Table 2.

Programs that Focus on Postpartum Smoking Relapse Prevention

Study	Intervention	Population Studied	No. of Participants	Outcome	Results	Comments/ Recommendations
44	Examine experiences of smoking relapse among postpartum women using narrative research.	Women who stopped smoking during pregnancy; Canada.	27	Experience due to postpartum cessation relapse.	Five general story lines were identified: (1) controlling one’s smoking (starting with one puff/constricting amount smoked); (2) vulnerable to smoking (inability to resist); (3) nostalgia for former self (freedom and happier times); (4) smoking for relief (manage emotions and stress); (5) never really having quit (did not want to quit for themselves).	Relapse among postpartum women is unique and requires specialized intervention.
45	Study examines the prevalence and intensity of smoking before, during and after pregnancy, and identifies correlates of postpartum smoking relapse.	Women in 10 states who had delivered live births.	17,378	Smoking behavior and correlates.	25.6% of women smoked before pregnancy. Of those, 44.5% quit during pregnancy, half of whom relapsed at time of survey (2 to 6 months postpartum).	Increased risk of postpartum: African American race, multiparity, late or no prenatal care, high maternal weight gain, stressful life events.
46	Study to gain insight into attitudes and perceptions about smoking during pregnancy, passive smoke exposure, barriers to quitting, and program preferences.	Nine focus group discussions were conducted with multiethnic, low-income mothers.	57	Attitudes and perceptions about smoking during pregnancy, passive smoke exposure, barriers to quitting, and program preferences.	Personal barriers to quitting included being around others who smoked, feelings of stress and boredom, addiction, and not believing smoking is dangerous enough. Participants tended to value pregnancy-related advice from female friends and relatives over advice from professionals.	Educational efforts are effective when directed at networks of women who share information.
18	Study comparing the rates of continuous smoking abstinence, daily smoking, and smoking cessation self-efficacy in treatment and control groups. Nurses provided counseling at birth and telephone counseling.	Pregnant women who quit smoking during pregnancy; Canada.	254	Postpartum cessation relapse.	6 months abstinence rate in treatment was 38% and 27% in the control. 48% of control vs 34% treatment smoked daily. Smoking cessation efficacy did not vary between groups.	Interventions can be strengthened if they are extended to the postpartum period.
47	Comparison study between two pre- and postnatal programs offered to pregnant smokers, HOPP (Healthy Options for Pregnancy and Parenting) offered telephone counseling; STORK (Stop Tobacco for OuR Kids) offered cessation counseling by staff during pre- and postpartum and well-baby visits.	Pregnant women who smoke in managed care settings, Minnesota.	2 postnatal programs.	Program implementation and efficacy.	97% of HOPP participants reported receiving calls; relapse rates delayed but not prevented. Problems with identification of target population and acceptance of repeated calls. 91% of STORK participants reported receiving the intervention in year 1, but delivery declined. Relapse was not significantly reduced at the 12-month mark.	A combined intervention that incorporates elements of both HOPP and STORK would be optimal if it could be implemented at reasonable cost.
11	Three groups: control received a self-help booklet only, a prepartum relapse prevention, or prepartum and postpartum relapse prevention. Postpartum relapse measured.	Pregnant smokers at 2 managed care organizations, Washington.	897 (457 in Seattle and 440 in Minnesota).	Postpartum abstinence rates.	Pre/post intervention delayed but did not prevent postpartum relapse to smoking. Prevention abstinence was significantly greater for pre/post intervention group at 8 weeks (booklet, 30%; prepartum, 35%; pre/post group, 39%) and at 6 months (booklet, 26%; prepartum, 24%; pre/post group, 33%)	Evaluation of relapse prevention interventions for smokers who quit during pregnancy reveals relapse prevention interventions need to be increased in duration and potency to prevent postpartum relapse.
