Lit Review (Results Section)
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Article9.pdf
Smoking Cessation and Relapse Among Pregnant African-American Smokers in Washington, DC
Ayman A. E. El-Mohandes • M. Nabil El-Khorazaty •
Michele Kiely • Marie G. Gantz
Published online: 8 June 2011
� Springer Science+Business Media, LLC (outside the USA) 2011
Abstract Smoking is the single most preventable cause
of perinatal morbidity. This study examines smoking
behaviors during pregnancy in a high risk population of
African Americans. The study also examines risk factors
associated with smoking behaviors and cessation in
response to a cognitive behavioral therapy (CBT) inter-
vention. This study is a secondary analysis of data from a
randomized controlled trial addressing multiple risks dur-
ing pregnancy. Five hundred African-American Washing-
ton, DC residents who reported smoking in the 6 months
preceding pregnancy were randomized to a CBT inter-
vention. Psycho-social and behavioral data were collected.
Self-reported smoking and salivary cotinine levels were
measured prenatally and postpartum to assess changes in
smoking behavior. Comparisons were made between active
smokers and those abstaining at baseline and follow-up in
pregnancy and postpartum. Sixty percent of participants
reported quitting spontaneously during pregnancy. In
regression models, smoking at baseline was associated with
older age,\a high school education and illicit drug use. At follow-up closest to delivery, smoking was associated with
lower education, smoking and cotinine level at baseline
and depression. At postpartum, there was a relapse of 34%.
Smokers postpartum were significantly more likely to
smoke at baseline and use illicit drugs in pregnancy.
Mothers in the CBT intervention were less likely to
relapse. African-American women had a high spontaneous
quit rate and no response to a CBT intervention during
pregnancy. Postpartum mothers’ resolve to maintain a quit
status seems to wane despite their prolonged period of
cessation. CBT reduced postpartum relapse rates.
Keywords Smoking � Pregnancy � African-Americans � Washington, DC
Introduction
Smoking during pregnancy is associated with problems of
placentation [1], low birthweight [2–8], prematurity [3, 9,
10], sudden infant death [10–12], infant mortality [12],
and later physical [13], developmental [13] and behav-
ioral [10, 14, 15] problems. A significant percentage of
smokers continue to smoke during pregnancy and are
unable to quit on their own despite their knowledge of the
risks involved. Existing behavioral interventions are only
modestly successful, having an attributable benefit of no
more than 10% above spontaneous quit rates among
pregnant women [16].
M. Nabil El-Khorazaty: Deceased.
Clinical trial registration: ClinicalTrials.gov, www.clinicaltrials.gov,
NCT00381823.
A. A. E. El-Mohandes
College of Public Health, University of Nebraska Medical
Center, Omaha, NE, USA
M. N. El-Khorazaty � M. G. Gantz RTI International (RTI International is a trade name of Research
Triangle Institute), Rockville, MD, USA
M. Kiely
National Institutes of Health, Bethesda, MD, USA
M. Kiely (&) Epidemiology Branch, Division of Epidemiology, Statistics and
Prevention Research, Eunice Kennedy Shriver National Institute
of Child Health and Human Development, National Institutes
of Health, 6100 Executive Blvd, Rm. 7B-05, Rockville,
MD 20852-7510, USA
e-mail: [email protected]
123
Matern Child Health J (2011) 15:S96–S105
DOI 10.1007/s10995-011-0825-6
Success in smoking cessation during pregnancy may be
different among different ethnic groups. In one study,
Mexican–Americans had three times higher cessation rates
than non-Hispanic whites [17]. Only a few studies in the
literature describe African-American smoking behaviors
during pregnancy and postpartum, and even fewer tested the
efficacy of smoking cessation interventions programs in that
population. Although smoking rates during pregnancy are
lower among African Americans, genetically mediated dif-
ferences in nicotine metabolism are associated with higher
nicotine levels among African Americans compared to
whites [18].
High rates of low birthweight and prematurity in Afri-
can-Americans may be partly attributable to smoking in
pregnancy [19], either independently or as a complicating
factor for other medical risks including chronic hyperten-
sion. Although contested by some authors in the literature
[20], the effect of smoking on poor birth outcomes has been
estimated as high as 14.4% among black births [21]. To
improve birth outcomes among African-Americans, there
is a need to better understand their smoking behaviors in
pregnancy and postpartum, including spontaneous cessa-
tion and relapse rates, associated variables impacting on
these rates, and responses to behavioral interventions.
