The description and evaluation of a longitudinal pilot study of a smoking relapse/reduction intervention for perinatal women

Addressing Postpartum Smoking Relapse Among Low-Income Women: A Randomized Control Trial

PURPOSE

Smoking during pregnancy can have dire consequences for both the baby and mother. Low-income pregnant women smoke at particularly high rates. Among women who quit during pregnancy, postpartum relapse is high. This randomized control trial tested the effect of adding postpartum assistance to an existing smoking cessation program (First Breath) designed for low-income women.

METHODS

Of 185 study participants, 94 women were randomly assigned to the standard First Breath program (control) and 91 to an enhanced program. First Breath consisted of evidence-based smoking cessation counseling provided at every prenatal visit. The enhanced program included all First Breath services plus 4 in-home counseling visits (3 postpartum), 3 postpartum counseling calls, support to others in the home, and incentives (gift cards) totaling $100. The primary outcome was biochemically verified abstinence at 6 months postpartum.

RESULTS

Among the 98 women who completed the study, the abstinence rate among the intervention participants (n=41) was significantly greater than among the control participants (n=57) (36.6% vs 12.3%, respectively; P<0.01). Analyzed on an intent-to-treat basis, with those lost to follow-up assumed to be smoking, the abstinence rate among intervention subjects (n=91) was 16.5% vs 7.4% among control participants (n=94); P=0.07.

CONCLUSIONS

Extending smoking cessation interventions into the postpartum period may help address postpartum relapse.

Publishing pilot intervention work

Pilot intervention studies can be viewed as rehearsals for subsequent full-scale trials. They can help investigators fine-tune later larger studies as well as explore issues related to project management and budget. Pilot studies permit testing of sampling strategies, participant recruitment, intervention content, delivery methods, data collection, and analysis. They also allow researchers to experience the more practical aspects of implementing a study, such as determining the number of study staff members needed to handle recruitment and data collection or identifying special equipment needs. Because pilot study findings may be generalizable, publication is encouraged as long as the preliminary nature of the work is clearly indicated in both the abstract and the article. The present article provides an overview of the types of information that can be gleaned from pilot intervention studies that are suitable for publication.

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

INTRODUCTION

Postpartum relapse rates are high among women who spontaneously quit smoking during pregnancy. This randomized clinical trial tested a Motivation and Problem-Solving (MAPS) treatment for reducing postpartum relapse among diverse low-income women who quit smoking during pregnancy (N = 251; 32% Black, 30% Latino, and 36% White; 55% <$30,000/year household income).

METHODS

Pregnant women were randomly assigned to MAPS/MAPS+ or Usual Care (UC). Continuation ratio logit models were used to examine differences in biochemically confirmed continuous abstinence at Weeks 8 and 26 postpartum by treatment group and moderators of the treatment effect. Analyses controlled for age, race/ethnicity, partner status, education, smoking rate, and the number of smokers in the participant's environment.

RESULTS

MAPS/MAPS+ was more efficacious than UC in the prevention of postpartum relapse (p = .05). An interaction between treatment and the number of cigarettes smoked per day before quitting approached significance (p = .09), suggesting that the MAPS/MAPS+ treatment effect was stronger among women who smoked more cigarettes per day.

DISCUSSION

MAPS, a holistic and dynamic approach to changing behavior using a combined motivational enhancement and social cognitive approach, is a promising intervention for postpartum smoking relapse prevention among low-income women, which may have particular relevance for women with higher prequit smoking rates.

Postpartum smoking relapse and secondhand smoke

OBJECTIVE

There has been an abundance of research evaluating prenatal and postnatal smoking abstinence programs. However, few researchers have tested postpartum relapse interventions that address secondhand smoke (SHS) exposure. Pregnant women exposed to SHS are more likely to relapse. This article explores the similarities and differences among postpartum interventions that incorporate SHS education. Generating knowledge about the components of postpartum relapse prevention interventions that do and do not achieve prolongation of abstinence is integral to the development of effective SHS interventions that help women achieve lifelong abstinence.

METHODS

We used a methodological review of 11 randomized, controlled trials testing the efficacy of relapse prevention interventions that address SHS exposure. We compared intervention strength, biomarker validation of home smoking and SHS, as well as abstinence and relapse rates. We examined three predictors of postpartum relapse: (1) partner smoking in the home, (2) adoption of home smoking restrictions, and (3) motivation/confidence to remain abstinent.

