Perceived support to stay quit: What happens after delivery?

Abstract

Objective

To assess whether perceived changes in postpartum support were associated with postpartum return to smoking.

Study design

This is a prospective repeated measures, mixed methods observational study. Sixty-five women who smoked prior to pregnancy were recruited at delivery and surveyed at 2, 6, 12, and 24 weeks postpartum; in-depth interviews were conducted when participants reported smoking.

Results

Fifty-two percent self identified as White, non-Hispanic. Forty-seven percent resumed smoking by 24 weeks postpartum. Women who had returned to smoking by 24 weeks had a significantly larger decrease in perceived smoking-specific support than women who remained abstinent (p < 0.001). By 24-week postpartum follow-up, only 24% of women reported that an obstetric clinician had discussed how to quit/stay quit. When qualitatively interviewed, more than half of women reported having no one to support them to stay quit or quit smoking.

Conclusion

Following delivery, women lack needed smoking-specific support. Decline in perceived smoking-specific support from family and friends is associated with postpartum smoking resumption.

Introduction

Approximately one-third of smokers quit once they learn that they are pregnant (Fingerhut et al., 1990, Floyd et al., 1993, LeClere and Wilson, 1997, Severson et al., 1995, Solomon and Quinn, 2004, Cnattingius, 2004). Women who remain tobacco abstinent after delivery experience health benefits that include protection of infants from secondhand smoke exposure, lower risk of poor pregnancy outcomes in subsequent pregnancies, and decreased risk for themselves of tobacco-related health problems (Mullen, 2004). However, up to two-thirds of women who stop smoking during pregnancy resume smoking within 6 months after delivery (Colman and Joyce, 2003, Fingerhut et al., 1990, Martin et al., 2008, McBride and Pirie, 1990, McBride et al., 1992, Ratner et al., 2000); this rate of relapse has remained static over the past two decades.

One factor predictive of postpartum relapse is perceived low social support, which is of concern since the postpartum period is a time during which women in general might feel a lack in needed support. This is evidenced through data from the Pregnancy Risk Assessment Monitoring System (PRAMS), in which women who were 2–9 months postpartum indicated lack of needed social support as their most frequent concern (Kanotra et al., 2007). Postpartum women's perceived dearth in support might be, in part, due to a shift in focus away from women toward their infants and a corresponding decline in women's social support. Indeed, a decline in partners' provision of emotional and smoking-specific support has been documented from pregnancy through the first year postpartum (McBride et al., 2004, Pollak et al., 2006, Pollak and Mullen, 1997).

Declines in women's perceived support may have negative ramifications for women who are struggling to maintain tobacco abstinence, but this has not been extensively studied. A few studies have examined the relationship between perceived partner social and smoking-specific support and postpartum relapse but have yielded somewhat differing results. Pollak and Mullen (1997) studied 72 women who quit smoking during pregnancy and found that neither perceived partner social nor smoking-specific support for quitting were associated with postpartum return to smoking. However, McBride et al. (1992) studied 106 women who quit smoking during pregnancy and found a significant negative relationship between perceived spouse support and postpartum relapse, even after controlling for the spouse's smoking status; women who perceived their spouses to be more helpful during pregnancy were more likely to relapse by 6 months postpartum compared women who had perceived their spouses to be less helpful during pregnancy. Pollak et al. (2006) examined women's perceived helpfulness with regard to quitting or cutting down on smoking and found that, compared to women who did not quit smoking during pregnancy and who had quit during and stayed quit postpartum, women who had quit smoking during pregnancy but relapsed by 12 months postpartum reported a steeper decline in perceived helpfulness. A potential explanation for these differing results is that an influential mechanism of postpartum relapse is women's perceived decrease in support postpartum. We will examine this issue in-depth in this paper, looking at women's perceived changes in both social and smoking specific support from all social networks across the 6-month postpartum period.

Also unknown is the extent to which health care professionals who see postpartum women address tobacco or provide support to remain tobacco abstinent after pregnancy. Data from the National Ambulatory Medical Care Survey (NAMCS) found that physicians caring for pregnant women identified pregnant women's smoking status at 81% of visits but provided smoking cessation counseling at only 23% of pregnant smoker visits (Moran, Thorndike, Armstrong, & Rigotti, 2003). Another study conducted in New Zealand documented that 85% of general practitioners will ask pregnant patients about their smoking status, yet only 71% of general practitioners will advise women to quit (Glover, Paynter, Bullen, & Kristensen, 2008). To date no one has examined how often clinicians caring for women postpartum identify smoking or counsel them about quitting/staying quit.

The objective of this paper is to determine whether a postpartum decline in perceived support is associated with return to smoking in the postpartum period. The purpose of the overall study from which these data were collected was to examine the role of mood in relapse to smoking (Park et al., 2009). We enrolled women, immediately after delivery, who had quit smoking during pregnancy and assessed perceived support and smoking status five times over 24 weeks. We hypothesized that a decrease in perceived support during the postpartum period would be associated with an increased likelihood of smoking at 24 weeks postpartum. Using qualitative methods, we also explored how women who had returned to smoking by 24 weeks postpartum perceived their support. Our study builds on previous research by (1) assessing the influence of changes in postpartum perceived support from all social networks (family, friends, coworkers) on postpartum smoking, (2) combining quantitative measures of perceived support with qualitative reports of support, and (3) quantifying support received from obstetric clinicians.