Weight concerns affect motivation to remain abstinent from smoking postpartum

Smoking cessation in pregnancy: a continuing challenge in the United States

Despite significant population level declines, smoking during pregnancy remains a major public health issue in the United States (US). Approximately 360,000-500,000 smoke-exposed infants are born yearly, and prenatal smoking remains a leading modifiable cause of poor birth outcomes (e.g. birth < 37 gestational weeks, low birth weight, perinatal mortality). Women who smoke during pregnancy are more likely to be younger and from disadvantaged socioeconomic and racial and ethnic groups, with some US geographic regions reporting increased prenatal smoking rates since 2000. Such disparities in maternal prenatal smoking suggests some pregnant women face unique barriers to cessation. This paper reviews the current state and future direction of smoking cessation in pregnancy in the US. We briefly discuss the etiology of smoking addiction among women, the pathophysiology and effects of tobacco smoke exposure on pregnant women and their offspring, and the emerging issue of electronic nicotine delivery systems. Current population-based and individual smoking cessation interventions are reviewed in the context of pregnancy and barriers to cessation among US women. Finally, we consider interventions that are on the horizon and areas in need of further investigation.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

Implications

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

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.

Weight Gain in Women after Smoking Cessation in Pregnancy

Introduction: Smoking during pregnancy is associated with adverse outcomes. Tobacco cessation in the general population is associated with weight gain. Aims: We sought to compare gestational weight gain (GWG) in women who quit smoking during pregnancy with those who continued smoking and non-smokers in two countries with high smoking prevalence in pregnancy. Methods: This study uses baseline data from a brief cessation intervention clustered randomised controlled trial; data were collected from clinical records and through questionnaires at post-partum hospitalisations during October 2011–May 2012. Women had attended one of 20 selected clusters of publicly funded prenatal care clinics in Argentina and Uruguay. Self-reported cessation was verified biochemically. Results: Of 2636 pregnant women, 29.9% were smokers at the beginning of pregnancy; among them 41.9% quit and 58.1% continued smoking. Most women (60.7%) had a normal pre-pregnancy body mass index (BMI). Adjusted mean weight gain was higher in quitters than in continuing smokers and non-smokers. Cessation increased GWG by 2.4 kg (95% confidence interval 1.3–3.4) after adjusting by pre-pregnancy BMI and other confounders in comparison with women who continued smoking(p < 0.001). Conclusions: GWG was slightly higher in women who quit smoking at any time during pregnancy.

Preventing Postpartum Smoking Relapse: A Randomized Clinical Trial

IMPORTANCE

Most women who quit smoking during pregnancy will relapse postpartum. Previous efforts to prevent postpartum relapse have been unsuccessful at increasing rates of sustained abstinence.

OBJECTIVE

To evaluate the relative efficacy of 2 different approaches to prevent postpartum smoking relapse.

DESIGN, SETTING, AND PARTICIPANTS

Pregnant women who recently had quit smoking were recruited before the end of pregnancy. Intervention sessions were conducted through a combination of telephone calls and in-person visits beginning at delivery and continuing through 24 weeks postpartum. Participants completed assessments at the prenatal baseline and at 12, 24, and 52 weeks postpartum. Participants were recruited between March 2008 and December 2012. The dates of the analysis were April 2014 to February 2015.

INTERVENTIONS

Women received postpartum-adapted, behavioral smoking relapse prevention intervention and were randomly assigned to an enhanced cognitive behavioral intervention that included additional specialized strategies and content focused on women's postpartum concerns about mood, stress, and weight (Strategies to Avoid Returning to Smoking [STARTS]) or a supportive, time and attention-controlled comparison (SUPPORT). Intervention began before delivery and continued through 24 weeks postpartum.

MAIN OUTCOMES AND MEASURES

The primary outcome was biochemically confirmed sustained tobacco abstinence at 52 weeks postpartum. Secondary outcomes were self-reported mood, levels of perceived stress, and degree of concern about smoking-related weight gain.

