Predictors of postpartum relapse to smoking

Association between maternal pre-pregnancy body mass index and offspring's outcomes at 9 to 15 years of age

OBJECTIVE

Maternal pre-pregnancy underweight, overweight and obesity might increase the risk for worse short- and long-term outcome in the offspring. There is a need for further study into the relationship between maternal pre-pregnancy body mass index (BMI) and the combined outcome of physical development, state of health and social behavior in children.

QUESTION

Is maternal pre-pregnancy BMI associated with the child outcome in terms of physical development, state of health and social behavior (school and leisure time behavior) at the age of 9 to 15 years?

METHODS

In the population-based birth cohort study Survey of Neonates in Pomerania (SNIP) children at the age 9-15 years and their families were re-examined by questionnaire-based follow-up. 5725 mother-child pairs were invited to SNiP-follow-up. This analysis is based on the recall fraction of 24.1% (n = 1379). Based on the maternal pre-pregnancy BMI (ppBMI), 4 groups were formed: underweight (ppBMI < 19 kg/m2, n = 117), normal weight (ppBMI 19-24.99 kg/m2, n = 913, reference), overweight (ppBMI 25-30 kg). /m2, n = 237) and obesity (ppBMI > 30 kg/m2, n = 109).

RESULTS

In the multiple regression model, the BMI-z-score for children of mothers in the underweight group was -0.50 lower, and 0.50/1.07 higher in the overweight/obese group (p < 0.001) compared to reference at median age of 12 years. No differences were found in children of underweight mothers with regard to social behavior (interaction with friends and family), school and sports performance (coded from "very good" to "poor"), other leisure activities (watching television, using mobile phones, gaming), and health (occurrence of illnesses) compared to children of normal weight mothers. In contrast, maternal pre-pregnancy overweight and obesity were associated with lower school and sports performance, and higher screen time (smart phone, gaming, television) compared to children of normal weight mothers.

CONCLUSION

Maternal pre-pregnancy overweight and obesity but not underweight was negatively associated with school performance and leisure time behavior in the offspring at 9-15 years of age.

Smoking cessation Through Optimization of clinical care in Pregnancy: the STOP pragmatic randomized controlled trial

BACKGROUND

Smoking cessation improves pregnancy outcomes, yet there is uncertainty around the efficacy of models of antenatal intervention for smoking cessation in pregnancy.

OBJECTIVE

This study aimed to test the Smoking cessation Through Optimization of clinical care in Pregnancy (STOP) clinic as an antenatal care pathway for smoking cessation in pregnancy. The STOP intervention is a smoking cessation clinic staffed by a dedicated multidisciplinary team of obstetricians, midwives, and smoking cessation practitioners, who provide motivational and psychological support and intensive clinical monitoring of pregnancy.

STUDY DESIGN

This was a pragmatic randomized controlled trial of the STOP clinic compared with routine antenatal care at a tertiary urban maternity hospital delivering >8000 infants per year. The primary outcome measured was continuous abstinence from smoking before 28+0 weeks' gestation, sustained throughout the duration of the pregnancy, and validated using biological measures. The secondary outcomes included maternal and fetal morbidity, delivery and neonatal outcomes, smoking outcomes, and qualitative measures.

RESULTS

A total of 436 women were randomized, with 430 women included in the primary outcome analysis. Women attending the STOP antenatal clinic were more likely to quit smoking compared with those in routine care (odds ratio, 3.62; 95% confidence interval, 1.43-9.17). In addition, women who continued to smoke in the STOP clinic smoked fewer cigarettes daily at the time of delivery compared with controls: 5±4 in the STOP clinic and 7±5 in the control group (odds ratio, 0.28; 95% confidence interval, 0.13-0.59). However, this intervention did not alter postpartum relapse rates (4.3% intervention arm vs 1.5% control arm, not significant) at 4 to 6 months following delivery. The mean birthweight was similar in the intervention and control arms; however, quitters in both groups had infants with significantly higher birthweights compared with those of continued smokers.

CONCLUSION

The STOP antenatal model of care leads to higher smoking cessation rates among pregnant smokers and lower daily cigarette consumption at time of delivery. Currently, there is no defined or dedicated antenatal pathway for pregnant smokers, despite the high-risk nature of their pregnancies. Our findings suggest that improved smoking cessation rates in pregnancy may be achieved using the holistic approach of the STOP model of care.

Knowledge, Attitudes, and Beliefs about Relapse Prevention Research Involving Bupropion among Current and Former Pregnant Individuals Who Smoke

Introduction

While many individuals quit smoking during pregnancy, most relapse within one year postpartum. Research into methods to decrease smoking relapse postpartum has been hampered by difficulties with recruitment.

Method

We conducted individual interviews with pregnant women (N = 22) who were interested in quitting smoking while pregnant about their attitudes regarding smoking and quitting during pregnancy, clinical trial participation, and smoking cessation medication use.

Results

Participants were aware of the risks of smoking while pregnant. Many wanted to quit smoking before delivery. Few used empirically supported treatments to quit. While research was viewed positively, interest in taking on new commitments postpartum and taking a medication to prevent relapse was low. Medication concerns were evident among most participants, especially among those planning to breastfeed. Further, several women noted medication was unnecessary, as they did not believe they would relapse postpartum. Financial incentives, childcare, and fewer and/or remote visits were identified as facilitators to participating in research. However, these factors did not outweigh women's concerns about medication use and time commitments.

Conclusions

Women are aware that quitting smoking during pregnancy and remaining smoke-free postpartum are important. However, beliefs that personal relapse risk is low and that medications are dangerous reduced enthusiasm for taking medication for postpartum relapse prevention. Future medication trials should educate women about the high likelihood of relapse, prepare to answer detailed questions about risks of cessation medications, and connect with participants' clinicians. For new mothers, studies conducted remotely with few scheduled appointments would reduce barriers to participation.

Cigarette smoking during breastfeeding in Papua New Guinea: Prevalence and demographic and socio-economic predictors

BACKGROUND

Cigarette smoking during breastfeeding is reported to contribute to significant changes in the composition of breast milk not only by reducing its protective features but also affecting infants' response to breastfeeding and breast milk. However, studies on the prevalence of cigarette smoking and associated factors during breastfeeding are limited in Papua New Guinea (PNG). This study estimates the prevalence of cigarette smoking and its association with demographic and economic factors among breastfeeding women in PNG.