RESULTS

Findings revealed a need for more comprehensive SHS interventions and a clear delineation of abstinence/relapse terminology. Biomarker validation of home smoking and SHS was primarily measured by self-report, passive nicotine monitors, and hair nicotine levels. Furthermore, studies using nurse- and pediatrician-led interventions resulted in the lowest relapse rates.

CONCLUSION

A comprehensive intervention that specifically prioritizes parental education on the health effects of SHS on the family, empowerment of the mother and family members to remain abstinent and adopt a smoke-free home smoking policy, and partner influence on smoking could result in a significant reduction in postpartum relapse rates.

Combining women's preferences and expert advice to design a tailored smoking cessation program

We designed a patient-centered smoking cessation program for women in 2004/2005, incorporating women's preferences and expert opinion. Our four-step process included: (1) concept-development focus groups; (2) an expert panel; (3) concept-testing focus groups, and (4) a pilot study. Data analyses occurred in 2004-2007. The new program offered options: the traditional Veterans Health Administration (VA) male-dominated program was the least selected option in the pilot study. Patients can be effectively involved in program development. The study's implications and limitations are noted. This research (conducted in Los Angeles, California) was funded by the American Legacy Foundation with additional VA support.

Listen to the consumer: designing a tailored smoking-cessation program for women

We used a consumer-driven approach to develop a model smoking-cessation program for women. Four focus groups (N = 23 [5-7/group]), each lasting 2 hours, were led by a professional moderator and audiotaped in 2004. Researchers reviewed transcripts; key themes were identified using scrutiny techniques (Ryan and Bernard, 2003). Necessary elements of a smoking-cessation program for women included support and choice (i.e., control over the program components), suggesting the need for an individualized program. Identifying appropriate components is a critical step in the development of efficacious programs that target substance-abusing populations; focus group methodology is useful in this endeavor. The study's implications and limitations are noted.

Examining smoking and cessation during pregnancy among an Appalachian sample: a preliminary view

BACKGROUND

Several transitions that a woman experiences prenatally may influence her desire or ability to discontinue smoking. This study explores the role of smoking for young, Appalachian, nulliparous pregnant women and their plans for smoking during their pregnancies.

RESULTS

The reports of women and their male partners were taken from baseline interviews conducted during the first trimester of pregnancy. Cigarette smoking appeared to be more than an isolated addictive activity; rather, smoking was interwoven in women's social and personal realms, often changing as their perceptions of self changed. Women and their partners who continued to smoke appeared to be depressed, reject authority, and perceived little control over issues related to being pregnant.

CONCLUSION

These findings support the argument that standard substance use treatments and polices based on stages-of-change theories may not be effective for all individuals particularly those experiencing significant developmental changes in their lives. Greater success might be obtained from treatment programs designed to recognize the impact of these transitions as it relates to the substance use. The changing experiences of pregnant women in terms of their identity development, views of others, and their relationships have not been adequately addressed in existing cessation programs. Empirically-based interventions targeting these lifestyle characteristics may lead to increased cessation success among pregnant women.

Adapting Smoking Relapse–Prevention Materials for Pregnant and Postpartum Women: Formative Research

OBJECTIVE

To decrease smoking relapse among pregnant and postpartum women by adapting existing, validated relapse-prevention materials to meet the unique needs of pregnant and postpartum women.

METHODS

A series of semi-structured interviews and learner verification activities were conducted with pregnant abstinent, postpartum abstinent, and postpartum relapsed women. Results were used to create new relapse-prevention materials, specific to the needs of pregnant and postpartum women, which are currently being used in a randomized clinical trial.

RESULTS

Findings are consistent with the recurrent themes in the literature regarding smoking cessation among pregnant and postpartum women and revealed exceptional needs for coping and stress reduction strategies related to remaining abstinent postpartum. Conflict levels were also high in areas of identity, social support, and reasons for quitting.

CONCLUSION

By interviewing women about their cessation related needs, the current study was able to produce smoking relapse-prevention materials specific to this population. Having pregnant and postpartum women review the modified program materials before starting the clinical trial enhanced the quality, dependability, and validity of the materials. We await the results of the clinical trial to determine if this intervention is indeed more efficacious than previous attempts to intervene with this population.