This study is a secondary analysis of a larger randomized
controlled trial (RCT) addressing multiple risks during
pregnancy. The main results of the RCT have been published
elsewhere [22, 23]. This paper investigates smoking cessa-
tion and relapse rates among African American women
reporting smoking in the 6 months preceding pregnancy in
Washington, DC Women were recruited during pregnancy
and followed through the postpartum period and randomized
to an integrated cognitive behavioral intervention addressing
smoking, environmental tobacco smoke exposure (ETSE),
depression, and intimate partner violence (IPV).
Method
Study Population
The population recruited to this study was part of a larger
cohort recruited to the District of Columbia Healthy Out-
comes of Pregnancy Education (DC-HOPE), under the
umbrella of the National Institutes of Health-District of
Columbia Initiative to Reduce Infant Mortality in Minority
Populations. DC-HOPE was a randomized controlled trial
evaluating the efficacy of an integrated cognitive behav-
ioral intervention targeting cigarette smoking, environ-
mental tobacco smoke exposure (ETSE), intimate partner
violence (IPV) and depression during pregnancy. Mothers
were eligible if they were 18 years or older, English-
speaking, less than 29 weeks gestation and Washington,
DC residents. Women were recruited from six prenatal care
sites and were screened using an audio-computer assisted
self-interview (A-CASI) (For details see El-Khorazaty
et al. [24]). Recruitment occurred between July 2001 and
October 2003 and followed through July 2004. Baseline
interviews for eligible women occurred on average 9 days
after screening. IRB approval was obtained from all par-
ticipating institutions.
There were 2,913 women screened and 1,515 were
ineligible. Of the 1,398 eligible women, 1,070 enrolled as
eligible minority participants. (See Fig. 1) 1,044 women
were included in these analyses; they self-identified as
African-American. Eligible women consented for ran-
domization into the intervention or usual care group. Per-
muted block randomization was site- and risk-specific. The
field staff were blinded with respect to the block size. Eight
women (6 intervention and 2 usual care) were identified as
suicidal during intervention or data collection and were
referred immediately to mental health care and excluded
from further participation. Five hundred women were
screened into the study as having smoked a puff of a cig-
arette or more in the 6 months preceding pregnancy. This
level was chosen to be as inclusive as possible because
these women were at risk for continuing to smoke or
relapsing if they had quit early in pregnancy.
Data and Saliva Sample Collection
Data on sociodemographic and behavioral risk were col-
lected during a baseline telephone interview, on average
within 9 days of screening. Follow-up telephone interviews
were conducted during the second and third trimesters
(22–26 weeks and 30–34 weeks, respectively) and 8–10
weeks postpartum to evaluate changes in the psycho-
behavioral risks. Interviewers were blinded to whether
women were in the intervention or usual care group.
Smoking risks during pregnancy and postpartum were
measured based on self-report. Saliva samples were col-
lected at the prenatal care site on average within 19 days
following the baseline interview, within a week from the
follow-up telephone interview and 23 days following the
postpartum interview. Salivary cotinine was measured by a
radio-immune assay using gas chromatography-mass
spectrometry (GC/MS) with lower detection limits of
10 ng/ml. IPV was measured using the Revised Conflict
Tactics Scale physical assault and sexual coercion sub-
scales [25]. Depression was measured using the 20-item
Hopkins Symptom Checklist-Depression Scale [26].
Intervention
Of the 500 women included in these analyses, 262 were
randomized to the intervention group and 238 were
Matern Child Health J (2011) 15:S96–S105 S97
123
randomized to usual care. This integrated intervention was
based on a conceptual framework of overlapping and
interactive behavioral risks. Such risk factors are known to
co-occur within a population of urban African-Americans
living in communities with high poverty rates. The risks
selected are all associated with poor pregnancy outcomes
[27]. The smoking intervention was delivered to women
who self-reported as smokers and not on a cutoff cotinine
level since randomization was based on the initial response
to the A-CASI.
