Motivation for smoking cessation among pregnant women

Trajectories of Situational Temptations in Pregnant Smokers participating in a Scheduled Gradual Reduction Cessation Trial

OBJECTIVE

The purpose of this paper was to examine changes in situational temptations to smoke among women in early to late pregnancy enrolled in a texting trial to help them quit smoking. We compared changes between (1) intervention arms, (2) those who quit, (3) those who reduced by 50% or more, and (4) those who reduced by less than 50%. We also examined cravings overtime in the intervention arm and the relationship between real-time cravings assessed via text message and situational temptations.

METHODS

This was a secondary analysis of the Baby Steps trial, a randomized controlled trial testing the efficacy of a text-based scheduled gradual reduction (SGR) intervention on cessation. We used t-tests to examine changes across intervention arms and repeated measured proc mixed to explore changes in situational temptations and cravings.

RESULTS

Among all women, situational temptations decreased from early to late pregnancy for the positive, negative, and habitual subscales, (ps < 0.001). We found no difference in situational temptations across arms. We found a positive relationship between negative situational temptation and average craving during the Weeks 2 and Weeks 3 of the intervention. Negative ST increased by 0.11 for each unit increase of craving at Week 2.

CONCLUSIONS

As women progress through pregnancy their temptation to smoke reduces. A different relationship might exist, however with negative affect situations in which women reported higher craving but not in response to other temptations. Future work might have a particular focus on the intersection of negative affect with cravings and temptations to promote cessation during pregnancy.

CLINICAL TRIAL

NCT01995097.

Stress- and smoke free pregnancy study protocol: a randomized controlled trial of a personalized eHealth intervention including heart rate variability-biofeedback to support pregnant women quit smoking via stress reduction

BACKGROUND

Maternal smoking and stress during pregnancy are associated with adverse health effects for women themselves and are risk factors for adverse developmental outcomes of the unborn child. Smoking and stress seem to be intertwined in various ways. First, the majority of smoking pregnant women is of lower socio-economic status, which is associated with higher levels of perceived stress. Second, smoking women often report to smoke because they feel stressed. Third, quitting smoking often increases perceived stress levels initially. Therefore, effective interventions are needed to support women with smoking cessation by reducing stress. The aim of this study is to test the effectiveness of an eHealth intervention on stress reduction and smoking cessation.

METHODS/DESIGN

The Stress- and Smoke Free Start of Life (SSFSL) study is a randomized controlled trial (RCT) comparing a personalized eHealth intervention with a control condition. Inclusion criteria for the women are: (1) > 18 years of age, (2) < 28 weeks pregnant at recruitment, (3) currently smoking. Consenting participants will be randomly assigned to the intervention or control group. Participants allocated to the intervention group will receive an 8-week intervention delivered on their smartphone. The application includes psycho-education on pregnancy, stress, and smoking (cessation); stress-management training consisting of Heart Rate Variability-biofeedback; and a personalized stop-smoking-plan. Participants in the control condition will be invited to visit a webpage with information on pregnancy, stress, and smoking (cessation). Study outcomes will be collected via online questionnaires, at four timepoints: pre-intervention (baseline; t0), post-intervention (8 weeks + 1 day after t0; t1), follow up at two weeks after birth (t2), and follow up at three months after birth (t3). The primary outcome measure is self-reported smoking cessation. Secondary outcomes include daily self-reported number of cigarettes smoked, perceived stress, pregnancy experience, birth outcomes, and negative affectivity scores of the baby. Moreover, the mediating effect of stress reduction on smoking cessation will be examined, and possible moderators will be tested.

DISCUSSION

If the eHealth intervention is effective in smoking cessation among pregnant smoking women, it can be implemented as a tool into the health care in the Netherlands.

TRIAL REGISTRATION

Netherlands Trial Register, ID: NL8156 . Registered on 11 November 2019.

Incentives for Smoking Cessation During Pregnancy: An Ethical Framework

Introduction

Smoking during pregnancy increases the risk of morbidity and mortality of the mother and child. The inability of the unborn child to protect itself, raises the social and academic responsibility to protect the child from the harmful effects of smoking. Interventions including rewards (incentives) for lifestyle changes are an upcoming trend and can encourage women to quit smoking. However, these incentives can, as we will argue, also have negative consequences, for example the restriction of personal autonomy and encouragement of smoking to become eligible for participation. To prevent these negative consequences, we developed an ethical framework that enables to assess and address unwanted consequences of incentive-based interventions whereby moral permissibility can be evaluated.

