in prompting relapse after the baby was born. During the immediate postpartum period women believed that physiological changes influence cigarette cravings. The stress of caring for a newborn, sleeplessness and adjusting to a new mothering identity were also reported to be important.

CONCLUSIONS

Among women who quit smoking during pregnancy, those who relapse postpartum talk commonly about no longer needing to protect the baby and the effects of stress. Partner support and a sense of changed identity are cited as factors preventing relapse.