METHODS

We used weighted survey data from the 2016-2018 PNG Demographic and Health Survey (PNGDHS). A weighted sample of 3,822 women who were breastfeeding during the survey were included in the study. The outcome variable in the present study is current cigarette smoking. A multiple logistic regression analysis was used to estimate the association between current cigarette smoking status and socio-demographic and economic variables of breastfeeding women. The regression analysis results were reported using adjusted odds ratios (aOR) with their respective 95% confidence intervals (CIs).

RESULTS

From the weighted sample, the prevalence of cigarette smoking among breastfeeding women was 21.9%; of which 60.8% smoked daily. The mean number of cigarettes smoked in the last 24 hours preceding the survey was 6.05(SD = 5.99). Multiple logistic regression analysis revealed that breastfeeding women who were from the Momase (aOR: 2.337, CI: 1.786-3.058, p<0.001) and Highlands (AOR: 1.589, CI: 1.213-2.082, p = 0.001), had no religious affiliation (aOR: 3.665, CI: 1.235-10.877, p = 0.019), and households with daughters as household heads (aOR: 1.901, CI: 1.231-2.935, p = 0.004) and being in more than one union (aOR: 2.374, CI: 1.805-3.123, p<0.001) were significantly more likely to smoke cigarette compared to women from southern region, those affiliated to Anglican church, those with husband as household heads, and being in one union respectively.

CONCLUSION

Cigarette smoking among breastfeeding women in PNG is relatively high, and region of residence, religion, relationship to household head, and the number of unions remain independent predictors. Interventions should target the individual socio-economic and cultural contexts within which breastfeeding occurs.

Indigenous Smoking Behaviors in Olmsted County, Minnesota: A Longitudinal Population-Based Study

OBJECTIVE

To describe smoking behaviors and pharmaceutical cessation aid uptake in a population-based Indigenous cohort compared with an age- and sex-matched non-Indigenous cohort.

PATIENTS AND METHODS

Using the health record-linkage system of the Rochester Epidemiology Project (January 1, 2006, to December 31, 2019), smoking data of Indigenous residents of Olmsted County in Minnesota were abstracted to define the smoking prevalence, incidence, cessation, relapse after cessation, and pharmaceutical smoking cessation aid uptake compared with a matched non-Indigenous cohort. Prevalence was analyzed with a modified Poisson regression; cessation and relapse were evaluated with generalized estimating equations. Incidence was evaluated with a Cox proportional hazards model.

RESULTS

Smoking prevalence was higher in the Indigenous cohort (39.0% to 47.0%; n=898) than the matched cohort (25.6% to 30.3%; n=1780). Pharmaceutical uptake was higher among the Indigenous cohort (35.8% of n=584 ever smokers vs 16.3% of n=778 ever smokers; P<.001). Smoking cessation events occurred more frequently in the Indigenous cohort (relative risk, 1.10; 95% CI, 1.06 to 1.13; P<.001). Indigenous former smokers were more likely to resume smoking (relative risk, 3.03; 95% CI, 2.93 to 3.14; P<.001) compared with the matched cohort. These findings were independent of socioeconomic status, age, and sex.

CONCLUSION

Smoking in this Indigenous cohort was more prevalent compared with a sex- and age-matched non-Indigenous cohort despite more smoking cessation events and higher use of smoking cessation aids in the Indigenous cohort. The relapse rate after achieving cessation in the Indigenous cohort was more than three times higher than the non-Indigenous cohort. This finding has not been previously described and represents a potential target for relapse prevention efforts in US Indigenous populations.

The Gendered Dimensions of Photovoice in Men's Health Promotion Research

The use of photovoice in men’s health promotion research has grown significantly over the past 15 years. Initially mobilized as an elixir for men’s talk about health practices and illness experiences, participant-produced photographs and accompanying narratives have grown significantly in reach, influence, and application. The current article highlights the gendered dimensions of photovoice in men’s health promotion research across three studies addressing (1) psychosocial prostate cancer care, (2) fathers’ tobacco reduction and smoking cessation, and (3) male suicidality. Insights drawn from the psychosocial prostate cancer care project emphasize the plurality of masculinities, and the implications for health promoters treating the common treatment side effect of erectile dysfunction. The relational nature of gender is central to the fathers’ tobacco reduction and smoking cessation work whereby the well-being of partners and children strongly influenced men’s behavior changes amid guiding adjustments to smoke-free policies. The male suicidality research highlights the unmuting powers of photovoice for making visible the interiority of men’s mental illness, and the destigmatizing potentials for sharing participants’ accompanying narratives. Evident across the three projects are the gendered dimensions of photovoice processes and products for advancing understandings of, and avenues toward, promoting the health of men and their families. After reflecting on these advances, we offer recommendations for future men’s health promotion photovoice work.

Tobacco consumption from the 1st trimester of pregnancy to 7 months postpartum: Effects of previous tobacco consumption, and depression and anxiety symptoms

OBJECTIVE

Previous tobacco consumption, and depression and anxiety symptoms are major predictors of women's tobacco consumption during pregnancy and the postpartum period. However, the joint effect of these predictors is still unexplored. This study aimed to analyse the effects of previous tobacco consumption, and depression and anxiety symptoms on women's tobacco consumption status and quantity from the 1st trimester of pregnancy to 7 months postpartum.

METHOD

A sample of 803 Spanish women was assessed at the 1st and the 3rd trimester of pregnancy, and at 2 and 7 months postpartum. Previous tobacco consumption, and depression and anxiety symptoms were self-reported. Pregnancy and postpartum tobacco consumption were confirmed with biochemical tests.

RESULTS

Women with more previous tobacco consumption or more anxiety symptoms presented a steeper decrease in the number of cigarettes smoked per week from the 1st trimester of pregnancy to the childbirth, although smoking more cigarettes than women with less previous tobacco consumption or less anxiety symptoms. Women with more depression symptoms showed a higher tendency to relapse smoking during the first 2 months postpartum.

CONCLUSIONS

Previous tobacco consumption and anxiety symptoms were associated with higher smoking quantity during pregnancy, while depression symptoms were associated with consumption relapse during postpartum period.

Factors Affecting Smoking Behaviors and Smoking Prevalence in Pregnancy and Postpartum Period of Women

Aim

This study aimed to determine the factors affecting smoking behaviors and smoking prevalence among women during pregnancy and postpartum period.