The 10-session intervention was delivered during pre-
natal (8 sessions) and postpartum (2 booster sessions) care
visits. Four prenatal sessions were considered minimal
adherence. The session duration was approximately
35 min. The smoking intervention was consistent with the
Smoking Cessation or Reduction in Pregnancy Trial
(SCRIPT) and the Counseling and Behavioral Interventions
Work Group of the United States Preventive Services Task
Force recommendations, a five-step behavioral counseling
approach [28, 29]. The intervention was tailored to the
woman’s stage of change. Women were encouraged to
avoid triggers and to use alternative coping and behavioral
change strategies. The intervention included content to
address both active smoking and ETSE, whether or not
they met criteria for ETSE.
The intervention sessions also addressed the other
associated risks. For depression, the intervention focused
on secondary prevention of symptoms in pregnancy and
extended into the postpartum period. Cognitive behavioral
therapy strategies for mood management, increasing posi-
tive social interactions, and pleasurable activities were
emphasized. The IPV interventions used the Parker’s
model to address the role of a negative partner support
[30]. Danger assessment to identify risks for harm and
prevention options were considered along with the devel-
opment of a safety plan. (For more details see Katz et al.
[27]). All measures were based on validated questionnaires.
Statistical Analysis
Women who were screened as having smoked a puff of a
cigarette or more in the 6 months preceding pregnancy
were compared according to their self-reported smoking
status at baseline interview, last follow-up interview
prior to delivery, and postpartum interview conducted
8–10 weeks after delivery. Comparisons were conducted
by means of Chi-square tests for binary variables and t tests
for continuous variables.
Based on the results of these bivariate comparisons, we
used logistic regression procedures to model the probabil-
ity of cigarette smoking at each of the three time points
controlling for covariates with P value \0.10 in the bivariate analyses. For control variables with a strong
colinearity, we selected the variables with the highest level
Fig. 1 Profile of project DC-HOPE randomized controlled trial
S98 Matern Child Health J (2011) 15:S96–S105
123
of significance or the greatest biological plausibility.
Control variables included alcohol and illicit drug use
during pregnancy, depression, IPV, prior smoking status,
cotinine levels, and the intervention. Variables descriptive
of demographic and socioeconomic status (maternal age,
education level, and Medicaid enrollment) were included
as covariates so their cumulative effects could be accoun-
ted for in the final logistic model. We used the LOGISTIC
procedure in SAS version 9.1.3 (SAS Institute, Cary, NC)
to conduct the analysis.
Results
Of the 500 mothers reporting cigarette smoking at
screening, data were available on 396 at a follow-up
interview prior to delivery and 384 mothers were inter-
viewed in the postpartum period. No significant differences
between the 500 and the 396 or 384 were seen in any
sociodemographic or behavioral characteristics at baseline.
(Data not shown) No significant differences were noted
between the intervention and usual care groups regarding
sociodemographic or behavioral characteristics at baseline.
Among the 500 women who reported smoking at A-CASI
screening and were included in these analyses, 39%
reported active smoking at baseline. An earlier paper from
our study showed that women who reported smoking at
A-CASI screening were significantly less likely to resolve
risk (smoking, ETSE, depression and IPV) during preg-
nancy [22].
A significant difference was noted in salivary cotinine
levels collected at baseline between mothers who self-
identified as smokers and non-smokers (179 ± 156 ng/ml
vs. 32 ± 59 ng/ml, P \ 0.001). At baseline 86.4% of women who reported themselves as non-smokers had a
salivary cotinine level \50 ng/ml and 90.3% \100 ng/ml. In a logistic regression model, the factors that remain
significantly associated with smoking at baseline are
reviewed in Table 4A. Older maternal age, education at
less than high school level and illicit drug use as reported
by mothers at baseline were the factors significantly asso-
ciated with smoking at baseline (Table 1).
At follow-up prior to delivery, 34% of mothers reported
smoking. A significant difference was noted in salivary
cotinine levels collected at that time between those
reporting smoking or not (135 ± 145 ng/ml vs.
28 ± 57 ng/ml, P \ 0.001). 83.5% of the women who reported themselves as non-smokers had a salivary cotinine
level\50 ng/ml and 88.5% had a level\100 ng/ml. Of the women reporting smoking during the follow-up interview,
13.0% had not been smoking at baseline and represented a
relapse. Similarly, 12.8% of non-smokers had smoked at
baseline but quit at a later stage of pregnancy. There was
no significant interventional effect on smoking behavior as
reported in the follow-up interviews during pregnancy.
Women who continued to smoke during pregnancy were
significantly older, had a lower level of education attain-
ment, and had higher rates of enrollment in Medicaid.
