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Irene Yang, PhD, RN and Lynne Hall, DrPH, RN
SMOKING CESSATION and Relapse Challenges Reported by Postpartum Women Abstract Purpose: To compare inpatient postpartum current and former smokers on: need for smoking cessation assistance; cessation interventions received from healthcare providers; cessation methods used; perceived barriers of cessation; exposure to second hand smoke (SHS); interest in postdischarge interventions; and smoking abstinence self-efficacy (SASE). Study Design and Methods: A descriptive comparative study was conducted using a cross-sectional survey of 24 postpartum women in the inpatient setting. Surveys were administered by face-to-face interview, with a paper-and-pencil option, and included questions from the Pregnancy Risk Assessment Monitoring System and the SASE Scale. Results: Women were predominantly low-income, unemployed, and Medicaid insured. Two-thirds of current smokers indicated that they needed help with smoking cessation. Most women in both groups received advice to quit smoking. Fewer, however, received specific types of assistance to stop smoking. The predominant November/December 2014
smoking cessation method attempted in both groups was the “cold turkey” method. More former smokers than current smokers maintained a nonsmoking home environment. More current smokers than former smokers were interested in postdischarge interventions. Clinical Implications: Current smokers need help quitting smoking and former smokers need postpartum relapse interventions. Providers should be intentional about offering existing interventions to help women quit smoking. Affordable and accessible interventions are needed that address unique stressors experienced by women, which include screening for depression and anxiety, and that incorporate smoking cessation interventions for spouses and partners who smoke. Cessation and relapse prevention interventions for postpartum women should start in the postpartum inpatient period and continue after discharge. Key words: Postpartum period; Pregnancy; Smoking; Smoking cessation. MCN
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Factors Associated With Perinatal Smoking Behavior Factors influencing persistent prenatal smoking include income (Tong, Jones, Dietz, D’Angelo, & Bombard, 2009), education (Ockene et al., 2002), employment (Lumley et al., 2009), partner smoking (Schneider, Huy, Schütz, & Diehl, 2010), stress level (Crittenden, Manfredi, Cho, & Dolecek, 2007), depression (Linares Scott, Heil, Higgins, Badger, & Bernstein, 2009), and marital status (Goodwin, Keyes, & Simuro, 2007). Similar factors affect postpartum smoking relapse (Kahn, Certain, & Whitaker, 2002) as well as selection of bottle feeding over breastfeeding, quit attempts in late pregnancy, and heavy nicotine dependence prior to pregnancy (Fang et al., 2004; Ratner, Johnson, Bottorff, Dahinten, & Hall, 2000). Smoking abstinence self efficacy is also related to a postpartum woman’s ability to cope with smoking triggers (Gaffney, 2006). Despite current knowledge of factors influencing perinatal smoking, little is known about what might motivate a woman to quit smoking after the birth of her baby or continue to be a nonsmoker after quitting during the pregnancy.
and relapse prevention interventions that could continue postdischarge. Smokers in the general population who received tobacco treatment during hospitalization and follow-up treatment for 1 month increased their odds of cessation by 65% at 6 and 12 months postdischarge compared to patients who received no treatment (Rigotti, Munafo, & Stead, 2008). Winickoff et al. (2010) tested an intervention for both mothers and fathers during the postpartum inpatient period. Although well received by patients, the intervention did not improve cessation outcomes compared to the control group. In contrast, Jiménez-Muro et al. (2013) found a beneficial effect for a brief telephone counseling smoking cessation intervention that started in the inpatient period and continued for 3 months afterward. Further testing of interventions for postpartum inpatient mothers is needed. Effective interventions require an understanding of factors that contribute to the smoking cessation process and how these differ between current and former smokers who are new mothers.
Study Design and Methods Design and Sample
This descriptive comparative study was conducted using a cross-sectional survey. Data were collected from postpartum inpatient mothers over a 4-month period in 2013. Recruitment occurred in a large urban hospital in the southeastern central United States. A total of 119 participants were screened for eligibility requirements, which included: any tobacco use in the last 10 months; at least 18 years of age; English speaking; no hearing impairment; gave birth to a healthy newborn baby; and postpartum vaginal birth Day 1 or postoperative cesarean birth Day 2. Of the 119 participants approached, 75 women did not meet inclusion criteria of tobacco use in the last 10 months; this translates to an overall smoking prevalence of 37% for those approached to participate. Out of the 28 women who were screened and met all eligibility requirements, four declined to participate. Of the remaining 24, 12 (50%) stated that they were current smokers and formed the persistent smoker group (50%) and 12 (50%) indicated they quit smoking during pregnancy and formed the former smoker group. CHASSENET / BSIP SA / Alamy
P
renatal smoking is a major health problem in the United States, with rates ranging from 4.5% in Utah to 30.5% in West Virginia (Tong et al., 2013). Many smoking cessation interventions have been tested in an attempt to avoid the negative consequences of smoking during pregnancy (Lumley et al., 2009). Less research, however, has focused on smoking cessation for postpartum women, and even less is known about the effectiveness of smoking cessation interventions for the immediate postpartum inpatient period. The few days in the hospital after birth, may provide an important window of opportunity for smoking cessation and smoking relapse interventions. Effective interventions must begin with an in-depth understanding of factors that contribute to perinatal smoking behavior and the smoking cessation process for both current and former smokers. The purpose of this study was to compare current and former inpatient postpartum smokers on their need for smoking cessation assistance; cessation interventions received from healthcare providers; cessation methods used; perceived barriers of cessation; exposure to second hand smoke (SHS); interest in postdischarge interventions; and smoking abstinence selfefficacy (SASE).