Aims and Methods

The possible adverse consequences of incentives were identified through an extensive literature search. Subsequently, we developed ethical criteria to identify these consequences based on the biomedical ethical principles of Beauchamp and Childress.

Results

Our framework consists of 12 criteria. These criteria concern (1) effectiveness, (2) support of a healthy lifestyle, (3) motivational for the target population, (4) stimulating unhealthy behavior, (5) negative attitudes, (6) personal autonomy, (7) intrinsic motivation, (8) privacy, (9) fairness, (10) allocation of incentives, (11) cost-effectiveness, and (12) health inequity. Based on these criteria, the moral permissibility of potential interventions can be evaluated.

Conclusions

Incentives for smoking cessation are a response to the responsibility to protect the unborn child. But these interventions might have possible adverse effects. This ethical framework aims to identify and address ethical pitfalls in order to avoid these adverse effects.

Implications

Although various interventions to promote smoking cessation during pregnancy exist, many women still smoke during pregnancy. Interventions using incentives for smoking cessation during pregnancy are a promising and upcoming trend but can have unwanted consequences. This ethical framework helps to identify and address ethical pitfalls in order to avoid these adverse effects.

It can be a practical tool in the development and evaluation of these interventions and in evaluating the moral permissibility of interventions using incentives for smoking cessation during pregnancy.

Are personality traits associated with smoking and alcohol use prior to and during pregnancy?

Cigarette smoking and alcohol consumption during pregnancy can have detrimental effects on the developing fetus, including fetal alcohol syndrome and low birth weight. Surprisingly little is known about the association of personality traits with smoking and alcohol consumption in the specific subpopulation of pregnant women. This study analyzed data from a geographically diverse sample of 603 pregnant women, aged 18 years and older, who provided information regarding their smoking and drinking habits before and during pregnancy. We compared women who consumed alcohol or smoked cigarettes before pregnancy with women who quit or continued smoking or drinking during pregnancy. Associations between personality and maladaptive behaviors prior to and during pregnancy were modeled using logistic regression. The study revealed that women who scored high on openness to experience were significantly more likely to continue alcohol consumption during pregnancy (OR = 1.07, 95% CI 1.01, 1.14, p = .02). This association was maintained after adjusting for potential confounds. This study demonstrated a significant relationship between personality traits and women's likelihood of continued alcohol consumption prior to and during pregnancy. Understanding personality-based determinants of health-detrimental behavior is important in order to design interventions that aim at decreasing rates of maladaptive health behaviors among pregnant women.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Specification of Change Mechanisms in Pregnant Smokers for Malleable Target Identification: A Novel Approach to a Tenacious Public Health Problem

Maternal smoking during pregnancy (MSDP) continues to be a leading modifiable risk factor for perinatal complications and a range of neurodevelopmental and cardio-metabolic outcomes across the lifespan. Despite 40 years of intervention research less than one in five pregnant smokers who receive an intervention quit by delivery. Within this context, recognition of pregnancy is commonly associated with abrupt suspension or reduction of smoking in the absence of intervention, yet has not been investigated as a volitional target. The goal of this article is to provide the empirical foundation for a novel direction of research aimed at identifying malleable targets for intervention through the specification of behavior change mechanisms specific to pregnant women. To do so, we: (1) summarize progress on MSDP in the United States generated from conventional empirical approaches to health behavior change; (2) discuss the phenomenon of spontaneous change in the absence of intervention among pregnant smokers to illustrate the need for mechanistic specification of behavior change motivated by concern for fetal well-being; (3) summarize component processes in neurobiological models of parental and non-parental social behaviors as a conceptual framework for understanding change mechanisms during pregnancy; (4) discuss the evidence for the malleability of these processes to support their translational relevance for preventive interventions; and (5) propose a roadmap for validating the proposed change mechanism using an experimental medicine approach. A greater understanding of social and interpersonal processes that facilitate health behavior change among expectant mothers and how these processes differ interindividually could yield novel volitional targets for prenatal interventions. More broadly, explicating other-oriented mechanisms of behavior change during pregnancy could serve as a paradigm for understanding how social and interpersonal processes positively influence health behaviors across the lifespan.