These women were also more likely to have reported
alcohol and illicit drug use during the baseline interview
and higher baseline cotinine levels. Depression at baseline
was a predictor of smoking at follow-up, while IPV was
not. Depression and IPV confirmed during the follow-up
interview were associated with smoking. No significant
differences were seen between the characteristics of
smokers randomized to the intervention group and those in
usual care (Table 2).
In a logistic regression model (Table 4B), the factors
that retained significant association with continued smok-
ing at follow-up were active smoking at baseline and sal-
ivary cotinine levels at baseline. Depression at the follow-
up period preceding delivery was also predictive of active
smoking during the same time period.
In the postpartum period, 50% of participants self-
reported as actively smoking. Salivary cotinine levels were
significantly higher in women reporting active smoking
(249 ± 176 ng/ml vs. 109 ± 149 ng/ml, P \ 0.001). Only 60.4% of the women who reported themselves as non-
smokers had a salivary cotinine level \50 ng/ml, and 64.4% had cotinine levels \100 ng/ml. The intensity of
Table 1 Women screening positive for smoking before pregnancy: baseline assessment
Characteristic Smoking
(n = 195)
Not smoking
(n = 305)
P value
Maternal age
(mean ± SD)
26.9 ± 6.3 23.6 ± 4.5 \0.001
Pregnancies (incl. current)
(mean ± SD)
4.8 ± 2.9 3.5 ± 2.2 \0.001
Previous live births
(mean ± SD)
2.2 ± 1.9 1.2 ± 1.4 \0.001
Relationship status: 0.770
Single/separated/
widowed/divorced
152 (78.0%) 241 (79.0%)
Married/living with
partner
43 (22.0%) 64 (21.0%)
Education level: 0.002
\High school 91 (46.7%) 97 (31.8%) High school/GED 79 (40.5%) 147 (48.2%)
Some college or more 25 (12.8%) 61 (20%)
Medicaid recipient 174 (89.2%) 241 (79.3%) 0.004
Alcohol use 68 (34.9%) 72 (23.7%) 0.007
Illicit drug use 54 (27.7%) 47 (15.4%) \0.001 Depression 102 (52.3%) 129 (42.3%) 0.029
Intimate partner violence 73 (37.4%) 89 (29.2%) 0.054
Matern Child Health J (2011) 15:S96–S105 S99
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smoking in the postpartum was significantly higher than
during the two preceding time points as confirmed by
cotinine levels. Among postpartum smokers salivary coti-
nine levels were significantly higher than the baseline
levels (P \ 0.001) or the levels at follow-up closest to delivery (P \ 0.001). Of the women reporting smoking postpartum, 34% had not reported smoking during the
follow-up interview during pregnancy. This group was
considered postpartum relapsers. A much smaller per-
centage (7.4%) of women not reporting smoking post-
partum had reported smoking during pregnancy. A higher
likelihood of smoking postpartum was associated in
bivariate analysis with older age, higher gravidity and
parity, lower educational attainment, higher Medicaid
enrollment, other substance use, active smoking at baseline
and follow-up (Table 3). Depression documented at base-
line, during follow-up interviews or in the postpartum was
significantly associated with active smoking. IPV did not
show a similar association at any of the three time points.
The intervention for the first time showed an association
with reported smoking abstinence in the postpartum period,
at a P value of 0.053.
In a logistic regression model, factors that increased the
likelihood of reported smoking in the postpartum were
active smoking as reported by mothers and cotinine levels
at baseline and illicit drug use during pregnancy. The
intervention had a significant protective effect against
smoking in the postpartum period (Table 4C).
Discussion
The results of this study confirm the difficulty pregnant
mothers who smoke have in quitting during pregnancy.