Method

This cross-sectional study was conducted between May 2012 and October 2012 on a sample of 640 women who had children aged between one and three years and who enrolled in any one of the 23 family health centers located in the province of Sivas in Turkey. The data were collected through the questionnaires created by the researchers by interviewing the participants face to face in own homes. The data obtained were analyzed using the Statistical Package for the Social Sciences Statistics 15.0 (SPSS Inc.; Chicago, IL, USA) package program and evaluated using number, percentage distribution, chi square test, logistic regression analysis and Kaplan-Meier survival analysis.

Results

Smoking prevalence was found to be 8% during pregnancy and 15.6% in the postpartum period. It was determined that 17.2% of the women smoked before their last pregnancy (n=110), more than half of the smokers quit smoking during pregnancy (n=59), and 46.4% of them continued to smoke during pregnancy. It was determined that 79.7% of the participants who quit smoking during pregnancy relapsed within the first one to three years of the postpartum period, and only 20.3% continued not to smoke. The Kaplan-Meier survival analysis showed that women who breastfed quit smoking for a significantly longer time (27.6 months) compared with those who did not breastfeed (12 months). According to the logistic regression analysis, the risk of postpartum relapse among women aged 30 years or more was 10.99-fold higher than women between the ages of 19 and 29.

Conclusion

The rate of pre-pregnancy smokers decreased in the pregnancy and increased in the postpartum period.

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.

Smoking cessation Through Optimisation of clinical care in Pregnancy: the STOP randomised controlled trial

BACKGROUND

Cigarette smoking negatively impacts on maternal and fetal health. Smoking cessation is one of the few interventions capable of improving pregnancy outcomes. Despite the risks, the most effective antenatal model of care for smokers is still unclear, and specific recommendations for screening for fetal growth restriction are absent.

METHODS

This is a pragmatic randomised controlled trial of a dedicated smoking cessation clinic versus routine antenatal care as an intervention to reduce cigarette smoking behaviour. Smoking mothers randomised to the Smoking cessation Through Optimisation of clinical care in Pregnancy (STOP) clinic will have all antenatal care provided by a team comprising an obstetrician, a midwife, and a smoking cessation practitioner. This intervention includes ultrasound screening for fetal growth restriction. The control arm comprises two groups: one receiving standard care with ultrasound screening for fetal growth restriction, and one receiving standard care with ultrasound screening for growth restriction only if clinically indicated by their healthcare provider. Four hundred and fifty women will be recruited and randomised to either intervention or control arms stratifying for age, parity, and history of fetal growth restriction.

RESULTS

The primary outcome is self-reported, continuous abstinence from smoking between the quit date and end of pregnancy, validated by exhaled carbon monoxide or urinary cotinine. The quit date is targeted as being at or before 16 weeks' gestation and no further than 28 weeks' gestation. The secondary outcomes are a set of variables including maternal and fetal morbidity and mortality, neonatal complications and delivery outcomes, smoking and psychological outcomes, and qualitative measures.

CONCLUSIONS

Despite much research into cigarette smoking in pregnancy, the optimal model of care for these women is still unknown. This study has the potential to improve the model of antenatal care provided to pregnant women who smoke and to improve outcomes for both mother and infant.

TRIAL REGISTRATION

ISRCTN11214785 . Registered on 8 February 2018.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Varenicline and nabilone in tobacco and cannabis co-users: effects on tobacco abstinence, withdrawal and a laboratory model of cannabis relapse

Tobacco and cannabis co-users (T+CUs) have poor cannabis cessation outcomes, but the mechanisms underlying this are not well understood. This laboratory study examined the effects of (1) the partial nicotinic agonist, varenicline, on tobacco cessation among T+CUs, and (2) varenicline, alone, and when combined with the cannabinoid agonist nabilone, on cannabis withdrawal and a laboratory model of cannabis relapse. Non-treatment-seeking T+CUs were randomized to active-varenicline or placebo-varenicline, and completed a 15-day outpatient phase; varenicline was titrated to 1 mg BID during days 1-8, and participants were instructed to abstain from tobacco during days 9-15. Participants then moved inpatient for 16 days, where they continued their outpatient medication and tobacco abstinence. Inpatient testing included two, 8-day medication periods, where active-nabilone and placebo-nabilone were administered in counterbalanced order, and measures of acute cannabis effects (days 1-2), withdrawal (days 4-5) and 'relapse' (days 6-8) were collected. Participants in the active-varenicline group were more likely to achieve cotinine-verified tobacco abstinence during the outpatient period versus placebo-varenicline group (46 percent versus 24 percent, respectively), and also reported less mood disturbance and cigarette craving while inpatient. Active-nabilone attenuated cannabis withdrawal in both groups but did not affect cannabis relapse. Regression analyses revealed that two tobacco-related variables, i.e. age of first cigarette use, and cigarette craving while inpatient, were independent predictors of cannabis relapse outcomes. Thus, varenicline holds promise in this population, as a tool to examine the effects of tobacco abstinence on cannabis use outcomes, and as a component of smoking cessation treatments targeting T+CUs.

Association of Postpartum Smoking Relapse With Breastfeeding and Body Mass Index

OBJECTIVE

This study aimed to determine the relationship between smoking relapse and breastfeeding and body mass index in the postpartum period.

METHODS

This descriptive, cross-sectional study was conducted between November 2016 and November 2017 in the polyclinic for children's health and common illnesses at a university hospital in eastern Turkey. One hundred eleven women who met the inclusion criteria constituted the sample of the study. The data were evaluated using the analyses of percentage, arithmetic mean, standard deviation, independent-samples t test, analysis of variance, and multiple linear regression.

RESULTS

In the study, the week of pregnancy period when the women quit smoking was 8.19 ± 5.17, and the week of postpartum smoking relapse was 8.47 ± 11.76. Furthermore, 72.1% of the women stated that they wanted to quit smoking permanently. The study determined that the status of wanting to quit smoking permanently, the status of smoking while breastfeeding, and gained weight during the last gestation are important predictors of postpartum smoking relapse.

ORIGINALITY AND VALUE

Knowledge on the characteristics of the women who started smoking again in the postpartum period is important for helping women who have quitted smoking in pregnancy but who are prone to relapse as a risk group by health care personnel.

Competitions for smoking cessation

BACKGROUND

Competitions might encourage people to undertake and/or reinforce behaviour change, including smoking cessation. Competitions involve individuals or groups having the opportunity to win a prize following successful cessation, either through direct competition or by entry into a lottery or raffle.

OBJECTIVES

To determine whether competitions lead to higher long-term smoking quit rates. We also aimed to examine the impact on the population, the costs, and the unintended consequences of smoking cessation competitions.