Home food preparation practices, experiences and perceptions: A qualitative interview study with photo-elicitation

Food-related choices have an important impact on health. Food preparation methods may be linked to diet and health benefits. However, the factors influencing people's food choices, and how they are shaped by food preparation experiences, are still not fully understood. We aimed to study home food preparation practices, experiences and perceptions amongst adults in North East England. A matrix was used to purposively sample participants with diverse socio-demographic characteristics. Participants developed photographic food diaries that were used as prompts during semi-structured interviews. Data were analysed using the Framework Method. Interviews were conducted with 18 adults (five men and 13 women), aged approximately 20 to 80 years, to reach data saturation. Participants' practices varied widely, from reliance on pre-prepared foods, to preparing complex meals entirely from basic ingredients. Key themes emerged regarding the cook (identity), the task (process of cooking), and the context (situational drivers). Resources, in terms of time, money and facilities, were also underpinning influences on food preparation. Participants' practices were determined by both personal motivations to cook, and the influence of others, and generally reflected compromises between varied competing demands and challenges in life. Most people appeared to be overall content with their food preparation behaviour, though ideally aspired to cook more frequently, using basic ingredients. This often seemed to be driven by social desirability. Home food preparation is complex, with heterogeneous practices, experiences and perceptions both between individuals and within the same individual over time, according to shifting priorities and circumstances. Generalisability of these findings may be limited by the regional participant sample; however the results support and build upon previous research. Focussing interventions on life transition points at which priorities and circumstances change, with careful targeting to stimulate personal motivation and social norms, may prove effective in encouraging home food preparation.

Cognitive and Behavioral Predictors of Quit Attempts and Biochemically-Validated Abstinence During Pregnancy

Introduction:

Initiating a quit attempt and achieving abstinence are distinct behaviors that have distinct correlates in general smokers. Studies predicting prenatal smoking have not addressed this.

Methods:

Pregnant smokers (N = 207), recruited to a cessation intervention trial, were used as an observational cohort. Women completed measures at baseline and 12-week follow-up (mid-late pregnancy). Outcomes were having made at least one quit attempt since baseline, and cotinine-validated 7-day abstinence at follow-up in attempters. Baseline predictors included demographics (age, deprivation, partner’s smoking), smoking behaviors (nicotine dependence, quit attempt history, previous prenatal smoking), and smoking beliefs (self-efficacy, determination, intention to quit, nonsmoker identity, social support, pregnancy-outcome beliefs). For each outcome, variables reaching p < .1 in logistic regression analyses were entered into a multivariate model controlling for trial arm. A complete case analysis was undertaken, with missing data assumptions tested in sensitivity analyses.

Results:

One hundred seventy-five women (85%) completed follow-up. Intention and determination to quit (p < .001), self-efficacy, nonsmoker identity, and not having previously smoked in pregnancy (p < .05) were univariate predictors of making a quit attempt, with stronger intention to quit the only independent predictor (multivariate odds ratio [OR] = 2.41, 95% confidence interval [CI] 1.19–4.87). Only nicotine dependence predicted validated abstinence among those who made a quit attempt (multivariate OR = 0.25, 95% CI 0.10–0.60).

Conclusions:

Initiating a quit attempt and achieving abstinence during pregnancy were found to have different correlates. For women yet to make a quit attempt in their pregnancy, smoking beliefs may be important intervention targets, but once they are engaged in quitting, nicotine dependence appears of prime importance.

Implications:

This study suggests that cognitive, particularly motivational, variables predict whether pregnant smokers will make a quit attempt, but they do not predict successful abstinence in those who attempt to quit, where nicotine dependence dominates. Interventions should facilitate quit attempts by targeting motivational variables among pregnant women who continue to smoke, but should focus on managing withdrawal once a woman initiates a quit attempt.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study

INTRODUCTION

The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation.

METHODS

We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis.

RESULTS

We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation.

CONCLUSION

Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing.

IMPLICATIONS

Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

Cognitive-behavioral intervention to promote smoking cessation for pregnant and postpartum inner city women

This study evaluated a theory-guided cognitive-behavioral counseling (CBC) intervention for smoking cessation during pregnancy and postpartum. It also explored the mediating role of cognitive-affective variables on the impact of CBC. Underserved inner city pregnant women (N = 277) were randomized to the CBC or a best practice (BP) condition, each of which consisted of two prenatal and two postpartum sessions. Assessments were obtained at baseline, late pregnancy, and 1- and 5-months postpartum. An intent-to-treat analysis found no differences between the two groups in 7-day point-prevalence abstinence. However, a respondents-only analysis revealed a significantly higher cessation rate in the CBC (37.3 %) versus the BP (19.0 %) condition at 5-months postpartum follow-up. This effect was mediated by higher quitting self-efficacy and lower cons of quitting. CBC, based on the Cognitive-Social Health Information Processing model, has the potential to increase postpartum smoking abstinence by assessing and addressing cognitive-affective barriers among women who adhere to the intervention.