Measures
Postpartum Inpatient Interventions The inpatient postpartum period is a brief, but potentially useful opportunity for starting smoking cessation 376
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Questions adapted from the Pregnancy Risk Assessment and Monitoring System (PRAMS, Centers for Disease Control and Prevention [CDC], 2012) included: exposure to SHS (household smoking rules, partner smoking status, number of smokers living in the home); November/December 2014
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healthcare provider cessation interventions; attempted cessation methods; and perceived barriers to cessation. The PRAMS demonstrated good reliability with kappa coefficients for portions of the PRAMS ranging from .72 to .81 (Ahluwalia, Helms, & Morrow, 2013). Validity was also supported with sensitivity ranging from 90.8% to 94.3% and specificity between 76.0% and 96.0% when measured against birth certificate data (Ahluwalia et al.). Smoking abstinence or cessation self-efficacy was measured using the abbreviated 9-item version of the 20-item SASE Scale (Velicer, DiClemente, Rossi, & Prochaska, 1990). It measures the ability of the individual to not smoke in challenging situations using a Likert scale to measure their confidence (1 = Not at all to 5 = Extremely). The SASE demonstrated good internal consistency (alphas from .88 to .92) as well as construct and predictive validity (DiClemente et al., 1991). Cronbach’s alpha for this sample was .80 indicating adequate internal consistency. Additional questions were added to the survey to assess interest in postdischarge telephone, quitline, web-based, or text messaging interventions.
Table 1. Sociodemographic Characteristics of Current and Former Smokers (n = 24) Characteristic
Current Smokers (n = 12)
Former Smokers (n = 12)
Monthly Income
n
%
n
%
Less than $1,000
4
33.3
1
8.3
$1,000 to $1,999
5
41.7
3
25.0
$2,000 to $2,999
0
0
4
33.3
$3,000 to $3,999
2
16.7
1
8.3
$4,000 to $4,999
1
8.3
2
16.7
Greater than $5,000
0
0
1
8.3
White
4
33.3
4
33.3
White, non-Hispanic
0
0
1
8.3
Hispanic
0
0
1
8.3
African American
7
58.3
5
41.7
Asian-Pacific Islander
0
0
0
0
Native American
0
0
0
0
The university’s Institutional Review Board and the hospital’s offi ce of research administration approved this study. We informed potential participants on the postpartum inpatient unit about the purpose of the study, and provided written, informed consent to those who met the inclusion criteria and were interested in participating in the study. Mothers were interviewed in-person or given the option to self-complete the survey. Data analysis was conducted using SPSS, version 22.0 (IBM Corp., 2013). Group differences were assessed using descriptive statistics, chi-square tests for categorical variables, and oneway analyses of variance.
Other
1
8.3
1
8.3
High school or less
7
58.3
6
50.0
Beyond high school
5
41.6
6
50.0
Unemployed
8
66.7
7
58.3
Employed
4
33.5
5
41.7
Not married
6
50.0
2
25.0
Married
6
50.0
10
83.3
Results
Insurance Medicaid
10
83.3
9
81.8
Private or Tricare
2
16.7
2
18.2
Missing
0
0
1
8.3
Procedure
The mean age of persistent smokers was 28 ± 5 (range 19–37 years). Former smokers were similar in age with a mean of 26 ± 5 (range 19–32 years). Table 1 displays sociodemographic characteristics of the sample. Of the total sample, 83% qualified as low-income (U.S. Department of Health and Human Services, 2012). Most were also unemployed and Medicaid insured. The two groups did not differ on marital status; the majority of women in both groups were married. The majority of the mothers were either African American or White, but a greater number of African American women comprised both groups. Current and former smokers did not differ in the proportion that chose breastfeeding versus bottle feeding; both groups predominantly chose bottle feeding. Mean weight gain of the two groups did not differ and ranged from 31.23 ± 26.07 lbs (former smokers) to 42.54 ± 16.29 lbs (persistent smokers). Need for Cessation Assistance and Actual Assistance Received
Two-thirds of the current smokers reported needing help with smoking cessation. Despite this, none reported November/December 2014
Race
Education
Employment Status
Marital Status
receiving help. One fourth of the former smokers stated they needed cessation assistance during the pregnancy, and one third of the former smokers reported receiving help. Providers advised 100% of current smokers and 58.3% of former smokers to quit smoking. Table 2 lists the specific types of assistance given by healthcare providers. The same number of participants in both groups indicated they had received suggestions to set a specific quit date, attend a class or program, and use nicotine gum. Slightly more former smokers than current smokers received other forms of assistance from their providers. For example, 41.7% of former smokers versus 16.7% of persistent smokers received booklets or videos. Only 16.7% of women in both groups received suggestions for a smoking cessation class or program. MCN
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Table 2. Smoking Cessation Assistance Offered by Healthcare Providers to Current Smokers and Former Smokers (n = 24) Current Smokers (n = 12)
Former Smokers (n = 12)
Cessation Advice
n
%
n
%
Advice to quit smoking from healthcare provider
12
100
7
58.3
home, whereas almost half of current smokers allowed smoking in certain parts of the home or during certain times (100% vs. 41.7%; χ2 [1, n = 24] = 4.04, p = .04, phi = .51). Consistent with this finding, the groups also differed significantly on whether their spouses or partners smoked inside the home. None of the spouses/partners of former smokers smoked inside the home, whereas most of the spouses/partners of current smokers did (0% vs. 80%, χ2 [1, n = 15] = 7.20, p = .004, phi = .85). Postdischarge Interventions and Smoking Abstinence Self-Efficacy
Types of Cessation Assistance Discussion
4
33.3
5
41.7
Suggested class or program
2
16.7
2
16.7
Provided booklets or videos
2
16.7
5
41.7
Referred to quitline
2
16.7
3
25.0
Suggested specific date
2
16.7
2
16.7
Recommended nicotine gum
2
16.7
2
16.7
Asked if support available
1
8.3
3
27.3
Recommended patch
1
8.3
2
16.7
Prescribed pill
1
8.3
0
0
Referred to counseling
0
0
1
8.3
Prescribed spray or inhaler
0
0
1
8.3
Comparison of Reduction/Cessation Methods Used
All former smokers used the “cold turkey” method. Eighty percent of the current smokers stated that they also tried this method. One fourth of the women in each group set a quit date as part of their process of cessation. Only one former smoker reported the use of booklets, videos, or classes. Neither group reported the use of the quitline, counseling, or medications in their attempt to quit smoking.