RESULTS

The study cohort comprised 300 participants (150 randomly assigned to each group). Their mean (SD) age was 24.99 (5.65) years. Overall, 38.0% (114 of 300), 33.7% (101 of 300), and 24.0% (72 of 300) of the sample maintained abstinence at 12, 24, and 52 weeks' postpartum, respectively. There were no differences between the intervention groups in abstinence or time to relapse. Self-reported depressive symptoms and perceived stress significantly improved over time, and improvements were similar for both intervention groups. Women with more depressive symptoms and higher levels of perceived stress were more likely to relapse (hazard ratio, 1.02; 95% CI, 1.00-1.04; P = .04 for depressive symptoms and hazard ratio, 1.04; 95% CI, 1.01-1.07; P = .003 for stress).

CONCLUSIONS AND RELEVANCE

An intervention designed to address women's concerns about mood, stress, and weight did not differentially improve rates of sustained tobacco abstinence postpartum compared with a time and attention-controlled comparison. Women in STARTS and SUPPORT reported postpartum improvements in mood and stress, and the experience of fewer depressive symptoms and less perceived stress was related to sustained abstinence. Given that most pregnant quitters will relapse within 1 year postpartum and that postpartum smoking has negative health consequences for women and children, effective interventions that target postpartum mood and stress are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00757068.

Nicotine Dependence Measures for Perinatal Women

This integrative review provides an overview of nicotine dependence measures used with perinatal women and an evaluation of their psychometric properties. Fifty-five articles that met inclusion and exclusion criteria were identified from five different databases. Most of the studies used the Fagerström Test for Nicotine Dependence (FTND). Other approaches included diagnostic tests, the Wisconsin Inventory of Smoking Dependence Motives (WISDM), the Tobacco Dependence Screener, and single-item measures. This review indicated that the FTND may not be the best option for measuring nicotine dependence in this population. The WISDM is a newer instrument that has excellent psychometric properties and captures nonnicotinic dimensions of nicotine dependence relevant to women. Future research is needed to assess its reliability in the perinatal population. Other recommendations from this review include the use of biomarker validation, thorough psychometric reporting on nicotine dependence instruments, and the use of multiple instruments to maximize comparability between nicotine dependence instruments.

Associations of Weight Concerns With Self-Efficacy and Motivation to Quit Smoking: A Population-Based Study Among Finnish Daily Smokers

INTRODUCTION

Concerns about weight gain occurring after smoking cessation may affect motivation and self-efficacy towards quitting smoking. We examined associations of smoking-specific weight concerns with smoking cessation motivation and self-efficacy in a population-based cross-sectional sample of daily smokers.

METHODS

Six-hundred biochemically verified (blood cotinine) current daily smokers comprising 318 men and 282 women aged 25-74 years, were studied as part of the National FINRISK (Finnish Population Survey on Risk Factors on Chronic, Noncommunicable Diseases) study and its DIetary, Lifestyle and Genetic factors in the development of Obesity and Metabolic syndrome (DILGOM) sub-study that was conducted in Finland in 2007. Self-reported scales were used to assess weight concerns, motivation and self-efficacy regarding the cessation of smoking. Multiple regression analyses of concerns about weight in relation to motivation and self-efficacy were conducted with adjustments for sex, age (years), body mass index (BMI, [kg/m(2)]), physical activity (times per week), and further controlled for nicotine dependence (Fagerström Test for Nicotine Dependence).

RESULTS

Higher levels of weight concerns were associated with lower self-efficacy (β = -0.07, p < .001) after adjusting for sex and age. The association remained after additional adjustment for BMI and physical activity (β = -0.07, p < .001). After further controlling for nicotine dependence the association became weaker but remained significant (β = -0.04, p = .02). There were no statistically significant associations between concerns about weight and motivation for smoking cessation (β = 0.02, p = 0.16).

CONCLUSIONS

These cross-sectional population-based data do not support earlier findings that suggest that smokers with high levels of weight concerns are less motivated to quit smoking. Our data suggest that daily smokers who are highly concerned about weight may have lower self-efficacy for cessation of smoking.