Mothers included in our study that were less educated,
depressed or using illicit substances were least likely to
quit. The literature emphasizes the underlying demographic
and psychosocial factors that impact smoking behaviors
among African-American women [31]. In spite of findings
that African-Americans were significantly more likely than
Table 2 Women screening positive for smoking before pregnancy: baseline smokers randomized to intervention versus usual care
Characteristic Intervention (n = 105) Usual care (n = 90) P value
Maternal age (mean ± SD) 26.9 ± 6.5 26.8 ± 6.1 0.930
Pregnancies (incl. current) (mean ± SD) 4.8 ± 3.1 4.7 ± 2.6 0.948
Previous live births (mean ± SD) 2.2 ± 2.1 2.2 ± 1.7 0.991
Relationship status: 0.522
Single/separated/widowed/divorced 80 (76.2%) 72 (80.0%)
Married/living with partner 25 (23.8%) 18 (20.0%)
Education level: 0.765
\High school 51 (48.6%) 40 (44.4%) High school/GED 42 (40.0%) 37 (41.1%)
Some college or more 12 (11.4%) 13 (14.4%)
Medicaid recipient 95 (90.5%) 79 (87.8%) 0.545
Alcohol use 39 (37.1%) 29 (32.2%) 0.472
Illicit drug use 28 (26.7%) 26 (28.9%) 0.730
Active smoking at follow-up 62 (74.7%) 54 (78.3%) 0.607
Active smoking at postpartum 64 (83.1%) 67 (91.8%) 0.111
Cotinine level at baseline (mean ± SD) 192.9 ± 165.0 162.4 ± 144.6 0.216
Cotinine level at follow-up (mean ± SD) 146.0 ± 139.4 131.9 ± 117.6 0.528
Cotinine level at postpartum (mean ± SD) 290.8 ± 182.7 236.1 ± 162.2 0.103
ETSE at baseline 89 (87.3%) 75 (84.3%) 0.555
ETSE at follow-up 66 (80.5%) 52 (75.4%) 0.448
ETSE at postpartum 58 (74.4%) 56 (78.9%) 0.516
Depression at baseline 57 (54.3%) 45 (50.0%) 0.550
Depression at follow-up 39 (47.0%) 34 (49.3%) 0.779
Depression at follow-up postpartum 23 (29.9%) 23 (31.5%) 0.828
Intimate partner violence at baseline 38 (36.2%) 35 (38.9%) 0.698
Intimate partner violence at follow-up 8 (9.8%) 6 (8.7%) 0.823
Intimate partner violence at postpartum 6 (7.8%) 7 (9.6%) 0.696
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whites to express a desire to quit smoking [32] it is not
clear what barriers prevent them from quitting. None of the
studies meeting the guidelines for inclusion in the Public
Health Service Report [33] specified abstinence rates by
racial/ethnic group [34]. The only studies that report on the
results of smoking cessation interventions during preg-
nancy by race come to opposite conclusions [35, 36].
Studies examining smoking cessation interventions during
pregnancy published since the Public Health Service
Report did not report their spontaneous cessation and
relapse rates in pregnancy and postpartum by race/ethnic-
ity, or found no differences in rates by race [37–41].
Our results agree with previous authors showing a sig-
nificant spontaneous cessation rate among smokers who
become pregnant [42, 43]. The quit rate of more than 60%
in our population of urban African-American pregnant
women experiencing other socioeconomic and psycholog-
ical stressors is encouraging. Notably, amongst this popu-
lation of smokers women who reported quitting during
pregnancy experienced a high rate of depression (42%) and
IPV (29%) throughout the pregnancy. Almost one-third of
these women who reported quitting on their own had not
completed high school, and the majority were Medicaid
enrollees. It is hard to determine whether the social desir-
ability of quitting during pregnancy within this community,
and/or the knowledge of the detrimental effects of smoking
on the fetus could have been the main driving force.