SEARCH METHODS

This review has merged two previous Cochrane reviews. Here we include studies testing competitions from the reviews 'Competitions and incentives for smoking cessation' and 'Quit & Win interventions for smoking cessation'. We updated the evidence by searching the Cochrane Tobacco Addiction Group Specialized Register in June 2018.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures in which participants were assigned to interventions by the investigators. Participants were smokers, of any age and gender, in any setting. Eligible interventions were contests, competitions, lotteries, and raffles, to reward cessation and continuous abstinence in smoking cessation programmes.

DATA COLLECTION AND ANALYSIS

For this update, data from new studies were extracted independently by two review authors. The primary outcome measure was abstinence from smoking at least six months from the start of the intervention. We performed meta-analyses to pool study effects where suitable data were available and where the effect of the competition component could be separated from that of other intervention components, and report other findings narratively.

MAIN RESULTS

Twenty studies met our inclusion criteria. Five investigated performance-based reward, where groups of smokers competed against each other to win a prize (N = 915). The remaining 15 used performance-based eligibility, where cessation resulted in entry into a prize draw (N = 10,580). Five of these used Quit & Win contests (N = 4282), of which three were population-level interventions. Fourteen studies were RCTs, and the remainder quasi-randomized or controlled trials. Six had suitable abstinence data for a meta-analysis, which did not show evidence of effectiveness of performance-based eligibility interventions (risk ratio (RR) 1.16, 95% confidence interval (CI) 0.77 to 1.74, N = 3201, I2 = 57%). No trials that used performance-based rewards found a beneficial effect of the intervention on long-term quit rates.The three population-level Quit & Win studies found higher smoking cessation rates in the intervention group (4% to 16.9%) than the control group at long-term follow-up, but none were RCTs and all had important between-group differences in baseline characteristics. These studies suggested that fewer than one in 500 smokers would quit because of the contest.Reported unintended consequences in all sets of studies generally related to discrepancies between self-reported smoking status and biochemically-verified smoking status. More serious adverse events were not attributed to the competition intervention.Using the GRADE system we rated the overall quality of the evidence for smoking cessation as 'very low', because of the high and unclear risk of bias associated with the included studies, substantial clinical and methodological heterogeneity, and the limited population investigated.

AUTHORS' CONCLUSIONS

At present, it is impossible to draw any firm conclusions about the effectiveness, or a lack of it, of smoking cessation competitions. This is due to a lack of well-designed comparative studies. Smoking cessation competitions have not been shown to enhance long-term cessation rates. The limited evidence suggesting that population-based Quit & Win contests at local and regional level might deliver quit rates above baseline community rates has not been tested adequately using rigorous study designs. It is also unclear whether the value or frequency of possible cash reward schedules influence the success of competitions. Future studies should be designed to compensate for the substantial biases in the current evidence base.

Smoking Behavior of Women Before, During, and after Pregnancy: Indicators of Smoking, Quitting, and Relapse

BACKGROUND

Smoking cessation during pregnancy and preventing relapse postpartum is a pivotal public health priority.

OBJECTIVES

This study examined the risk and protective indicators of women who (a) smoke before pregnancy, (b) smoke during the entire pregnancy, (c) successfully quit smoking during pregnancy, and (d) relapse postpartum.

METHOD

This paper reports secondary analyses of the Dutch population-based Monitor on Substance Use and Pregnancy (2016). A representative sample of mothers of young children (n = 1,858) completed questionnaires at youth health care centers. Bivariate and multivariate logistic regression analyses were conducted.

RESULTS

Main results showed that women's smoking around pregnancy was strongly associated with the partner's smoking status before pregnancy, partner's change in smoking during pregnancy, and partner's change in smoking postpartum. Women's educational level and cannabis use before pregnancy were also related with women's smoking before and during pregnancy. Women's intensity of alcohol use before pregnancy was ambiguously related with women's smoking before and during pregnancy.

CONCLUSIONS

One of the key findings of this study suggests that it is essential that partners quit smoking before pregnancy and do not smoke during pregnancy. If partners continue smoking during pregnancy, they should quit smoking postpartum. Health care professionals can play an important role in addressing partners' smoking and giving them evidence-based cessation support before, during, and after pregnancy.

Attitudes, barriers and facilitators to smoking cessation among Central and Eastern European nurses: A focus group study

PURPOSE

Smoking among nurses is a barrier to providing smoking cessation interventions to patients. In Central and Eastern Europe-where tobacco use is the leading cause of preventable death and disease-there is limited knowledge about nurses' attitudes toward cessation interventions. Our aim was to describe the attitudes of nurses who are former and current smokers toward providing cessation interventions to patients as well as explore barriers and facilitators to their own quit efforts.

METHODS

Nine focus groups with 81 nurses (94% females) in five Central and Eastern European countries. Content analysis was used to identify major themes.

RESULTS

Nurses agreed that they should set a good example by not smoking; should be involved in helping patients stop smoking; and needed additional training in tobacco control. Five common themes were identified as barriers to quitting: smoking cues in the environment; presence of smokers in the environment; relapse postpartum; stress and nicotine addiction; and misperceptions about the dangers of smoking. Former smokers reported facilitators to quitting including: seeing the health consequences of smoking among their patients; personal and family health concerns; receiving support from family; and pregnancy.

CONCLUSION

There is a need to build upon nurses' positive attitudes about engaging in smoking cessation interventions with patients to ensure that cessation interventions are standard nursing practice. Future studies should focus on programs that support nurses' quit efforts by addressing barriers to smoking cessation, which will improve their health and patient care.

The Potential Utility for Massage Therapy During Pregnancy to Decrease Stress and Tobacco Use

BACKGROUND

A significant number of women continue to smoke tobacco during pregnancy despite the increased risk of complications to fetal and infant development. Therefore, effective interventions are needed to assist pregnant women with the process of tobacco cessation. Traditional counseling programs have demonstrated some success; however, novel approaches that target stress as a mechanism in the maintenance of addiction would be valuable.

OBJECTIVE

To examine the role of stress in addiction and the utility of massage therapy to decrease stress during pregnancy.

CONCLUSION

Preliminary evidence suggests massage therapy may be beneficial to decreasing tobacco use, and research in pregnant populations is needed.

