Adapting Smoking Relapse Prevention Materials for

Pregnant and Postpartum Women

Gwendolyn P. Quinn, Ph.D.

Pregnancy and Smoking

The majority of pregnant women (except for this one in the photo) are aware that smoking has deleterious effects on unborn children

Pregnancy and Smoking

Smoking is associated with ectopic pregnancy, premature birth, low-birth weight and placental complications

Health risks to the unborn child of a smoker remain a factor after birth – postpartum smoking is linked to sudden infant death syndrome, ear infections, and asthma

Pregnancy and Smoking

While most mothers are aware of the dangers of smoking during pregnancy, less are aware of how these health risks prevail after the birth of their child.

Pregnant women are often highly motivated to quit smoking during the pregnancy and tend to report an easier time quitting than non-pregnant women

Pregnancy and Smoking

Because pregnant women report having an easier time quitting (higher motivation and reduced cravings and withdrawal symptoms) they tend to quit spontaneously and without a plan.

This lack of planning may account for the relapse rate of 70-85% among post-partum women

Pregnancy and Smoking

The purpose of this study was to gain formative research data on the barriers and facilitative factors of using existing, theoretically based, empirically supported relapse prevention materials, as they were adapted to meet the unique needs of pregnant and postpartum women.

Forever Free

The Forever Free relapse prevention program is a series of eight empirically based booklets, validated in two clinical trials to reduce relapse among adult former smokers.

Brandon, T. et al. Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: Dismantling the effects of content versus contact. J consult Clin Psychol 2004; 72 (5) 797-808.

Forever Free

The Forever Free materials are distinct in that their focus is not on smoking cessation, but rather on preventing relapse among former smokers who have already quit or attempted to.

MethodsSemi-structured interviews were conducted with 38 women who were: 18 or older A smoker for at least a year Stopped smoking before or

during pregnancy Been abstinent at least two

months during pregnancy No sooner than 5 months

pregnant and no more than 8 months postpartum

Recruitment

Recruiting women for the study was a challenge. We placed ads in newspapers, posted flyers in grocery and baby stores, worked through local health depts.,OB and pediatrician offices.

Women were reluctant to admit to being a smoker at any time during the pregnancy

Participants

The resulting sample was comprised of 22 white, 5 Asian, and 10 black women who represented the three categories of: (PA) Pregnant Abstinent – at least 6 months

pregnant and not smoking (PPA) Postpartum Abstinent – within 8 months

postpartum and not smoking (PPR) Postpartum Relapsed – within 8 months

postpartum and relapsed to smoking

Semi-structured interviewsQualitative interviews were conducted in private rooms of the research office, or at the participants homes. Child care and $25 compensation was providedThe interview guide was developed based on common cessation and relapse factors in the literature as well as a review of the Forever Free booklets. One of the goals of the project was to ask the women for input in adapting the existing materials to meet the needs of pregnant and postpartum women

Data Analysis

Verbatim transcripts of interviews were initially hand coded and later managed with EthnographContent analysis, using a template analysis plan, was performed to identify key themes in the women’s beliefs and experiencesData were used to edit and restructure the existing Forever Free materials and create tailored messages for pregnant and postpartum women

Results

Findings showed varied results across the three groups in terms of the definition of “quitting smoking” versus making a decision to quit

Overall, women in all groups experienced conflict about their identities as new parents or parents to be in relation to their new social roles and a smoke-free life.

Results

Feedback about needed changes to the booklets did not vary across the three groups.

Suggested names for the new booklets included: Baby’s Breath, New Beginnings, Forever Free for Baby and Me

The majority said they would expect to be offered the booklets by their health care provider and would be reluctant to use them if distributed from another source

Sample ResultsIssues (PA) Pregnant

Abstinent (n=6)(PPA) Postpartum Abstinent (n= 8)

(PPR) Postpartum Relapse (n=8)

Stress Physical, financial Adjusting to staying at home or returning to work

Financial, looking for work, in ability to quit smoking

“Being able to get a job in my field while pregnant is impossible”

“I can’t afford to go back to work and I can’t afford to stay home”

“Keeping a balance between work and the baby and everything else is a challenge. Quitting smoking has been a huge challenge too”

ResultsIssue PA PPA PPR

Timing of Quitting

When pregnancy was confirmed

Decided to quit when pregnancy was confirmed, serious effort a few months later

Decision to quit when pregnancy confirmed, cut down on # of cigarettes

“The minute my doctor said I was pregnant, I threw out my cigarettes”

“It took me about six weeks after I found out I was pregnant”

“I quit as soon as I found out and lowered by cigarettes to one a day for the first trimester “

Results

Issue PA PPA PPR

Barriers Being around other smokers

Other smokers, alcohol, coffee, driving

Daily life stress

“I go out with my old friends and they have their ashtrays and I don’t have that anymore”

“When my husband goes outside to smoke I think ‘there goes my old life’ and I miss it”

“When I get into an argument I really want a cigarette”

ResultsIssue PA PPA PPR

Spouse/Partner Support

Spouse quitting was helpful

Spouse quit for pregnancy resumed after

Spousal comments often negative and unhelpful

“My husband smokes outside and not around me.. It’s helpful”

“At first he put the window down if he smoked in the car or went outside to smoke, now he doesn’t and it drives me crazy”

“He said ‘look honey, if you’re going to smoke at least try to lose some weight. You can’t be fat and a smoker”

Results

All women liked the layout of the booklets and found content usefulRespondents requested additional information about weight gain, dealing with social situation, moodiness, cravings

Women said that information specific to each trimester and the postpartum period would be helpful – the issues are different at each stageWomen requested personal stories or case histories of other pregnant women who were successful at remaining smoke free

Results

The most appealing messages included information aboutCosts of smokingBehavioral and mental coping skillsPreparing for “triggers” to smokingPreparing for differences in withdrawal

during pregnancy and postpartum periodReminders of reasons to quit smoking for

their own health as well as the child

Conclusions

Results underscore those found in other studies – women often “suspend” smoking during pregnancy

Women tend to not make a plan for long-term smoking cessation, either intending to resume after baby is born or assuming that the ease of remaining smoke-free during pregnancy will continue through postpartum period

Conclusions

The focus of the project is on preventing relapse among this population and adapting the Forever Free materials for this groupTo this end, attention must be paid to the language and definitions used by women describe to “quitting”The role of the spouse/partner is also a key factorPreparing women for the different potential relapse situations they may encounter in the postpartum period is also essential

End

A clinical trial to test the efficacy of the booklets with this population is on-going. Results will be available by mid 2007

The research was supported by NCI grant RO1 CA 94256. Copies of the Forever Free for Baby and Me booklets may be requested from Dr. Thomas Brandon: brandont@moffitt.usf.edu

This presentation is based on the article:

Quinn, G., Ellison, B., Meade, C., Roach, N., Lopez, E., Albrecht, T., Brandon, T. (2005). Adapting Smoking Relapse Prevention Materials for Pregnant and Postpartum Women: Formative Research

For details about this presentation or the article please contact :Gwendolyn P. Quinn, Ph.D.

H.L. Moffitt Cancer Center and Research Institute

University of South Florida, College of Medicine quinng@moffitt.usf.edu