Current smokers showed more interest in postdischarge interventions. Forty-two percent expressed interest in the quitline and text messaging; 33% were interested in a web-based program. Interest from former smokers was low. The SASE levels for both current and former smokers did not differ. The mean score was 2.86 ± .76 (range 1.56–4.11) for current smokers and 2.68 ± 1.15 (range 1–4.44) for former smokers. These mean scores suggest that both groups have less than a moderate level of selfefficacy when it comes to smoking abstinence.
Limitations Several limitations may have had an impact on the interpretation of results of this study. First, the small sample size limited ability for more in-depth comparisons. External validity issues related to generalizability also exist because convenience sampling was used. As this sample was primarily composed of low-income women, findings may not be applicable to other populations. Finally, selfreport bias may have existed for women in the former smoker group because their smoking status was not confirmed with biomarker verification.
Table 3. Perceived Smoking Cessation Barriers and Aids for Current Smokers and Former Smokers (n = 22)
n
Perceived Barriers to Smoking Cessation
Table 3 lists the perceived barriers to smoking cessation reported by both groups. Both groups reported “cravings for a cigarette” as the top barrier to successful smoking cessation. The strategies that they used to deal with cravings included: “Hard peppermint and ice,” “e-cigarettes,” “just tried to cut back,” and “cinnamon toothpicks and gum.” “Lack of a way to handle stress” was the second most frequently listed barrier. Notably, 60% of current smokers listed worsening depression and anxiety as barriers to smoking cessation. Second Hand Smoke Exposure
There was no difference between the two groups in the number of smokers in the home, but they did differ signifi cantly on their home smoking rules. None of the former smokers permitted smoking anywhere in their 378
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Former Smokers (n = 12)
Current Smoker (n = 10)
Perceived Barriers
%
%
n
Cravings for a cigarette
9
90
10
83
Lack of a way to handle stress
8
80
9
75
Other people smoking around you
8
80
9
75
Worsening depression
6
60
2
17
Worsening anxiety
6
60
4
33
Fear of gaining weight
5
50
2
17
Cost of medicines or products
4
40
0
0
Cost of classes
3
30
0
0
Lack of support
3
30
2
17
Other reason
1
10
2
17
November/December 2014
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Clinical Nursing Implications The women in this sample were predominantly low-income, unemployed, and Medicaid insured. These socioeconomic characteristics support prior research that indicated there is a greater prevalence of smoking in women from a low socioeconomic background (Adams, Melvin, & Raskind-Hood, 2008). There were a greater number of African American women in both groups. Research on racial differences between persistent and former smokers is inconsistent, with some studies reporting higher proportions of White women who quit prenatally, whereas other studies reported Black and Hispanic women were more likely to quit (Solomon & Quinn, 2004). Women in both groups listed stress as a major barrier for smoking cessation. The relationship between stress and prenatal smoking is well documented. Women who smoke during pregnancy perceived more stress in their lives than those who quit (Higgins et al., 2009). Parenting challenges, living in disruptive home environments, and lack of social support (Pletsch, Morgan, & Pieper, 2003) are sources of stress that affect prenatal smoking status. The majority of current smokers listed worsening depression and anxiety as barriers to smoking cessation. This is consistent with research in which depressive symptoms predicted prenatal smoking status (Linares Scott et al., 2009) and anxiety was significantly associated with prenatal smoking (Goedhart, van der Wal, Cuijpers, & Bonsel, 2009). Current smokers were more likely to allow smoking in their home and have spouses/partners who smoked compared to former smokers. This confirms findings in the literature that indicate that having a husband/partner who smokes increases the likelihood of persistent prenatal smoking (Schneider et al., 2010) and having a nonsmoking husband/partner is strongly associated with cessation success (Solomon & Quinn, 2004). The SASE levels for both groups did not differ and the overall mean score suggests that both groups had less than a moderate level of self-efficacy relative to smoking abstinence. One possible explanation for this lack of difference in SASE scores between groups is that the former smokers had already experienced a drop in self-efficacy levels postbirth. Research has shown that pregnant women who quit smoking show a high level of self-efficacy; however, once the external motivation of pregnancy is gone, they are susceptible to relapse (Stotts, DiClemente, Carbonari, & Mullen, 1996). The majority of current smokers reported needing help to quit smoking that indicated a desire to quit. The “cold turkey” strategy that most current smokers used was not successful. It is encouraging that most of the participants were advised to quit smoking, yet the overall percentage of women who were offered concrete forms of assistance was low. Although the 5 As (Ask, Advise, Assess, Assist, Arrange) are considered best practice for clinical smoking cessation intervention (Fiore et al., 2008), few prenatal providers go beyond the first two steps (Chapin & Root, 2004). Nurses have a unique opportunity in the prenatal period to provide the full range of cessation interventions November/December 2014
Suggested Clinical Implications • Offer affordable and accessible smoking cessation classes, programs, or products. • Stress management should be relevant to a woman’s unique stressors • Depression and anxiety screening is essential. • Educate women about the importance of implementing a strict no-smoking policy at home. • Incorporate smoking cessation interventions for spouses, partners, and close family members. • Provide postpartum smoking cessation and relapse prevention interventions that start after birth in the hospital and continue postdischarge.