Parenting and addiction: neurobiological insights

Addiction remains a significant public health concern that affects multiple generations within families, and in particular the early relationship between parents and their developing child. This article will discuss recent advances in our understanding of the neurobiology of parenting and addiction. Specifically, the discussion will focus on the reward-stress dysregulation model of addicted parenting, which proposes that the dysregulation of stress and reward neural circuits by addiction represents a neurobiological pathway through which to understand how caregiving may be compromised in addicted parents. Empirical research in parents and non-parents will be discussed in support of this model and critical consideration of the model and its limitations will be provided.

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.

Women's Longitudinal Patterns of Smoking during the Pre-Conception, Pregnancy and Postnatal Period: Evidence from the UK Infant Feeding Survey

BACKGROUND

An understanding of women's longitudinal patterns of smoking during the pre-conception, pregnancy and postnatal period and the factors associated with these patterns could help better inform smoking cessation services and interventions.

METHODS

Latent class analysis (LCA) was used to empirically identify women's smoking patterns in a sample of 10,768 mothers from the 2010 UK Infant Feeding Survey. Multinomial logistic regression was used to identify characteristics associated with these patterns.

RESULTS

LCA identified five distinct smoking patterns during the pre-conception, pregnancy and postnatal period: "non-smokers" (74.1% of women); "pregnancy-inspired quitters" (10.2%); "persistent smokers" (10.1%); "temporary quitters" (4.4%); and postnatal quitters (1.1%). Smoking patterns varied markedly according to socio-demographic variables and parity. After adjusting for these variables, mothers who lived during pregnancy with a partner who smoked were more likely to be temporary quitters (aOR 2.64, 95% CI 1.74-3.99) or persistent smokers (aOR 3.32, 95% CI 2.34-4.72) than pregnancy-inspired quitters. Mothers who lived during pregnancy with someone else other than a partner who smoked were more likely to be persistent smokers (aOR 2.34, 95% CI 1.38-3.97) or postnatal quitters (aOR 2.97, 95% CI 1.07-8.24) than pregnancy-inspired quitters. Mothers given information on how their partner could stop smoking if they lived during pregnancy with a smoking partner were less likely to be persistent smokers (aOR 0.42, 95% CI 0.27-0.65) than pregnancy-inspired quitters.

CONCLUSION

Health professionals should ask about smoking at every opportunity, and refer women who self-report as current smokers to an evidence based smoking cessation service.

Social and Environmental Factors Related to Smoking Cessation among Mothers: Findings from the Geographic Research on Wellbeing (GROW) Study

OBJECTIVES

The current study examined associations between race/ethnicity and psychosocial/environmental factors with current smoking status, and whether psychosocial/environmental factors accounted for racial differences in smoking status in a population-based sample of mothers in California.

METHODS

Cross-sectional data from 542 women with a history of smoking were used. Analyses adjusted for age, partner status, and educational attainment.

RESULTS

In models adjusted for sociodemographics, black women had significantly lower odds, and Latina immigrants had significantly higher odds of being a former smoker compared to white women. Persons smoking in the home, having a majority of friends who smoke, having perceptions of their neighborhood as being somewhat or very unsafe, and experiencing food insecurity were associated with decreased odds of being a former smoker. When these variables were entered into a single model, only being a Latina immigrant and having a majority of friends who smoke were significantly associated with smoking status.

CONCLUSIONS

Black women demonstrated a notable disparity compared with white women in smoking status, accounted for by psychosocial/environmental factors. Immigrant Latinas demonstrated notable success in ever quitting smoking. Social networks may be important barriers to smoking cessation among women.

Early Breastfeeding Problems Mediate the Negative Association between Maternal Obesity and Exclusive Breastfeeding at 1 and 2 Months Postpartum

BACKGROUND

Compared with normal-weight women, women with obesity experience poorer breastfeeding outcomes. Successful breastfeeding among women with obesity is important for achieving national breastfeeding goals.

OBJECTIVES

The objectives were to determine whether the negative association between obesity and any or exclusive breastfeeding at 1 and 2 mo postpartum is mediated through breastfeeding problems that occur in the first 2 wk postpartum and if this association differs by parity.

METHODS

Mothers (1151 normal-weight and 580 obese) in the Infant Feeding Practices Study II provided information on sociodemographic and psychosocial characteristics, body mass index, and breastfeeding outcomes. At 1 mo postpartum, participants reported the breastfeeding problems they experienced in the first 2 wk postpartum from a predefined list of 17 options. We used factor analysis to condense these problems into 4 explanatory variables; continuous factor scores were computed for use in further analyses. We used maximum likelihood logistic regression to assess mediation of the association between obesity and breastfeeding outcomes through early breastfeeding problems.

RESULTS

No significant effect of obesity was found on any breastfeeding at 1 or 2 mo. At 1 mo postpartum, for both primiparous and multiparous women, there was a significant direct effect of obesity on exclusive breastfeeding and a significant indirect effect of obesity through early breastfeeding problems related to the explanatory mediating variable "Insufficient Milk" (throughout the remainder of the Abstract, this factor will be denoted by upper case notation). At 2 mo postpartum both the direct effect of obesity and the indirect effect through Insufficient Milk were significant in primiparous women but only the indirect effect remained significant in multiparous women.

CONCLUSIONS

Early problems related to Insufficient Milk may partially explain the association between obesity and poor exclusive breastfeeding outcomes. Women who are obese, particularly those reporting breastfeeding problems that grouped in the Insufficient Milk factor in the early postpartum period, may benefit from additional breastfeeding support.

The Relationship Between Postpartum Depression and Perinatal Cigarette Smoking: An Analysis of PRAMS Data

INTRODUCTION

This study examines the relationship between postpartum depression (PPD) and cigarette smoking from prior to pregnancy to postpartum.

METHODS

The study sample consisted of 29,654 U.S. women who reported smoking in the 3months prior to pregnancy and for whom data on PPD were available from the Pregnancy Risk Assessment Monitoring System (PRAMS). Two sets of analyses were conducted. The first compared smoking at 2 time points (prior to pregnancy and postpartum) and the second at 3 time points (prior to pregnancy, during pregnancy, and postpartum). PPD was defined as responses of "often" or "always" to 2 questions: "Since your baby was born, how often have you felt down, depressed, or sad?" and "Since your new baby was born, how often have you had little interest or little pleasure in doing things?"