Strategies to Avoid Returning to Smoking (STARTS): a randomized controlled trial of postpartum smoking relapse prevention interventions

The majority of women who quit smoking during pregnancy relapse postpartum and many experience increased depressive symptoms and concerns about body shape and weight. Given the relationship of weight concerns and negative mood to smoking relapse, interventions designed to address the postpartum experience are indicated. However, there are several challenges to research with postpartum women. We describe the rationale of a randomized controlled trial of postpartum smoking relapse prevention intervention and discuss methods to address the specific challenges to recruiting, retaining and conducting health behavior interventions among postpartum former smokers. Pregnant women who had quit smoking for at least one month prior to the 34 week of pregnancy and who were motivated to stay quit postpartum were recruited. Women were randomized either to a postpartum specific intervention designed to address concerns about mood, stress and weight using cognitive-behavioral techniques or to a support-only condition designed to control for time and attention. Intervention continues through six months postpartum and women complete follow-up assessments at 12-, 24- and 52-weeks after delivery. Women (n=300) who had quit smoking as a result of pregnancy were recruited and are being followed. The intervention described in this report is designed to address stress, negative mood and concerns about weight that mediate smoking relapse postpartum to sustain abstinence and improve maternal and infant health.

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.

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.

Eating the elephant whole or in slices: views of participants in a smoking cessation intervention trial on multiple behaviour changes as sequential or concurrent tasks

BACKGROUND

This paper explores smoking cessation participants' perceptions of attempting weight management alongside smoking cessation within the context of a health improvement intervention implemented in Glasgow, Scotland.

METHODS

One hundred and thirty-eight participants were recruited from smoking cessation classes in areas of multiple deprivation in Glasgow and randomised to intervention, receiving dietary advice, or to control groups. The primary outcome of the study was to determine the % change in body weight. Semi-structured interviews were conducted with a purposive sample of 15 intervention and 15 control participants at weeks 6 (during the intervention) and 24 (at the end of the intervention). The current paper, though predominantly qualitative, links perceptions of behaviour modification to % weight change and cessation rates at week 24 thereby enabling a better understanding of the mediators influencing multiple behaviour change.

RESULTS

Our findings suggest that participants who perceive separate behaviour changes as part of a broader approach to a healthier lifestyle, and hence attempt behaviour changes concurrently, may be at comparative advantage in positively achieving dual outcomes.

CONCLUSIONS

These findings highlight the need to assess participants' preference for attempting multiple behaviour changes sequentially or simultaneously in addition to assessing their readiness to change. Further testing of this hypothesis is warranted.

TRIAL REGISTRATION

ISRCTN94961361.

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.

The effect of smoking cessation counselling in pregnant women: a meta-analysis of randomised controlled trials

BACKGROUND

Pregnant smokers are often prescribed counselling as part of multicomponent cessation interventions. However, the isolated effect of counselling in this population remains unclear, and individual randomised controlled trials (RCTs) are inconclusive.

OBJECTIVE

To conduct a meta-analysis of RCTs examining counselling in pregnant smokers.

SEARCH STRATEGY

We searched the CDC Tobacco Information and Prevention, Cochrane Library, EMBASE, Medline and PsycINFO databases for RCTs evaluating smoking cessation counselling.

SELECTION CRITERIA

We included RCTs conducted in pregnant women in which the effect of counselling could be isolated and those that reported biochemically validated abstinence at 6 or 12 months after the target quit date.

DATA COLLECTION AND ANALYSIS

Overall estimates were derived using random effects meta-analysis models.

MAIN RESULTS

Our search identified eight RCTs (n = 3290 women), all of which examined abstinence at 6 months. The proportion of women that remained abstinent at the end of follow up was modest, ranging from 4 to 24% among those randomised to counselling and from 2 to 21% among control women. The absolute difference in abstinence reached a maximum of only 4%. Summary estimates are inconclusive because of wide confidence intervals, albeit with little evidence to suggest that counselling is efficacious at promoting abstinence (odds ratio 1.08, 95% confidence interval 0.84-1.40). There was no evidence to suggest that efficacy differed by counselling type.

CONCLUSIONS

Available data from RCTs examining the isolated effect of smoking cessation counselling in pregnant women are limited but sufficient to rule out large treatment effects. Future RCTs should examine pharmacological therapies in this population.