Predictors of pregnant quitters' intention to return to smoking postpartum

INTRODUCTION

Although many pregnant women quit smoking, most return to smoking postpartum. Returning to smoking is strongly related to women's stated intention about smoking during pregnancy. We examined factors related to women's intention to return to smoking to improve intervention trials.

METHODS

We report cross-sectional baseline data from a randomized controlled trial to prevent postpartum return to smoking. Women (n = 382; 98% consent rate) were English-speaking women who smoked at least 100 cigarettes in their lifetimes and at least 5 cigarettes a day prior to becoming pregnant. We fit logistic regression models to test whether women's intention to return to smoking was associated with demographic and smoking factors such as race, parity, and smoker self-identity.

RESULTS

Forty-three percent of women had a strong intention of returning to smoking. Factors independently associated with intending to return to smoking were: stating they did not want to be currently pregnant (OR = 2.1, CI = 1.1-3.9), reporting being abstinent for fewer days (OR = 0.8, CI = 0.7-0.9), being less concerned about the harmful effects of smoking to themselves (OR = 1.6, CI = 0.9-2.8), viewing quit as temporary (OR = 2.1, CI = 1.2-3.6), and self-identifying selves as smokers (OR = 8.7, CI = 5.0-15.2).

CONCLUSIONS

Although some factors related to intention to return to smoking were unchangeable, it might be possible to attempt to change women's attribution of why they quit to be more permanent and to have them change their self-identity to be a "nonsmoker" from a "smoker who is not currently smoking." Helping women have stronger intentions to stay quit could promote less return to smoking postpartum.

Predictors of smoking cessation counseling adherence in a socioeconomically disadvantaged sample of pregnant women

Implementing and evaluating smoking cessation interventions in underserved populations has been found difficult due to high rates of non-adherence to the prescribed protocol. To understand better the barriers to cessation participation, we studied low-income inner-city pregnant women who were enrolled in either a standard or highly intensive quit smoking counseling program. The results showed that 1) in the prenatal phase, non-attendance was predicted by a greater number of cigarettes smoked per day; 2) in the postpartum follow-up phase, non-attendance was predicted by lower educational level and higher self-efficacy for quitting smoking; and 3) participants with more children living at home were at increased risk of rescheduling the postpartum follow-up session. These findings suggest that innovative delivery strategies are needed more effectively to assess and address risk factors for non-adherence to smoking cessation trials among underserved minority pregnant/postpartum smokers.

Reasons for quitting cigarette smoking and electronic cigarette use for cessation help

Despite the lack of clarity regarding their safety and efficacy as smoking cessation aids, electronic cigarettes (e-cigarettes) are commonly used to quit smoking. Currently, little is understood about why smokers may use e-cigarettes for help with smoking cessation compared with other, proven cessation aids. This study aimed to determine the reasons for wanting to quit cigarettes that are associated with the use of e-cigarettes for cessation help versus the use of conventional nicotine replacement therapy (NRT) products (e.g., gums). Cross-sectional, self-report data were obtained from 1,988 multiethnic current daily smokers (M age = 45.1, SD = 13.0; 51.3% women) who had made an average of 8.5 (SD = 18.7) lifetime quit attempts but were not currently engaged in a cessation attempt. Reasons for wanting to quit smoking were assessed by using the Reasons for Quitting scale. Path analyses suggested that among reasons for quitting cigarettes, "immediate reinforcement"-a measure of wanting to quit cigarettes for extrinsic reasons such as bad smell, costliness and untidiness-was significantly associated with having tried e-cigarettes for cessation help, and "concerns about health" was associated with having tried NRT-only use. E-cigarettes appear to provide an alternative "smoking" experience to individuals who wish to quit cigarette smoking because of the immediate, undesirable consequences of tobacco smoking (e.g., smell, ash, litter) rather than concerns about health. Provided that the safety of e-cigarette use is ensured, e-cigarettes may be effectively used to reduce tobacco exposure among smokers who may not want to quit cigarettes for intrinsic motivation.