that are available. Pregnant smokers should be offered resources such as the state quitline, smoking cessation classes, and cessation materials. In addition to intentionally offering existing interventions, there is a need for improved prenatal smoking cessation interventions. Even the women in this study who received different types of assistance from their providers chose to use strategies like going “cold turkey,” which may indicate that current interventions do not appeal to pregnant smokers. Insights from this study suggest possible ways that interventions might be improved. Interventions must be accessible and affordable for women from low socioeconomic (SES) backgrounds. This is an important issue as 30% to 40% of the current smokers listed the cost of medicines/products and classes as a barrier to quitting smoking. Interventions should address the barriers of smoking cessation identified in this study. Stress management is important for smoking cessation (Fiore et al., 2008); however, effective stress management should address stressors that are relevant for the mother. Sixty percent of current smokers reported worsening depression and anxiety as barriers to quitting smoking. Screening for depression and anxiety is a critical first step to help women achieve improved mental health and address a barrier to smoking cessation. Interventions should address the important influence that SHS exposure has on maternal smoking by encouraging women to enforce a no-smoking policy in the home and by incorporating smoking cessation interventions for spouses, partners, and other close family members. Finally, developing postpartum interventions that start during the inpatient period may offer current smokers another opportunity to quit smoking and former smokers help in preventing relapse. Although former smokers expressed low interest in postdischarge interventions, the high rate of postpartum smoking relapse (CDC, 2007) and the mean SASE level in this study suggest the likelihood of relapse and the benefit of intervention. Future research would benefit from surveying larger groups of women. Qualitative research investigating women’s perceptions of current interventions, their MCN
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perceptions of what interventions would be helpful, and details about the kinds of stressors experienced would provide valuable information to aid in designing more effective interventions. ✜
Irene Yang, Postdoctoral Research Fellow, Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road NE, Room 341, Atlanta, GA 30322. She can be reached via email at irene.yang@ emory.edu Lynne Hall is an Associate Dean of Research, University of Louisville School of Nursing, Louisville, KY. The author declares no conflict of interest. This research was funded by a grant from the University of Louisville, School of Interdisciplinary Graduate Studies Research Fund awarded to Dr. Yang. DOI:10.1097/NMC.0000000000000082 References
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Jiménez-Muro, A., Nerín, I., Samper, P., Marqueta, A., Beamonte, A., Gargallo, P., …, Rodríguez, G. (2013). A proactive smoking cessation intervention in postpartum women. Midwifery, 29(3), 240-245. doi:10.1016/j.midw.2012.01.003 Kahn, R. S., Certain, L., & Whitaker, R. C. (2002). A reexamination of smoking before, during, and after pregnancy. American Journal of Public Health, 92(11), 1801-1808. doi:10.2105/AJPH.92.11.1801 Linares Scott, T. J., Heil, S. H., Higgins, S. T., Badger, G. J., & Bernstein, I. M. (2009). Depressive symptoms predict smoking status among pregnant women. Addictive Behaviors, 34(8), 705-708. doi:10.1016/j. addbeh.2009.04.003 Lumley, J., Chamberlain, C., Dowswell, T., Oliver, S., Oakley, L., & Watson, L. (2009). Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, (3), CD001055. doi:10.1002/14651858.CD001055.pub3 Ockene, J., Ma, Y., Zapka, J., Pbert, L., Valentine Goins K., & Stoddard, A. (2002). Spontaneous cessation of smoking and alcohol use among low-income pregnant women. American Journal of Preventive Medicine, 23(3), 150-159. doi:10.1016/S0749-3797(02)00492-0 Pletsch, P. K., Morgan, S., & Pieper, A. F. (2003). Context and beliefs about smoking and smoking cessation. MCN: The American Journal of Maternal Child Nursing, 28(5), 320-325. doi:10.1097/00005721200309000-00012 Ratner, P. A., Johnson, J. L., Bottorff, J. L., Dahinten, S., & Hall, W. (2000). Twelve-month follow-up of a smoking relapse prevention intervention for postpartum women. Addictive Behaviors, 25(1), 81-92. doi:10.1016/S0306-4603(99)00033-7 Rigotti, N. A., Munafo, M. R., & Stead, L. F. (2008). Smoking cessation interventions for hospitalized smokers: A systematic review. Archives of Internal Medicine, 168(18), 1950-1960. doi:10.1001/ archinte.168.18.1950 Schneider, S., Huy, C., Schütz, J., & Diehl, K. (2010). Smoking cessation during pregnancy: A systematic literature review. Drug and Alcohol Review, 29(1), 81-90. doi:10.1111/j.1465-3362.2009.00098.x Solomon, L., & Quinn, V. (2004). Spontaneous quitting: Self-initiated smoking cessation in early pregnancy. Nicotine & Tobacco Research, 6(Suppl. 2), S203-S216. doi:10.1080/14622200410001669132 Stotts, A. L., Diclemente, C. C., Carbonari, J. P., & Mullen, P. D. (1996). Pregnancy smoking cessation: A case of mistaken identity. Addictive Behaviors, 21(4), 459-471. doi:10.1016/0306-4603(95)00082-8 Tong, V. T., Dietz, P. M., Morrow, B., D’Angelo, D. V., Farr, S. L., Rockhill, K. M., England, L. J. (2013). Trends in smoking before, during, and after pregnancy—Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000-2010, Morbidity and Mortality Weekly Report. Surveillance Summaries, 62(6), 1-19. Tong, V. T., Jones, J. R., Dietz, P. M., D’Angelo, D., Bombard, J. M. (2009). Trends in smoking before, during, and after pregnancy—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 31 sites, 2000-2005. Morbidity and Mortality Weekly Report. Surveillance Summaries, 58(4), 1-29. U.S. Department of Health and Human Services. (2012). 2012 Poverty guidelines. Federal Register, 77(17). Retrieved from http://aspe.hhs. gov/poverty/12fedreg.shtml Velicer, W. F., DiClemente, C. C., Rossi, J. S., & Prochaska, J. O. (1990). Relapse situations and self-efficacy: An integrative model. Addictive Behaviors, 15(3), 271-283. doi:10.1016/0306-4603(90)90070-E Winickoff, J. P., Healey, E. A., Regan, S., Park, E. R., Cole, C., Friebely, J., & Rigotti, N. A. (2010). Using the postpartum hospital stay to address mothers’ and fathers’ smoking: The NEWS study. Pediatrics, 125(3), 518-525. doi:10.1542/peds.2009-0356