The underlying depressive symptoms in our study pop-
ulation may have interfered with their ability to control
their smoking. There is a growing awareness of the prev-
alence of depressive symptoms within the smoking popu-
lation, with a range of 22–61% amongst those entering
smoking cessation programs [44–46]. The literature is
mixed regarding the effect of depression on the success of
smoking cessation. One may infer that depression inter-
feres with short term quit rates and not long-term success in
smoking cessation [47, 48]. In the logistic analyses we
conducted at three time points, depression was predictive
Table 3 Women screening positive for smoking before pregnancy: postpartum assessment
Characteristic Smoking (n = 191) Not smoking (n = 193) P value
Maternal age (mean ± SD) 25.9 ± 6.0 24.0 ± 4.9 \0.001 Pregnancies (incl. current) (mean ± SD) 4.5 ± 2.6 3.3 ± 2.2 \0.001 Previous live births (mean ± SD) 2.0 ± 1.9 1.2 ± 1.4 \0.001 Relationship status: 0.957
Single/separated/widowed/divorced 149 (78.0%) 151 (78.2%)
Married/living with partner 42 (22.0%) 42 (21.8%)
Education level: \0.001 \High school 89 (46.6%) 55 (28.5%) High school/GED 79 (41.4%) 96 (49.7%)
Some college or more 23 (12.0%) 42 (21.8%)
Medicaid recipient 172 (90.1%) 149 (77.6%) \0.001 Alcohol use 67 (35.1%) 43 (22.4%) 0.006
Illicit drug use 57 (29.8%) 23(11.9%) \0.001 Active smoking at baseline 131 (68.6%) 19 (9.8%) \0.001 Active smoking at follow-up 100 (64.5%) 8 (4.7%) \0.001 ETSE at baseline 159 (85.0%) 134 (70.5%) \0.001 ETSE at follow-up 115 (74.7%) 95 (55.6%) \0.001 ETSE at postpartum 147 (79.0%) 97 (51.1%) \0.001 Cotinine level at baseline (mean ± SD) 143.3 ± 155.4 36.3 ± 73.1 \0.001 Cotinine level at follow-up (mean ± SD) 122.3 ± 128.6 33.7 ± 75.0 \0.001 Cotinine level at postpartum (mean ± SD) 248.8 ± 176.0 109.3 ± 149.2 \0.001 Depression at baseline 98 (51.3%) 82 (42.5%) 0.008
Depression at follow-up 78 (50.3%) 59 (34.3%) 0.003
Depression at postpartum 62 (32.6%) 42 (21.8%) 0.017
Intimate partner violence at baseline 73 (38.2%) 57 (29.5%) 0.072
Intimate partner violence at follow-up 16 (10.3%) 11 (6.4%) 0.200
Intimate partner violence at postpartum 22 (11.6%) 15 (7.8%) 0.210
Intervention group 88 (46.1%) 108 (56.0%) 0.053
Matern Child Health J (2011) 15:S96–S105 S101
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of smoking during the follow-up period during pregnancy
but neither at baseline nor postpartum.
Other studies have confirmed the effect of psychosocial
challenges as a mediator of smoking in pregnancy [49, 50].
Alcohol and illicit drug use in the Washington, DC residents
we recruited may have also interfered with their ability to
quit. The relationship between alcohol use and smoking
during pregnancy has been previously confirmed, although
not in an exclusively African-American population [51].
Studies have shown smoking cessation in alcohol drinkers
to be more difficult due to reactivity between alcohol and
nicotine withdrawal [52, 53]. In our logistic models, alcohol
effect was not seen to be significantly associated with
smoking at any of the three time points. Illicit drug use
significantly increased the chances of smoking at baseline
and during the postpartum period. Illicit drug use may have
served as a surrogate for the severity of addiction to nico-
tine, a reliable marker for maintenance of smoking and
failure of cessation attempts among African-Americans
[54]. This is confirmed by our findings that active smoking
at baseline and cotinine level at baseline, markers for
intensity of smoking, were both predictors of smoking
during the follow-up interview closest to delivery and
postpartum. Other studies show similar results using
reported number of cigarettes smoked early in pregnancy as
a marker for intensity of smoking [40].
The literature shows an association between poverty and
smoking during pregnancy and postpartum [51, 55, 56]. In
this study we used Medicaid enrollment as a marker for
poverty. In bivariate analyses, Medicaid was a significant
predictor of smoking during the three time points. In the
logistic models, Medicaid lost its significance and a low
level of education was only significantly associated with
smoking at baseline. However, other studies have shown
that education is negatively associated with smoking dur-
ing pregnancy and with relapse after delivery [57]. It is
plausible that level of education may influence the
knowledge base mothers draw upon in their decision
making during pregnancy. A more compelling argument
would be a high resilience in mothers attaining higher
educational levels under challenging living conditions in
environments of urban poverty. Such women may also
possess a higher level of self-efficacy proven to impact
significantly on successful smoking cessation [40]. Women
with higher levels of education may be products of a more
supportive social environment, which is known to influence
successful quitting during pregnancy as well [39].
Some women may quit early in pregnancy due to
physical aversion to tobacco smoke during the first tri-
mester [58]; these pregnant mothers may then be suscep-
tible to relapse at a later stage. Our results show relapse
during pregnancy as reported by the population we studied
(13%) to be lower than previously reported in the Canadian
study (21%) [43]. In fact, the reported smoking rates in our
population declined from 39% at baseline to 33% during
follow-up.