Stressful events and continued smoking and continued alcohol consumption during mid-pregnancy

Aim

to examine whether the severity of different categories of stressful events is associated with continued smoking and alcohol consumption during mid-pregnancy. Also, we explored the explanation of these associations by anxiety and depressive symptoms during pregnancy. Finally, we studied whether the severity of stressful events was associated with the amount of cigarettes and alcohol used by continued users.

Method

we conducted a cross-sectional analysis using data from a population-based prospective cohort study. Pregnant women were recruited via midwifery practices throughout The Netherlands. We analyzed women who continued smoking (n = 113) or quit (n = 290), and women who continued alcohol consumption (n = 124) or quit (n = 1403) during pregnancy. Smoking, alcohol consumption, and perceived severity of stressful events were measured at 19 weeks of gestation. The State Trait Anxiety Inventory and the Edinburgh Postnatal Depression Scale were filled out at 14 weeks of gestation. Odds ratios were calculated as association measures and indicated the relative increase for the odds of continuation of smoking and alcohol consumption for the maximum severity score compared to the minimum score.

Findings

severity of the following stressful event categories was associated with continued alcohol consumption: ‘conflict with loved ones’ (OR = 10.4, p<0.01), ‘crime related’ (OR = 35.7, p<0.05), ‘pregnancy-specific’ (OR = 13.4, p<0.05), and the total including all events (OR = 17.2, p<0.05). Adjustment for potential confounders (age, parity and educational level) did not notably change the estimates. There was no association of anxiety and depressive symptoms with continued smoking or alcohol consumption. No associations emerged for continued smoking and severity of stressful events. The amount of cigarettes and alcohol consumption among continued users was not associated with severity of stressful events.

Conclusions

Our findings may be relevant for health care providers, in particular midwives and general practitioners. The impact of stressful events may be considered when advising pregnant women on smoking and alcohol consumption.

Smoking is bad for babies: obstetric care providers' use of best practice smoking cessation counseling techniques

PURPOSE

To use direct observations of first prenatal visits to describe obstetric providers' adherence to the evidence-based clinical practice guideline for smoking cessation counseling recommended by the American College of Obstetricians and Gynecologists, the 5 A's (Ask, Advice, Assess, Assist, and Arrange).

DESIGN

Observational study using audio recordings of first obstetric visits.

SETTING

An urban academic hospital-based clinic.

PARTICIPANTS

Obstetric care providers and pregnant women attending their first obstetric visit.

METHOD

First obstetric visits were audio recorded. Visits were identified in which patients reported smoking, and discussions were analyzed for obstetric providers' use of the 5 A's in smoking cessation counseling.

RESULTS

Obstetric providers asked about smoking in 98% of the 116 visits analyzed, but used 3 or more of the 5 A's in only 21% (24) of visits. In no visits did providers use all 5 A's. In 54% of the visits, providers gave patients information about smoking, most commonly about risks associated with perinatal smoking.

CONCLUSION

Few obstetric care providers performed the recommended 5 A's smoking cessation counseling with their pregnant smokers. Effective and innovative methods are needed to improve obstetric providers' use of the 5 A's.

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.

Maternal self concept as a provider and cessation of substance use during pregnancy

OBJECTIVE

Maternal substance use during pregnancy is a common modifiable risk factor for poor birth outcomes, and is associated with long term psychological risks to offspring. As self concept is known to affect substance use behaviors in non-pregnant women, we hypothesized that self concept as a provider may be particularly salient to cessation of use during pregnancy. To isolate psychological processes specific to pregnancy from those associated with the transition to parenthood, we examined birth mothers who made adoption placements participating in the Early Growth and Development Study.

METHODS

We obtained lifetime and pregnancy substance use history and psychological measures at 3 to 4months postpartum from 693 women recruited from the Northwest, Southwest, and Mid-Atlantic regions of the United States. Life history calendar and computer-assisted personal interviewing methods were used to minimize reporting bias. Using logistic regression, we assessed the association of self concept as an adequate provider with cessation of substance use during pregnancy, controlling for sociodemographic variables, depressive symptoms experienced during pregnancy, past year antisocial behaviors, family history of substance abuse, timing of pregnancy recognition, timing of initiation of prenatal care, and emotional adjustment to the adoption decision.