RESULTS

Overall, 22% of the sample endorsed PPD symptoms. In the 2 time-point analysis, controlling for known confounders, participants whose smoking was reduced or unchanged postpartum were about 30% more likely to have PPD compared to those who quit (OR: 1.34; 95% CI=1.10-1.60, p=0.001; OR:1.32; 95% CI: 1.10-1.50, p<0.001 respectively). Participants who increased smoking postpartum were 80% more likely to have PPD compared those who quit (OR: 1.80; 95% CI: 1.50-2.30, p<0.001). In the 3 time-point analysis, participants who continued smoking at any level during pregnancy and postpartum had 1.48 times the odds of reporting PPD (95% CI: 1.26, 1.73) compared to those who quit during pregnancy and remained quit postpartum. Participants who quit during pregnancy but resumed postpartum had 1.28 times the odds of reporting PPD (95% CI: 1.06, 1.53) compared to those who quit during pregnancy and remained quit postpartum.

CONCLUSION

Results suggest an association among women who smoke cigarettes prior to pregnancy between PPD and continued smoking during pregnancy and postpartum.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

Predictors of Changes in Smoking From Third Trimester to 9 Months Postpartum

INTRODUCTION

While much has been written about postpartum smoking relapse prevention, few have examined changes in smoking behavior from pregnancy (third trimester) through 9 months postpartum among pregnant smokers, particularly for the large number of women who decrease tobacco consumption during pregnancy but do not quit altogether.

METHODS

Data were obtained from 168 women who smoked during their pregnancy. Women were followed longitudinally from their first prenatal appointment through 9 months postpartum. Maternal substance use was assessed using the Timeline Followback and verified by maternal salivary analyses. Breastfeeding, other substance use, and partner smoking were assessed through maternal interviews at each time point and were considered as potential predictors of change in smoking.

RESULTS

Women returned to more than half of their levels of preconception tobacco consumption by 9 months postpartum. There was one significant predictor of changes in smoking patterns pregnancy to postpartum. Women who breastfed their infants for at least 90 days smoked far less postpartum than women who breastfed for a short time or did not breastfeed at all.

CONCLUSIONS

As noted in previous research of pregnant quitters, postpartum relapse prevention or harm reduction interventions should ideally be timed early in the postpartum period. Additionally, promoting breastfeeding among pregnant smokers and supporting women through at least 3 months of breastfeeding may be beneficial to such interventions.

Preventing smoking during pregnancy: the importance of maternal knowledge of the health hazards and of the treatment options available

OBJECTIVE

To examine the pattern of tobacco use and knowledge about tobacco-related diseases, as well as to identify popular types of electronic media, in pregnant women, in order to improve strategies for the prevention or cessation of smoking among such women.

METHODS

A cross-sectional study involving 61 pregnant women, seen at primary care clinics and at a university hospital, in the city of Botucatu, Brazil. For all subjects, we applied the Hospital Anxiety and Depression Scale. For subjects with a history of smoking, we also applied the Fagerström Test for Nicotine Dependence, and we evaluated the level of motivation to quit smoking among the current smokers.

RESULTS

Of the 61 pregnant women evaluated, 25 (40.9%) were smokers (mean age, 26.4 ± 7.4 years), 24 (39.3%) were former smokers (26.4 ± 8.3 years), and 12 (19.8%) were never-smokers (25.1 ± 7.2 years). Thirty-nine women (63.9%) reported exposure to passive smoking. Of the 49 smokers/former smokers, 13 (26.5%) were aware of the pulmonary consequences of smoking; only 2 (4.1%) were aware of the cardiovascular risks; 23 (46.9%) believed that smoking does not harm the fetus or newborn infant; 21 (42.9%) drank alcohol during pregnancy; 18 (36.7%) reported increased cigarette consumption when drinking; 25 (51.0%) had smoked flavored cigarettes; and 12 (24.5%) had smoked a narghile. Among the 61 pregnant women evaluated, television was the most widely available and favorite form of electronic media (in 85.2%), as well as being the form most preferred (by 49.2%).

CONCLUSIONS

Among pregnant women, active smoking, passive smoking, and alternative forms of tobacco consumption appear to be highly prevalent, and such women seem to possess little knowledge about the consequences of tobacco use. Educational programs that include information about the consequences of all forms of tobacco use, employing new and effective formats tailored to this particular population, should be developed, in order to promote smoking prevention and cessation among pregnant women. Further samples to explore regional and cultural adaptations should be evaluated.

Perinatal smoking and depression in women with concurrent substance use

OBJECTIVE

The purpose of this report was to examine the course of smoking among pregnant women with concurrent substance use, and to assess the impact of depression on smoking.

METHODS

Data were gathered as part of a randomized controlled trial assessing the efficacy of substance abuse treatment in pregnant women. Women (n=176) were recruited before 28 completed weeks of pregnancy, and followed until 3months postpartum. Depression was assessed using the Inventory of Depressive Symptomatology and the MINI Neuropsychiatric Interview. Our outcome was the average number of cigarettes smoked per day. Linear mixed effects regression was used to measure differential changes in smoking.

RESULTS

66% of women smoked in the three months before pregnancy, 42% of pre-pregnancy smokers achieved abstinence before delivery and 60% of the baseline cohort smoked postpartum. Smoking did not differ significantly between depressed and non-depressed groups. After delivery both groups increased smoking at similar rates.

CONCLUSION

Smoking was common among our cohort of pregnant women with a history of substance use. Women were able to discontinue or decrease smoking during pregnancy, but were likely to resume or increase smoking postpartum. Having clinically significant depressive symptoms or a diagnosis of depression did not have an obvious effect on smoking behaviors.

Individual and combined effects of multiple high-risk triggers on postcessation smoking urge and lapse

INTRODUCTION

Negative affect, alcohol consumption, and presence of others smoking have consistently been implicated as risk factors for smoking lapse and relapse. What is not known, however, is how these factors work together to affect smoking outcomes. This paper uses ecological momentary assessment (EMA) collected during the first 7 days of a smoking cessation attempt to test the individual and combined effects of high-risk triggers on smoking urge and lapse.

METHODS

Participants were 300 female smokers who enrolled in a study that tested an individually tailored smoking cessation treatment. Participants completed EMA, which recorded negative affect, alcohol consumption, presence of others smoking, smoking urge, and smoking lapse, for 7 days starting on their quit date.

RESULTS

Alcohol consumption, presence of others smoking, and negative affect were, independently and in combination, associated with increase in smoking urge and lapse. The results also found that the relationship between presence of others smoking and lapse and the relationship between negative affect and lapse were moderated by smoking urge.