Gestational weight gain and subsequent postpartum weight loss among young, low-income, ethnic minority women

OBJECTIVE

Document weight change trajectories that lead to gestational weight gain or postpartum weight loss outside clinical recommendations established by the Institute of Medicine.

STUDY DESIGN

Women aged 14-25 receiving prenatal care and delivering singleton infants at term (n = 427). Medical record review and 4 structured interviews conducted: second and third trimester, 6- and 12-months postpartum. Longitudinal mixed modeling to evaluate weight change trajectories.

RESULTS

Only 22% of participants gained gestational weight within Institute of Medicine guidelines. There were 62% that exceeded maximum recommendations-more common among those overweight/obese (body mass index ≥25.0; P < .0001). 52% retained ≥10 lb 1-year postpartum. Increased weight gain and retention documented among smokers and women with pregnancy-induced hypertension; breastfeeding promoted postpartum weight loss (all P < .02). Body mass index by race interaction suggested healthier outcomes for Latinas (P = .02).

CONCLUSION

Excessive pregnancy weight gain and inadequate postpartum weight loss are highly prevalent among young low-income ethnic minority women. Pregnancy and postpartum are critical junctures for weight management interventions.

Development and validation of a multidimensional measure of stress among African American light smokers

The complete Multidimensional Measure of Stress (MMOS) measure may be made available to interested persons by contacting the corresponding author.

CONTEXT

Smoking rates are higher among inner-city and lower-income African Americans, perhaps due to psychosocial barriers to cessation efforts, including stress.

OBJECTIVE

To describe the development of the MMOS and examine the psychometric properties of the MMOS among African American light smokers.

DESIGN

Secondary analysis of data generated from a 2x2 randomized clinical trial, designed to examine the efficacy of nicotine replacement and cessation counseling among 755 African American light smokers.

RESULTS

Fourteen items were included in the final MMOS (alpha = .83). An exploratory factor analysis identified 3 factors: interpersonal (alpha = .80), safety (alpha = .70), and financial (alpha = .75). The MMOS was significantly correlated with the Perceived Stress scale (r = 0.49, p < .001) and was associated with several demographic, psychosocial, and tobacco-related variables.

CONCLUSIONS

The MMOS appears to be a valid measure of stress among African American light smokers enrolled in a cessation trial.

Weight concerns, mood, and postpartum smoking relapse

BACKGROUND

The majority of women who quit smoking as a result of pregnancy will resume smoking during the first 6 months postpartum. Evidence suggests that changes in depressive symptoms, perceived stress, and concerns about weight may relate to postpartum smoking relapse.

PURPOSE

This study was designed to prospectively evaluate the relationship of mood and weight concerns to postpartum smoking among women who quit smoking during pregnancy.

METHODS

Pregnant women who had quit smoking (N=183) were recruited between February 2003 and November 2006. Women completed assessments of mood (depressive symptoms, perceived stress, positive and negative affect) and weight concerns during the third trimester of pregnancy and at 6, 12, and 24 weeks postpartum. Self-reported smoking status was verified by expired-air carbon monoxide and salivary cotinine at each assessment. Cox regression analyses in which mood and weight concerns were treated as time-dependent covariates were conducted in 2007 and 2009.

RESULTS

By 24 weeks postpartum, 65% of women had resumed smoking. Smoking-related weight concerns increased risk of relapse, and positive affect and self-efficacy for weight management without smoking decreased risk of relapse postpartum. Moreover, after controlling for variables previously related to postpartum relapse, weight concerns remained significantly related to smoking relapse.

CONCLUSIONS

Smoking-related weight concerns and positive affect increase the likelihood that a woman will resume smoking postpartum. Moreover, weight concerns appear to be salient even in the context of other factors shown to affect postpartum smoking. This study suggests that interventions may need to address women's weight concerns and mood to help sustain smoking abstinence after childbirth.

Smoking-related weight concerns among underserved, black maternal smokers

OBJECTIVE

To expand understanding of a smoking cessation barrier for women, weight concerns, in a medically underserved population.