RESULTS

More positive self-concept as an adequate provider was independently associated with cessation of substance use and earlier initiation of prenatal care during pregnancy [OR=1.223; 95% C.I. (1.005-1.489); B(SE)=.201(.100)]. Familial substance abuse, depressive symptoms, and antisocial behaviors during pregnancy, were also independent predictors, and more strongly associated with cessation [OR=.531; 95% C.I. (.375-.751); B(SE)=-.634 (.178)], [OR. 940; 95% C.I. (.906-.975); B(SE)=-.062 (.019)], [OR=.961; 95% C.I. (.927-.996); B(SE)=-.040 (.018)].

CONCLUSIONS

Enhancing maternal identity as a provider for the fetus during pregnancy, along with treatment of depression, may improve motivation to stop substance use.

Predictors of spontaneous smoking cessation among Chinese men whose wives are pregnant

This is an exploratory study to identify the predictors that Chinese men will spontaneously quit smoking during their wives' pregnancy. Smoking husbands who accompanied their non-smoking pregnant wives to an antenatal clinic were invited to complete a questionnaire soliciting information regarding their smoking behaviours, perceptions of support received from their wives, and motivating factors for quitting smoking. A total of 74 men were recruited. Two-thirds (67.6%) were daily smokers, had started smoking under the age of 18 (66.2%), and smoked 6-15 cigarettes (48.6%) a day. Nearly one-third of the smoking husbands (n = 50, 67.6%) reported that their wife was the person who provided them with the necessary main support in quitting. Nearly a quarter (18 out of 74, 24.3%) of the husbands indicated that they quit smoking during their wives' pregnancy. Those more likely to quit were the 'occasional smokers' (61.1% vs. 38.9%), those who craved cigarettes a few hours after getting up (0% vs. 100%), those who were confident in their ability to quit (77.8% vs. 22.2%), and those who had previously attempted to quit (88.9% vs. 11.1%). The level of negative support from wives to quit smoking was significantly related to men's quitting (55.6% vs. 44.4%). The results of this study identified the husbands most likely to spontaneously quit smoking during their wives' pregnancy as those who were occasional smokers, were confident about smoking cessation, and reported their wives as being bothered by smoke.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Socio-demographic factors and processes associated with stages of change for smoking cessation in pregnant versus non-pregnant women

Background

The tobacco control community assumes that the most effective interventions are personalized. Nevertheless, little attention is paid to understanding differences between pregnant and non-pregnant European women in terms of the social factors that influence tobacco use and the processes of change used to quit smoking.

Methods

The study consecutively enrolled 177 pregnant women who acknowledged smoking the year before pregnancy and 177 non-pregnant women who acknowledged smoking the year before their clinic visit for a Pap test.

Results

With respect to socio-demographic factors, the stages of change in pregnant women were associated with level of education, marital status, and the presence of roommates, partners and friends who smoke. In pregnant women, there was no statistically significant difference in the processes used to stop smoking among the stages of change. Furthermore, behavioral processes were higher in non-pregnant women than in pregnant women, and the difference was statistically significant in the advanced stages of behavioral change. Both pregnant and non-pregnant women showed higher levels of acceptance towards smoking in the earlier stages of change, but the acceptability of smoking in the pre-contemplative stage was higher in non-pregnant women. Greater craving was detected in non-pregnant vs. pregnant women at all stages and reached a statistically significant level at the pre-contemplative stage.

Conclusion

Pregnancy is a favorable time to stop smoking since pregnant women are more likely to be in an advanced stage of behavioral change. Pregnant and non-pregnant women are distinct populations in the types and processes of change involved in smoking cessation. The intervention programs to promote smoking cessation and prevent relapses will need to take these differences into account.

Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy

Pregnancy is a time of relative urgency and opportunity for the treatment of substance use disorders in women, yet little is known about modifiable factors that contribute to successful abstinence. We examined self-worth, depression, anxiety, and novelty seeking in the context of substance use cessation during pregnancy in a sample of women with a high prevalence of substance abuse. Subjects were 448 birth mothers who participated in a prospective adoption study. Discontinuation rates were: tobacco 22.2%, alcohol 64.7%, marijuana 77.2%, and other drugs, 73.7-100%. Depression, anxiety, and novelty seeking were lower among women who discontinued substance use, compared to those who did not. Self-worth was higher in women who discontinued substance use. Among 110 polysubstance users, the number of substances discontinued during pregnancy was correlated with depression, anxiety, and self-worth in the hypothesized direction. Possible clinical implications are discussed. 