CONCLUSIONS

The current study found significant individual effects of alcohol consumption, presence of other smoking, and negative affect on smoking urge and lapse. Combing the triggers increased smoking urge and the risk for lapse to varying degrees, and the presence of all 3 triggers resulted in the highest urge and lapse risk.

Prepartum and postpartum predictors of smoking

INTRODUCTION

Reduction of smoking during pregnancy and in the postpartum period remains a public health priority. This study tested whether variables (demographic, pregnancy related, emotional, and smoking related) assessed in abstinent women during their pregnancy predicted resumed smoking at 1 month and 1 year postpartum. Additionally, pregnancy-related and smoking-related variables obtained in the immediate postpartum period were examined as predictors of smoking at 1 year postpartum.

METHODS

Participants were pregnant women in their second and third trimester (N = 504) who enrolled in a randomized controlled trial of a smoking relapse-prevention intervention. Multivariate regression analyses were conducted with baseline data collected during pregnancy and follow-up assessments completed at 1 month and 12 months postpartum.

RESULTS

Independent predictors of smoking at 1 month postpartum included not intending to remain abstinent, lower quitting confidence, the presence of other household smokers, and not planning to breast feed. Smoking at 12 months postpartum was predicted by only not intending to remain abstinent and having a partner who maintained his or her smoking rate. In contrast, when assessed at 1 month postpartum, smoking at 12 months was predicted by current smoking status and lower quitting confidence.

CONCLUSIONS

Baseline variables measured during pregnancy differentially predicted early versus late smoking status. After delivery, the best predictor of later smoking status was current smoking status, reinforcing the need to focus on preventing early postpartum relapse. The importance of quitting confidence, or self-efficacy, was also reinforced. Findings may be useful for screening women at risk of relapse and targeting interventions to key variables.

Relations of maternal psychopathologies, social-obstetrical factors and mother-infant bonding at 2-month postpartum: a sample of Turkish mothers

BACKGROUND

The mental health of the mother influences early mother-infant relationship. This study aimed to explore the relations between maternal psychopathologies, particularly postpartum depression, social-obstetrical factors and mother-infant bonding.

METHODS

One hundred and eighty-nine mother-infant pairs who participated in the longitudinal study entitled "Mother-Infant Care Study" were evaluated at the second month postpartum. The Brief Symptom Inventory (BSI) had been applied to all mothers in the first 3 days postpartum. At the second month postpartum, mothers were assessed with the Edinburgh Postpartum Depression Scale (EPDS), Postpartum Bonding Questionnaire (PBQ), and Mother-Infant Bonding Scale (MIBS).

RESULTS

The mean maternal age was 25.1 (± 5.2) years. The EPDS scores were higher in the mothers who had been supported lifelong by a psychologist due to psychological problems, had a birth interval of ≤ 2 years, and had smoking habits at the second month postpartum. Mothers with a female infant had higher PBQ score than those with a male infant. The EPDS score was correlated positively with the PBQ and MIBS scores. There were positive correlations between the EDS scores and all subscales of PBQ and MIBS scores. Some subscales and indexes of the BSI were correlated with the PBQ, MIBS and EPDS scores.

CONCLUSION

Identifying postpartum depression and other psychopathologies in mothers is critical for prevention of mother-infant bonding impairment in the early postpartum period.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth 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 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 fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) 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, and subgroup analyses and sensitivity analysis were conducted in SPSS.

MAIN RESULTS

Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing.

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 reduce low birthweight and preterm births.

Prevalência do uso de drogas de abuso por gestantes

OBJETIVO: Determinar a prevalência do uso de drogas de abuso por gestantes. MÉTODO: Estudo transversal que incluiu 394 gestantes usuárias de serviço de atenção primária. A variável dependente foi o uso de drogas de abuso durante a gestação e as variáveis independentes foram: socioeconômicas e obstétricas. RESULTADOS: A prevalência do uso de drogas ilícitas entre gestantes foi de 18,28%. A regressão logística multivariada indicou como variáveis significativas: anos de estudo, participação em grupo de gestante e orientação de profissional de saúde quanto ao risco de usar drogas de abuso durante a gestação. CONCLUSÃO: Os resultados indicam a predominância de gestantes jovens, pardas, com baixa escolaridade e renda de até três salários mínimos e que faz uso de drogas de abuso, sendo que a mais utilizada o cigarro, seguido do álcool. As drogas ilícitas utilizadas foram a cocaína e seu derivado o crack e a maconha.

Do risk factors for post-partum smoking relapse vary according to marital status?

We aimed to examine associations between factors readily obtainable in health care settings and post-partum smoking relapse in women of differing marital status. We analysed data on 1,829 mothers in the Millennium Cohort Study who reported quitting smoking during their pregnancy using multivariate logistic regression. We analysed single, married and cohabiting women separately. Fifty-seven percent of mothers who quit during pregnancy had relapsed at 9 months. The risk of relapse was highest for single women, followed by cohabiting, then married women. Higher parity and not managing financially were associated with relapse for single women. For married women the greatest risk of relapse was associated with having a partner who also relapsed. Women whose husbands continued to smoke had an increased risk of relapse but those whose husbands had sustained a quit were protected. Other significant risk factors were not breastfeeding, having other children and drinking at moderate frequencies. A similar pattern was seen for cohabiting women, except that having a partner who quit but then relapsed did not appear to confer an additional risk. Drinking at moderate intervals (only) was associated with relapse but breastfeeding and parity were not. The association between married couple relapse was not evident when only the husband's smoking status during the pregnancy was considered, indicating that partner follow-up is important post-partum. Risk factors for relapse appear to differ according to marital status. A 'one size fits all' package of post-partum relapse prevention is unlikely to be an appropriate intervention strategy.

The importance of social networks on smoking: perspectives of women who quit smoking during pregnancy

While up to 45% of women quit smoking during pregnancy, nearly 80% return to smoking within a year after delivery. Interventions to prevent relapse have had limited success. The study objective was to understand what influences return to smoking after pregnancy among women who quit smoking during pregnancy, with a focus on the role of social networks. We conducted in-depth, semi-structured interviews during the postpartum hospital stay with women who quit smoking while pregnant. Over 300 pages of transcripts were analyzed using qualitative methods to identify common themes. Respondents [n = 24] were predominately white (63%), had at least some college education (54%) and a mean age of 26 years (range = 18-36). When reflecting on the experience of being a smoker who quit smoking during pregnancy, all participants emphasized the importance of their relationships with other smokers and the changes in these relationships that ensued once they quit smoking. Three common themes were: (1) being enmeshed in social networks with prominent smoking norms (2) being tempted to smoke by members of their social networks, and (3) changing relationships with the smokers in their social networks as a result of their non-smoking status. We found that women who quit smoking during pregnancy found themselves confronted by a change in their social network since most of those in their social network were smokers. For this reason, smoking cessation interventions may be most successful if they help women consider restructuring or reframing their social network.