CDC: Pregnancy Risk Assessment Monitoring System (PRAMS) Questionnaires www.cdc.gov/prams/Questionnaire.htm The HABITS Lab at UMBC: Self-Efficacy Scales Smoking Abstinence Self-Efficacy Scale (SASE) available for public use at www.umbc.edu/ psyc/habits/content/ttm_measures/self-efficacy/index. html Smoking Cessation For Pregnancy And Beyond: A Virtual Clinic www.smokingcessationandpregnancy.org/resources CDC: Tobacco Use and Pregnancy Resources www.cdc.gov/reproductivehealth/TobaccoUsePreg nancy/Resources.htm November/December 2014
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Irene Yang, PhD, RN and Lynne Hall, DrPH, RN
SMOKING CESSATION and Relapse Challenges Reported by Postpartum Women Abstract Purpose: To compare inpatient postpartum current and former smokers on: need for smoking cessation assistance; cessation interventions received from healthcare providers; cessation methods used; perceived barriers of cessation; exposure to second hand smoke (SHS); interest in postdischarge interventions; and smoking abstinence self-efficacy (SASE). Study Design and Methods: A descriptive comparative study was conducted using a cross-sectional survey of 24 postpartum women in the inpatient setting. Surveys were administered by face-to-face interview, with a paper-and-pencil option, and included questions from the Pregnancy Risk Assessment Monitoring System and the SASE Scale. Results: Women were predominantly low-income, unemployed, and Medicaid insured. Two-thirds of current smokers indicated that they needed help with smoking cessation. Most women in both groups received advice to quit smoking. Fewer, however, received specific types of assistance to stop smoking. The predominant November/December 2014
smoking cessation method attempted in both groups was the “cold turkey” method. More former smokers than current smokers maintained a nonsmoking home environment. More current smokers than former smokers were interested in postdischarge interventions. Clinical Implications: Current smokers need help quitting smoking and former smokers need postpartum relapse interventions. Providers should be intentional about offering existing interventions to help women quit smoking. Affordable and accessible interventions are needed that address unique stressors experienced by women, which include screening for depression and anxiety, and that incorporate smoking cessation interventions for spouses and partners who smoke. Cessation and relapse prevention interventions for postpartum women should start in the postpartum inpatient period and continue after discharge. Key words: Postpartum period; Pregnancy; Smoking; Smoking cessation. MCN
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Factors Associated With Perinatal Smoking Behavior Factors influencing persistent prenatal smoking include income (Tong, Jones, Dietz, D’Angelo, & Bombard, 2009), education (Ockene et al., 2002), employment (Lumley et al., 2009), partner smoking (Schneider, Huy, Schütz, & Diehl, 2010), stress level (Crittenden, Manfredi, Cho, & Dolecek, 2007), depression (Linares Scott, Heil, Higgins, Badger, & Bernstein, 2009), and marital status (Goodwin, Keyes, & Simuro, 2007). Similar factors affect postpartum smoking relapse (Kahn, Certain, & Whitaker, 2002) as well as selection of bottle feeding over breastfeeding, quit attempts in late pregnancy, and heavy nicotine dependence prior to pregnancy (Fang et al., 2004; Ratner, Johnson, Bottorff, Dahinten, & Hall, 2000). Smoking abstinence self efficacy is also related to a postpartum woman’s ability to cope with smoking triggers (Gaffney, 2006). Despite current knowledge of factors influencing perinatal smoking, little is known about what might motivate a woman to quit smoking after the birth of her baby or continue to be a nonsmoker after quitting during the pregnancy.
and relapse prevention interventions that could continue postdischarge. Smokers in the general population who received tobacco treatment during hospitalization and follow-up treatment for 1 month increased their odds of cessation by 65% at 6 and 12 months postdischarge compared to patients who received no treatment (Rigotti, Munafo, & Stead, 2008). Winickoff et al. (2010) tested an intervention for both mothers and fathers during the postpartum inpatient period. Although well received by patients, the intervention did not improve cessation outcomes compared to the control group. In contrast, Jiménez-Muro et al. (2013) found a beneficial effect for a brief telephone counseling smoking cessation intervention that started in the inpatient period and continued for 3 months afterward. Further testing of interventions for postpartum inpatient mothers is needed. Effective interventions require an understanding of factors that contribute to the smoking cessation process and how these differ between current and former smokers who are new mothers.