4	Examine the association between early weaning and smoking relapse.	Women who stopped smoking during pregnancy; Canada.	228	Postpartum cessation relapse and early weaning.	65% of women who relapsed to daily smoking weaned before 26 weeks (early weaning) vs 34% who remained abstinent or smoked occasionally. Women who resumed daily smoking were almost 4 times more likely to wean early than those who abstained or smoked occasionally.	Smoking relapse prevention in the postpartum period is one of the most effective interventions in ensuring that women who stop smoking for pregnancy remain stopped and breast-feed their babies for the recommended duration.
56	Study examined long-term effectiveness of postpartum relapse prevention intervention by evaluating the smoking status and cessation self-efficacy of original study participants at 12 months after delivery.	Women who participated in Johnson, 2000 study; Canada.	238	Postpartum cessation relapse.	12-month abstinence: 21% treatment and 18.5% control; smoking daily: 41% treatment and 50% control; treatment attained higher self-efficacy.	Four variables associated with relapse to daily smoking are: breast-feeding and mental health had protective effects, and partners who smoked and greater amount smoked before pregnancy had adverse effects.
14	Examine the efficacy of physicians’ advice and referral to individual counseling in preventing cessation relapse.	Women who quit before first prenatal visit; Vermont.	414 (188 in intervention and 226 in usual care group).	Postpartum cessation relapse.	No significant differences between intervention and usual care groups during pregnancy or 1 year postpartum (23%; 32% vs 22%).	Referral to individual relapse counseling did not have a significant impact; however, the level of attention paid to smoking by physicians has contributed to overall lower relapse rates. Physicians could benefit from training on how to gain a pregnant smokers’ commitment to change her smoking behavior, an office prompt system, and individualized smoking behavior change counseling.
50	Participants were classified as PC (precontemplation), C (contemplation), PA (preparation), or A (action) after being assessed for personal goals, self-efficacy, and smoking behavior. Group differences in smoking were assessed at 6 weeks and 3, 6, and 12 months postpartum.	Pregnant women who quit smoking during pregnancy; Texas.	256.	Postpartum cessation relapse.	Percentage of women who returned to postpartum smoking was highest in the precontemplation stage and decreased with each subsequent stage (6 weeks, 83% of PCs, 64% of Cs, 35% of PAs, and 24% of As had relapsed).	Stage-based interventions should be developed to assist women in maintaining postpartum abstinence.
51	Test the effects of low-intensity, smoking cessation/ relapse prevention intervention delivered by clinicians based on stages-of-change and motivational interviewing techniques.	Pregnant women who quit smoking during pregnancy; Oregon.	3,907 (historical comparison of 1028, interim comparison of 824, and intervention group of 2055).	Pre and postpartum relapse	Self-reported quit rates were significantly higher in treatment group for quit rates and sustained abstinence rates at 6 and 12 months.	An intervention that supports women who want to quit smoking during pregnancy should be offered. It will also increase the likelihood for a woman to stay smoke-free after delivery.
52	Women received 15 to 30 minutes relapse prevention from nurse; included counseling about reasons for maintaining cessation and developing a plan. Pediatricians were given women’s smoking history and brief tips on cessation counseling. At the 2-week, 2-month, and 4-month well-baby visits with pediatrician, women received reinforcement and encouragement to try to (stay) quit.	Women just delivered at area hospitals and who smoked in the last 30+ days before pregnancy and quitting during pregnancy, predominantly white, Oregon.	287 (141 experimental, 146 control).	Abstinence rates during pregnancy and postpartum.	No difference in the relapse rates of women in the intervention and control. Moderate association between confidence to stay quit and nonrelapse. No significant association between experimental and control group between days until relapse, time before 1st cigarette in the morning, number of quit attempts since delivery, number of cigarettes smoked each day. Effective at getting providers to offer intervention, but intervention itself was not effective	Relapse prevention should (1) be added to cessation interventions; (2) include messages aimed at bolstering confidence in staying quit; (3) be delivered during prenatal, postpartum, and early childhood care; and (4) presented to a woman and her social network by ancillary staff.
53	Study assessed providers’ performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers.	WIC program staff, obstetric and pediatric clinicians at community health clinics; Massachusetts.	6 centers; 177 clinical staff members.	Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators.	Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance.	Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. The provider’s own commitment to helping mothers stop smoking was important.