The association of maternal mental health with prenatal smoking cessation and postpartum relapse in a population-based sample

To examine the association between mental health factors with smoking cessation during pregnancy and postpartum relapse. We used data from 1,416 women who participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey in 2004-2006 and reported smoking immediately prior to pregnancy. Maternal mood during pregnancy, stressful life events and postpartum depression were the mental health variables. We used multivariate logistic regression to examine the association between these variables and two outcomes, smoking cessation during pregnancy and postpartum relapse. Stressful life events was associated with smoking cessation in multivariate regression models, however maternal mood was not. Smoking cessation was also associated with pre-conception smoking intensity, maternal education, and income. Maternal mood, stressful life events and postpartum depression were not associated with relapse in multivariate regression models. Breastfeeding at the time of the survey was the strongest correlate of relapse, with women who breast fed 60% less likely to resume smoking during the postpartum. Post-hoc analysis suggests that mental health variables may interact with other mitigating factors to influence smoking behavior during pregnancy. Mental health variables may be important to successful prenatal smoking cessation. Further research with larger sample sizes is needed to explore the possibility of interactive relationships between mental health variables and other co-factors on prenatal smoking cessation and postpartum relapse.

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.

A qualitative study of postpartum mothers' intention to smoke

BACKGROUND

Many women stop smoking during pregnancy. Factors associated with relapse are known, but no intervention prevents the return to smoking among pregnant women. The objective of this study was to determine why women return to smoking after prolonged abstinence during pregnancy by examining mothers' intention to smoke at the time of delivery and the perceptions that shape their intention.

METHODS

We conducted in-depth, semi-structured interviews during their postpartum hospital stay with 24 women who stopped smoking while pregnant. We asked participants whether they intended to resume smoking after pregnancy and why. Transcripts were analyzed using grounded theory-based qualitative methods to identify themes.

RESULTS

Participants ranged in age from 18 to 36 years, and 63 percent were white. Three themes emerged from the interviews with the mothers: 1) they did not intend to return to smoking but doubted whether they would be able to maintain abstinence; 2) they believed that it would be possible to protect their newborns from the harms of cigarette smoke; and 3) they felt that they had control over their smoking and did not need help to maintain abstinence after pregnancy.

CONCLUSIONS

Although most participants did not intend to resume smoking, their intentions may be stymied by their perceptions about second-hand smoke and by their overestimation of their control over smoking. Further study should quantify these barriers and determine their evolution over the first year after pregnancy with the goal of informing more successful, targeted interventions.

Predictors of risk for smoking relapse in men and women: a prospective examination

The current study examined whether prequit trait negative mood and smoking motives have different predictive patterns of smoking relapse in men and women. Thirty-three female (mean age±SEM: 34.9±2.5) and 38 male (mean age±SEM: 37.1±2.3) smokers interested in smoking cessation completed forms on smoking history, negative mood (i.e., depression, anxiety, and anger), stress, and smoking motives. Participants also provided samples for measurement of cotinine and carbon monoxide. Then, they set a quit date and were required to abstain from smoking at least for 24 hours. Participants were followed up for 12 months postcessation to measure their smoking status. Cox proportional hazard models revealed that motivation to reduce craving was a unique predictor of smoking relapse in men, while depressive mood, anxiety, anger, and perceived stress were predictive of time to relapse among women. These findings remained significant after statistically controlling for smoking-related variables, providing preliminary evidence that different factors may be associated with nicotine withdrawal and smoking relapse in men and women.

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.

The epidemiology of hospitalized postpartum depression in New York State, 1995-2004

PURPOSE

The purpose of this study is to describe the patterns of hospitalization for depression in the year after delivery in relation to social, demographic, and behavioral characteristics.

METHODS

Data on births were linked to hospitalizations for depression over the subsequent year to describe the frequency and patterns of hospitalized postpartum depression among 2,355,886 deliveries in New York State from 1995 to 2004. We identified "definite postpartum depression" based on International Classification of Diseases (ICD) codes indicative of "mental disorders specific to pregnancy," and "possible postpartum depression" by ICD codes for hospitalization with any depressive disorders.

RESULTS

In New York State, we identified 1363 women (5.8 per 10,000) who were hospitalized with definite postpartum depression, and 6041 women (25.6 per 10,000) with possible postpartum depression, with lower risks in the New York City area. Postpartum depression was more common in later years and among mothers who were older, Black, smokers, lacking private insurance, and with multiple gestations, and was rarer among Asians. For possible postpartum depression, socioeconomic gradients were enhanced.

CONCLUSIONS

Risk of hospitalized postpartum depression is strongly associated with socioeconomic deprivation and varies markedly by ethnicity, with direct implications for screening and health services, also providing suggestions for etiologic studies.

Incident smoking during pregnancy and the postpartum period in a low-income urban population

OBJECTIVES

We determined the prevalence of first lifetime use of cigarettes during pregnancy or in the early postpartum period (incident smoking) and identified sociodemographic and health-related characteristics of incident smokers.

METHODS

We used statistics based on data from a longitudinal study of a large cohort of pregnant, low-income, urban women (n = 1,676) to describe the timing of first-time use and to compare incident smokers with those who had never smoked and those who had already smoked prior to pregnancy.

RESULTS

About one in 10 (10.2%) women who had not previously smoked initiated cigarette smoking during pregnancy or in the early postpartum period. Compared with those who had never smoked, incident smokers were more likely to report high levels of stress and to have elevated levels of depressive symptomatology, which may be rooted in relatively poor social and economic conditions.

CONCLUSION

A significant number of women may be initiating smoking during pregnancy or in the early postpartum period. These women have characteristics that are consistent with the risk factors associated with smoking. Further research is warranted to determine prevalence in other populations, identify the risk factors for incident smoking, and assess the potential for primary prevention efforts designed to help women who had previously avoided cigarette use to remain smoke-free throughout pregnancy and in the postpartum period.

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

OBJECTIVE

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.

METHOD

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).

RESULTS

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.

CONCLUSIONS

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.