Study Design and Methods Design and Sample
This descriptive comparative study was conducted using a cross-sectional survey. Data were collected from postpartum inpatient mothers over a 4-month period in 2013. Recruitment occurred in a large urban hospital in the southeastern central United States. A total of 119 participants were screened for eligibility requirements, which included: any tobacco use in the last 10 months; at least 18 years of age; English speaking; no hearing impairment; gave birth to a healthy newborn baby; and postpartum vaginal birth Day 1 or postoperative cesarean birth Day 2. Of the 119 participants approached, 75 women did not meet inclusion criteria of tobacco use in the last 10 months; this translates to an overall smoking prevalence of 37% for those approached to participate. Out of the 28 women who were screened and met all eligibility requirements, four declined to participate. Of the remaining 24, 12 (50%) stated that they were current smokers and formed the persistent smoker group (50%) and 12 (50%) indicated they quit smoking during pregnancy and formed the former smoker group. CHASSENET / BSIP SA / Alamy
P
renatal smoking is a major health problem in the United States, with rates ranging from 4.5% in Utah to 30.5% in West Virginia (Tong et al., 2013). Many smoking cessation interventions have been tested in an attempt to avoid the negative consequences of smoking during pregnancy (Lumley et al., 2009). Less research, however, has focused on smoking cessation for postpartum women, and even less is known about the effectiveness of smoking cessation interventions for the immediate postpartum inpatient period. The few days in the hospital after birth, may provide an important window of opportunity for smoking cessation and smoking relapse interventions. Effective interventions must begin with an in-depth understanding of factors that contribute to perinatal smoking behavior and the smoking cessation process for both current and former smokers. The purpose of this study was to compare current and former inpatient postpartum smokers on their need for smoking cessation assistance; cessation interventions received from healthcare providers; cessation methods used; perceived barriers of cessation; exposure to second hand smoke (SHS); interest in postdischarge interventions; and smoking abstinence selfefficacy (SASE).
Measures
Postpartum Inpatient Interventions The inpatient postpartum period is a brief, but potentially useful opportunity for starting smoking cessation 376
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Questions adapted from the Pregnancy Risk Assessment and Monitoring System (PRAMS, Centers for Disease Control and Prevention [CDC], 2012) included: exposure to SHS (household smoking rules, partner smoking status, number of smokers living in the home); November/December 2014
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healthcare provider cessation interventions; attempted cessation methods; and perceived barriers to cessation. The PRAMS demonstrated good reliability with kappa coefficients for portions of the PRAMS ranging from .72 to .81 (Ahluwalia, Helms, & Morrow, 2013). Validity was also supported with sensitivity ranging from 90.8% to 94.3% and specificity between 76.0% and 96.0% when measured against birth certificate data (Ahluwalia et al.). Smoking abstinence or cessation self-efficacy was measured using the abbreviated 9-item version of the 20-item SASE Scale (Velicer, DiClemente, Rossi, & Prochaska, 1990). It measures the ability of the individual to not smoke in challenging situations using a Likert scale to measure their confidence (1 = Not at all to 5 = Extremely). The SASE demonstrated good internal consistency (alphas from .88 to .92) as well as construct and predictive validity (DiClemente et al., 1991). Cronbach’s alpha for this sample was .80 indicating adequate internal consistency. Additional questions were added to the survey to assess interest in postdischarge telephone, quitline, web-based, or text messaging interventions.
Table 1. Sociodemographic Characteristics of Current and Former Smokers (n = 24) Characteristic
Current Smokers (n = 12)
Former Smokers (n = 12)
Monthly Income
n
%
n
%
Less than $1,000
4
33.3
1
8.3
$1,000 to $1,999
5
41.7
3
25.0
$2,000 to $2,999
0
0
4
33.3
$3,000 to $3,999
2
16.7
1
8.3
$4,000 to $4,999
1
8.3
2
16.7
Greater than $5,000
0
0
1
8.3
White
4
33.3
4
33.3
White, non-Hispanic
0
0
1
8.3
Hispanic
0
0
1
8.3
African American
7
58.3
5
41.7
Asian-Pacific Islander
0
0
0
0
Native American
0
0
0
0
The university’s Institutional Review Board and the hospital’s offi ce of research administration approved this study. We informed potential participants on the postpartum inpatient unit about the purpose of the study, and provided written, informed consent to those who met the inclusion criteria and were interested in participating in the study. Mothers were interviewed in-person or given the option to self-complete the survey. Data analysis was conducted using SPSS, version 22.0 (IBM Corp., 2013). Group differences were assessed using descriptive statistics, chi-square tests for categorical variables, and oneway analyses of variance.