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Clinical trials and tribulations: lessons learned from recruiting pregnant ex-smokers for relapse prevention

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

Olfactory and gustatory sensory changes to tobacco smoke in pregnant smokers

Models of smoking behavior change include addiction, social, and behavioral concepts. The purpose of this study was to explore the prevalence of two biologic factors, olfactory and gustatory responses to tobacco smoke, as potentially powerful contributors to smoking behavior change among pregnant women. Data were obtained from 209 pregnant smokers. The majority of women reported olfactory (62%) and gustatory (53%) aversions to tobacco. Aversions first appeared during the first trimester of pregnancy. Women who experienced olfactory aversions were more likely also to experience gustatory aversions. Olfactory aversions were associated with women smoking less. Aversions to tobacco smoke are common among pregnant smokers, are associated with women smoking less, and could help explain pregnant women's smoking patterns.

Smoking cessation processes in low-SES women: the impact of time-varying pregnancy status, health care messages, stress, and health concerns

We tracked smoking outcomes - quitting, stage of readiness, action, motivation, self-efficacy, and confidence - over time among 943 low-SES women smokers accrued in an earlier smoking cessation intervention trial conducted in public health clinics. We assessed outcomes at 2, 6, 12 and 18 months post-initial clinic visit. Controlling for baseline characteristics and earlier program participation, we used hierarchical linear modeling to assess how intervening life events - pregnancy and exposure to subsequent clinic smoking interventions - affected smoking outcomes directly and indirectly, through the mediators, perceived stress and health concerns.

RESULTS

All longitudinal smoking outcomes were positively related to health concerns and negatively related to perceived stress. Pregnancy favorably influenced all smoking outcomes but confidence, but exposure to additional interventions affected only motivation. Health concerns and stress partially mediated the positive impact of pregnancy.

CONCLUSION

Public health efforts targeted to low-SES women smokers should continue to emphasize the benefits of quitting smoking for health maintenance and incorporate more effective stress-coping mechanisms. Pregnancy increases abstinence, but preventing post-delivery relapse may require stress management and re-focusing of health concerns.

Weight concerns affect motivation to remain abstinent from smoking postpartum

BACKGROUND

Although many women quit smoking during pregnancy, most resume smoking postpartum. One factor that may be important in postpartum relapse is a pregnant woman's motivation to remain abstinent after delivery.

PURPOSE

We assessed motivation for postpartum abstinence among pregnant women who had quit smoking and examined the relationship of weight concerns and mood to abstinence motivation.

METHODS

Pregnant former smokers, recruited between February 2000 and November 2004, completed assessments of smoking, weight concerns, depressive symptoms, and perceived stress.

RESULTS

Sixty-five percent were highly motivated to remain abstinent postpartum. Women who were and were not motivated were similar in age, race, and nicotine dependence. However, motivated women reported more stress, greater self-efficacy for weight management, less hunger, and less smoking for weight control than did less motivated women. After controlling for intention to breast-feed, nicotine dependence, years of smoking, partner smoking, and race, self-efficacy for weight control was related to motivation to maintain postpartum abstinence.

CONCLUSIONS

These data suggest that weight concerns are associated with motivation for postpartum smoking abstinence, and interventions designed to prevent postpartum smoking relapse may need to target eating, weight, and shape concerns.

Self-efficacy and motivation to quit during participation in a smoking cessation program

The associations between failure to quit and posttreatment self-efficacy and motivation were examined among 600 African American smokers enrolled in a randomized trial testing the efficacy of bupropion for smoking cessation. Participants also received brief motivational counseling and were followed for 6 months. Baseline levels of self-efficacy and motivation for all participants were high (8.2 and 8.5 on a 10-point scale, respectively). Longitudinal analyses indicated that smokers who failed to quit were less likely than quitters to report high self-efficacy and motivation from posttreatment to follow-up. However, examination of mean self-efficacy and motivation scores at posttreatment and follow-up revealed that smokers continued to sustain high self-efficacy and motivation. Mean self-efficacy and motivation scores differed by less than 1 point from baseline levels, even though the majority of participants failed to quit smoking. Results suggest that unsuccessful participation in a smoking cessation program does not meaningfully reduce smokers' self-efficacy and motivation to quit.

Relapse: a concept analysis

The concept of relapse has had many and varied applications in research literature. Great confusion exists in the application of the term to scientific measurement within the various studies. Therefore, an in-depth analysis of the generic term relapse was undertaken through the evolutionary approach offered by Rodgers and Knafl.