METHODS

Baseline weight concerns were examined among 235 low-income, black maternal smokers enrolled in a smoking trial. Logistic regression evaluated factors related to weight concerns.

RESULTS

Higher BMI (OR 3.35, P < .001), intention to quit (OR 2.12, P = .02), more previous quit attempts (OR 1.14, P = .03), and less support for quitting (OR 0.81, P = .05) predicted weight concerns.

CONCLUSIONS

This is the first study to delineate factors predicting weight concerns in this population, thus expanding our understanding of a key cessation barrier and informing future cessation strategies in a population known to bear increased risk of tobacco-related disease.

Preventing postpartum smoking relapse: an opportunity for neonatal nurses

Smoking during pregnancy and exposure to environmental tobacco smoke have harmful and sometimes devastating effects on the health of the newborn. Although interventions for smoking cessation during pregnancy demonstrate effectiveness for increasing smoking abstinence, the majority of women relapse in the postpartum period. However, modifying contributing factors for relapse may improve the success of sustained abstinence. Many parents are eager to quit smoking and willing to participate in smoking cessation interventions. Through a population-based approach to healthcare, neonatal nurses are in an ideal position to prevent relapse and to promote smoking abstinence; they can coordinate and lead efforts for establishing smoking cessation strategies that integrate obstetric, newborn, and pediatric services.

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.

Relationships between prenatal smoking cessation, gestational weight gain and maternal lifestyle characteristics

OBJECTIVES

To describe maternal characteristics and lifestyle factors associated with prenatal smoking habits and to appraise the effect of quitting smoking in early gestation on maternal weight gain during pregnancy.

METHODS

This is a follow-up study of 1753 women who gave birth in 1984/1985 in Stockholm, Sweden. Multivariate logistic models were used to evaluate the association between smoking cessation and weight gain above the American Institute of Medicine (IOM) recommendations, based on pre-pregnancy BMI.

RESULTS

About 22% of all participants identified themselves as current smokers and 11.6% reported smoking cessation during pregnancy. Smokers were more likely to be single mothers and reported low quality of breakfast (e.g. eating only 1 food group at breakfast). Non-smokers were older, more likely to be married and have a healthier lifestyle. Quitters also adopted healthier eating habits (e.g. improvement in their breakfast quality). Women who quit smoking gained, on average, 15.3 kg (SD 4.4) during pregnancy, non-smokers gained 14.1 kg (SD 4.0) and smokers gained 13.8 kg (SD 4.3). Quitters gained significantly more weight than both non-smokers and smokers (p<0.001). Smoking cessation was significantly associated with gaining weight above IOM recommendations, even after controlling for potential confounders (OR: 2.0; 95%CI: 1.4-3.0; p<or=0.0001).

CONCLUSIONS

In this population, smoking cessation in early pregnancy doubled the likelihood of gaining excess weight. This finding highlights the need for supportive measures to help control weight gain among women who quit smoking during pregnancy.

The relation between body size perception and change in body mass index over 13 years: the Coronary Artery Risk Development in Young Adults (CARDIA) study

The authors assessed associations of body size perception and weight change over 13 years in black men and women and white men and women from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1992-2005). The perceptions of self and ideal body size were measured by using the Stunkard 9-figure scale at the year 7 examination (1992-1993). Figures were classified into underweight, normal weight, overweight, and obese. Self-ideal discrepancy yielded 4 body size satisfaction categories. Body mass index (BMI) (measured at years 7, 10, 15, and 20) was the dependent variable in gender-specific adjusted multiple regression models stratified by year 7 BMI. Obese women who perceived themselves as obese lost 0.09 BMI units annually, while those who perceived themselves as normal weight gained 0.31 units annually (P = 0.0005); obese women who considered their body size much too large had less annual weight gain than did those who considered their body size a bit too large (0.21 vs. 0.38 BMI units; P = 0.009). Obese women with overweight ideal body size gained less weight annually than did those with normal weight ideal body size (0.12 vs. 0.27 BMI units; P = 0.04). Results for men showed fewer and weaker associations. When obese women perceive themselves as obese and feel that their body size is too large, they gain less weight over time.