Other
1
8.3
1
8.3
High school or less
7
58.3
6
50.0
Beyond high school
5
41.6
6
50.0
Unemployed
8
66.7
7
58.3
Employed
4
33.5
5
41.7
Not married
6
50.0
2
25.0
Married
6
50.0
10
83.3
Results
Insurance Medicaid
10
83.3
9
81.8
Private or Tricare
2
16.7
2
18.2
Missing
0
0
1
8.3
Procedure
The mean age of persistent smokers was 28 ± 5 (range 19–37 years). Former smokers were similar in age with a mean of 26 ± 5 (range 19–32 years). Table 1 displays sociodemographic characteristics of the sample. Of the total sample, 83% qualified as low-income (U.S. Department of Health and Human Services, 2012). Most were also unemployed and Medicaid insured. The two groups did not differ on marital status; the majority of women in both groups were married. The majority of the mothers were either African American or White, but a greater number of African American women comprised both groups. Current and former smokers did not differ in the proportion that chose breastfeeding versus bottle feeding; both groups predominantly chose bottle feeding. Mean weight gain of the two groups did not differ and ranged from 31.23 ± 26.07 lbs (former smokers) to 42.54 ± 16.29 lbs (persistent smokers). Need for Cessation Assistance and Actual Assistance Received
Two-thirds of the current smokers reported needing help with smoking cessation. Despite this, none reported November/December 2014
Race
Education
Employment Status
Marital Status
receiving help. One fourth of the former smokers stated they needed cessation assistance during the pregnancy, and one third of the former smokers reported receiving help. Providers advised 100% of current smokers and 58.3% of former smokers to quit smoking. Table 2 lists the specific types of assistance given by healthcare providers. The same number of participants in both groups indicated they had received suggestions to set a specific quit date, attend a class or program, and use nicotine gum. Slightly more former smokers than current smokers received other forms of assistance from their providers. For example, 41.7% of former smokers versus 16.7% of persistent smokers received booklets or videos. Only 16.7% of women in both groups received suggestions for a smoking cessation class or program. MCN
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Table 2. Smoking Cessation Assistance Offered by Healthcare Providers to Current Smokers and Former Smokers (n = 24) Current Smokers (n = 12)
Former Smokers (n = 12)
Cessation Advice
n
%
n
%
Advice to quit smoking from healthcare provider
12
100
7
58.3
home, whereas almost half of current smokers allowed smoking in certain parts of the home or during certain times (100% vs. 41.7%; χ2 [1, n = 24] = 4.04, p = .04, phi = .51). Consistent with this finding, the groups also differed significantly on whether their spouses or partners smoked inside the home. None of the spouses/partners of former smokers smoked inside the home, whereas most of the spouses/partners of current smokers did (0% vs. 80%, χ2 [1, n = 15] = 7.20, p = .004, phi = .85). Postdischarge Interventions and Smoking Abstinence Self-Efficacy
Types of Cessation Assistance Discussion
4
33.3
5
41.7
Suggested class or program
2
16.7
2
16.7
Provided booklets or videos
2
16.7
5
41.7
Referred to quitline
2
16.7
3
25.0
Suggested specific date
2
16.7
2
16.7
Recommended nicotine gum
2
16.7
2
16.7
Asked if support available
1
8.3
3
27.3
Recommended patch
1
8.3
2
16.7
Prescribed pill
1
8.3
0
0
Referred to counseling
0
0
1
8.3
Prescribed spray or inhaler
0
0
1
8.3
Comparison of Reduction/Cessation Methods Used
All former smokers used the “cold turkey” method. Eighty percent of the current smokers stated that they also tried this method. One fourth of the women in each group set a quit date as part of their process of cessation. Only one former smoker reported the use of booklets, videos, or classes. Neither group reported the use of the quitline, counseling, or medications in their attempt to quit smoking.
Current smokers showed more interest in postdischarge interventions. Forty-two percent expressed interest in the quitline and text messaging; 33% were interested in a web-based program. Interest from former smokers was low. The SASE levels for both current and former smokers did not differ. The mean score was 2.86 ± .76 (range 1.56–4.11) for current smokers and 2.68 ± 1.15 (range 1–4.44) for former smokers. These mean scores suggest that both groups have less than a moderate level of selfefficacy when it comes to smoking abstinence.
Limitations Several limitations may have had an impact on the interpretation of results of this study. First, the small sample size limited ability for more in-depth comparisons. External validity issues related to generalizability also exist because convenience sampling was used. As this sample was primarily composed of low-income women, findings may not be applicable to other populations. Finally, selfreport bias may have existed for women in the former smoker group because their smoking status was not confirmed with biomarker verification.
Table 3. Perceived Smoking Cessation Barriers and Aids for Current Smokers and Former Smokers (n = 22)
n
Perceived Barriers to Smoking Cessation
Table 3 lists the perceived barriers to smoking cessation reported by both groups. Both groups reported “cravings for a cigarette” as the top barrier to successful smoking cessation. The strategies that they used to deal with cravings included: “Hard peppermint and ice,” “e-cigarettes,” “just tried to cut back,” and “cinnamon toothpicks and gum.” “Lack of a way to handle stress” was the second most frequently listed barrier. Notably, 60% of current smokers listed worsening depression and anxiety as barriers to smoking cessation. Second Hand Smoke Exposure
There was no difference between the two groups in the number of smokers in the home, but they did differ signifi cantly on their home smoking rules. None of the former smokers permitted smoking anywhere in their 378
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Former Smokers (n = 12)
Current Smoker (n = 10)
Perceived Barriers
%
%
n
Cravings for a cigarette
9
90
10
83
Lack of a way to handle stress
8
80
9
75
Other people smoking around you
8
80
9
75
Worsening depression
6
60
2
17
Worsening anxiety
6
60
4
33
Fear of gaining weight
5
50
2
17
Cost of medicines or products
4
40
0
0
Cost of classes
3
30
0
0
Lack of support
3
30
2
17
Other reason
1
10
2
17
November/December 2014
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Clinical Nursing Implications The women in this sample were predominantly low-income, unemployed, and Medicaid insured. These socioeconomic characteristics support prior research that indicated there is a greater prevalence of smoking in women from a low socioeconomic background (Adams, Melvin, & Raskind-Hood, 2008). There were a greater number of African American women in both groups. Research on racial differences between persistent and former smokers is inconsistent, with some studies reporting higher proportions of White women who quit prenatally, whereas other studies reported Black and Hispanic women were more likely to quit (Solomon & Quinn, 2004). Women in both groups listed stress as a major barrier for smoking cessation. The relationship between stress and prenatal smoking is well documented. Women who smoke during pregnancy perceived more stress in their lives than those who quit (Higgins et al., 2009). Parenting challenges, living in disruptive home environments, and lack of social support (Pletsch, Morgan, & Pieper, 2003) are sources of stress that affect prenatal smoking status. The majority of current smokers listed worsening depression and anxiety as barriers to smoking cessation. This is consistent with research in which depressive symptoms predicted prenatal smoking status (Linares Scott et al., 2009) and anxiety was significantly associated with prenatal smoking (Goedhart, van der Wal, Cuijpers, & Bonsel, 2009). Current smokers were more likely to allow smoking in their home and have spouses/partners who smoked compared to former smokers. This confirms findings in the literature that indicate that having a husband/partner who smokes increases the likelihood of persistent prenatal smoking (Schneider et al., 2010) and having a nonsmoking husband/partner is strongly associated with cessation success (Solomon & Quinn, 2004). The SASE levels for both groups did not differ and the overall mean score suggests that both groups had less than a moderate level of self-efficacy relative to smoking abstinence. One possible explanation for this lack of difference in SASE scores between groups is that the former smokers had already experienced a drop in self-efficacy levels postbirth. Research has shown that pregnant women who quit smoking show a high level of self-efficacy; however, once the external motivation of pregnancy is gone, they are susceptible to relapse (Stotts, DiClemente, Carbonari, & Mullen, 1996). The majority of current smokers reported needing help to quit smoking that indicated a desire to quit. The “cold turkey” strategy that most current smokers used was not successful. It is encouraging that most of the participants were advised to quit smoking, yet the overall percentage of women who were offered concrete forms of assistance was low. Although the 5 As (Ask, Advise, Assess, Assist, Arrange) are considered best practice for clinical smoking cessation intervention (Fiore et al., 2008), few prenatal providers go beyond the first two steps (Chapin & Root, 2004). Nurses have a unique opportunity in the prenatal period to provide the full range of cessation interventions November/December 2014
Suggested Clinical Implications • Offer affordable and accessible smoking cessation classes, programs, or products. • Stress management should be relevant to a woman’s unique stressors • Depression and anxiety screening is essential. • Educate women about the importance of implementing a strict no-smoking policy at home. • Incorporate smoking cessation interventions for spouses, partners, and close family members. • Provide postpartum smoking cessation and relapse prevention interventions that start after birth in the hospital and continue postdischarge.
that are available. Pregnant smokers should be offered resources such as the state quitline, smoking cessation classes, and cessation materials. In addition to intentionally offering existing interventions, there is a need for improved prenatal smoking cessation interventions. Even the women in this study who received different types of assistance from their providers chose to use strategies like going “cold turkey,” which may indicate that current interventions do not appeal to pregnant smokers. Insights from this study suggest possible ways that interventions might be improved. Interventions must be accessible and affordable for women from low socioeconomic (SES) backgrounds. This is an important issue as 30% to 40% of the current smokers listed the cost of medicines/products and classes as a barrier to quitting smoking. Interventions should address the barriers of smoking cessation identified in this study. Stress management is important for smoking cessation (Fiore et al., 2008); however, effective stress management should address stressors that are relevant for the mother. Sixty percent of current smokers reported worsening depression and anxiety as barriers to quitting smoking. Screening for depression and anxiety is a critical first step to help women achieve improved mental health and address a barrier to smoking cessation. Interventions should address the important influence that SHS exposure has on maternal smoking by encouraging women to enforce a no-smoking policy in the home and by incorporating smoking cessation interventions for spouses, partners, and other close family members. Finally, developing postpartum interventions that start during the inpatient period may offer current smokers another opportunity to quit smoking and former smokers help in preventing relapse. Although former smokers expressed low interest in postdischarge interventions, the high rate of postpartum smoking relapse (CDC, 2007) and the mean SASE level in this study suggest the likelihood of relapse and the benefit of intervention. Future research would benefit from surveying larger groups of women. Qualitative research investigating women’s perceptions of current interventions, their MCN
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perceptions of what interventions would be helpful, and details about the kinds of stressors experienced would provide valuable information to aid in designing more effective interventions. ✜
Irene Yang, Postdoctoral Research Fellow, Emory University Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road NE, Room 341, Atlanta, GA 30322. She can be reached via email at irene.yang@ emory.edu Lynne Hall is an Associate Dean of Research, University of Louisville School of Nursing, Louisville, KY. The author declares no conflict of interest. This research was funded by a grant from the University of Louisville, School of Interdisciplinary Graduate Studies Research Fund awarded to Dr. Yang. DOI:10.1097/NMC.0000000000000082 References
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CDC: Pregnancy Risk Assessment Monitoring System (PRAMS) Questionnaires www.cdc.gov/prams/Questionnaire.htm The HABITS Lab at UMBC: Self-Efficacy Scales Smoking Abstinence Self-Efficacy Scale (SASE) available for public use at www.umbc.edu/ psyc/habits/content/ttm_measures/self-efficacy/index. html Smoking Cessation For Pregnancy And Beyond: A Virtual Clinic www.smokingcessationandpregnancy.org/resources CDC: Tobacco Use and Pregnancy Resources www.cdc.gov/reproductivehealth/TobaccoUsePreg nancy/Resources.htm November/December 2014
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