Similarities in affect, perceived stress, and weight concerns between Black and White women who quit smoking during pregnancy

Mood and weight concerns may relate to postpartum smoking, and racial differences in these concerns may be important in developing interventions to prevent postpartum relapse. We compared differences in the smoking patterns, mood, and weight concerns of Black and White women who quit smoking during pregnancy (N = 174). In univariate comparisons, there were no consistent differences in nicotine dependence, smoking history, or motivation to remain abstinent postpartum. Moreover, although there were univariate differences in negative affect, smoking for weight control, and eating disinhibition, after controlling for differences in income and educational background between Black and White women, these differences in mood and weight concerns were no longer significant. In our sample of pregnant women who had quit smoking, Black and White women did not differ in mood and weight concerns, two potentially modifiable variables that may affect smoking postpartum relapse.

Women's interest in treatment to stay abstinent from cigarettes postpartum

PURPOSE

Most women who quit smoking during pregnancy resume smoking in the postpartum period. Interventions to improve rates of sustained tobacco abstinence postpartum may need to address psychosocial factors during the postpartum period. However, given the multiple demands on mothers of young children, it is unclear whether women will find postpartum relapse prevention treatment acceptable. We sought to determine the acceptability of a postpartum smoking relapse prevention intervention and the appeal of strategies to address concerns about mood, stress, and weight to prevent postpartum relapse.

METHODS

Women (n = 36) who had quit smoking during pregnancy and either remained abstinent or relapsed within the first year postpartum completed a survey about postpartum relapse prevention program modalities, topics, and barriers to treatment. The responses of women who had and had not relapsed to smoking were compared.

MAIN FINDINGS

Both groups endorsed the opportunity to talk with a counselor about relapse prevention, and those who had and had not relapsed did not differ in their endorsement of different treatment modalities. Discussing mood, stress, and weight concerns were endorsed by both groups of women, but those who had relapsed were more likely to endorse stress management as an intervention topic. Those who had relapsed also were more likely to endorse the use of pharmacologic aids than were those who had remained abstinent.

CONCLUSIONS

These data suggest that postpartum women would find a smoking relapse prevention program that includes group and individual counseling and the use of strategies to address mood, stress, and weight concerns acceptable.

Effects of cigarette smoking and family history of alcoholism on sweet taste perception and food cravings in women

BACKGROUND

Despite popular beliefs that smoking affects the sensitivity and liking of sweet-tasting foods and beverages, few psychophysical studies have examined this phenomenon and none have taken into account the individual's family history of alcoholism (FH+), a predictor of heightened sweet preferences.

METHODS

A within- and between-subjects study was conducted to determine the effect of both cigarette smoking and an acute exposure to nicotine on sweet taste sensitivity and preferences in women. Two groups were studied on 2 days separated by 1 week: women who were current smokers (n = 27, 18 were FH+) and those who never smoked in their lifetime (n = 22, 9 were FH+). Current smokers smoked nicotine-containing cigarettes during 1 test session and nicotine-free cigarettes during the other. The procedures were identical during both test sessions for the group of never smokers, with the exception that they did not smoke. Two-alternative staircase methods and forced-choice tracking procedures were used to assess sucrose thresholds and preferences, respectively, during both test session. Standardized questionnaires were administered to assess food cravings as well as smoking and alcohol usage and dependence. The Family Interview for Genetic Studies was used to detect alcoholism according to the DSM III criteria for family members up to second-degree relatives.

RESULTS

Acute exposure to nicotine did not affect sucrose detection thresholds or preferences, but smokers had significantly higher sucrose detection thresholds than never smokers. The greater the smoking dose in pack-years, the lower the sucrose sensitivity. Regardless of smoking status, women who were FH+ preferred significantly higher sucrose concentrations and craved sweets more often than women who were not.

CONCLUSIONS

Both smoking and having a family history of alcoholism had differential effects on sweet taste. Smoking was associated with decreased sweet taste sensitivity whereas having a family history of alcoholism was associated with heightened sweet preferences. These findings suggests that future research on the effects of smoking on food habits and cravings should take into account family history of alcoholism given its association with sweet liking and the increased likelihood to develop a tobacco disorder.