The postpartum period represents a different challenge,
where a high percentage of women resume smoking after a
prolonged period of cessation. The literature cites media-
tors to resumed smoking such as postpartum depression
and concerns related to weight gain [59, 60]. Although this
has not been studied in populations that are predominately
Table 4 Logistic regression models to predict active
smoking among pregnant
women at baseline, follow-up,
and postpartum
a This model also controlled for
Medicaid status, alcohol use
during pregnancy, depression at
baseline and IPV at baseline b This model also controlled for
maternal age, education,
Medicaid enrollment status,
alcohol and illicit drug use
during pregnancy and IPV at
follow-up c This model also controlled for
maternal age, education,
Medicaid enrollment status,
alcohol, depression at
postpartum and IPV at baseline
Characteristic Odds ratio 95% Confidence interval
(A) Active smoking at baselinea
Maternal age 1.14 1.10, 1.18
Education level:
\High school 2.43 1.30, 4.54 Completed high school or GED 1.36 0.75, 2.47
At least some college (reference) 1.00 –
Illicit drug use 2.09 1.27, 3.44
(B) Active smoking at follow-upb
Active smoking at baseline 18.54 8.63, 39.84
Cotinine level at baseline (10 ng/ml) 1.09 1.05, 1.13
Depression at follow-up prior to delivery 2.69 1.27, 5.68
(C) Active smoking at postpartumc
Active smoking at baseline 10.89 5.28, 22.47
Cotinine level at baseline (10 ng/ml) 1.04 1.01, 1.08
Illicit drug use 2.38 1.11, 5.12
Intervention group 0.45 0.25, 0.80
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123
black, in a study based on the Pregnancy Risk Assessment
Monitoring system, postpartum relapse was significantly
more likely among black mothers [59]. It is also possible
mothers are less aware of the harms of ETSE to infants as
compared to in utero exposure. The added stress of par-
enting a newly born infant, especially among mainly single
mothers with limited social network and community sup-
port, may trigger the need for stress relief associated with
smoking [49]. Sixty-five percent of women who quit during
pregnancy will relapse by 3 months and an additional 10%
by 6 months postpartum [61]. Other studies show that of
those who quit smoking during pregnancy, half relapse at
2–6 months [62] and 60–70% relapse within 1 year [63]
after delivery. In our study, women who reported actively
smoking increased from 33 to 50% during our follow-up
period of 10 weeks postpartum.
Few studies address the efficacy of interventions tar-
geting reduction of postpartum relapse [64, 65]. We were
encouraged this integrated intervention did impact on
relapse rates reported postpartum. This could be explained
by a longer exposure to the intervention, but also the
emphasis on ETSE as a significant risk to the newborn
infant, which may have encouraged mothers to maintain
their quit status. In addition, emphasis on mood regulation
could have assisted mothers in dealing with postpartum
depression and the stress associated with caring for a
newborn. Previous studies showing similar success post-
partum emphasized interventions including partners and
close friends, and encouraging the social networks to
support the mother in her decision [66, 67]. Although our
intervention did not address either of these strategies
directly, it encouraged women to establish a supportive
social network, and as such may have had similar effects.
Furthermore, studies emphasize the postpartum success of
interventions if they start earlier in pregnancy [67], which
was our case.
The strength and limitation of our study is that it was
conducted with high-risk African American women. The
results cannot be generalizable to other populations without
corroboration. Although the intervention did not influence
smoking behavior significantly during the pregnancy, it had
a protective effect against relapse during the postpartum.
This study also confirmed the importance of associated
addictions to illicit drugs and co-occurring depression as
important associations with smoking during pregnancy in
this population. More qualitative research to examine why
African American women may or may not be inclined to
stop smoking in pregnancy may inform research in the
future in the design of appropriate interventions with effi-
cacy in this population.
The results of this study support the importance of
screening early in pregnancy and providing mothers
with opportunities for behavioral modification through
culturally informed interventions. Behavioral interventions
for smoking should be available but cannot be relied upon
alone as the intervention of choice for mothers who con-
tinue to smoke during pregnancy. More research is needed
to test efficacy and safety of pharmacological therapy with
proven efficacy in non-pregnant populations. Studies such
as ours emphasize the importance of expanding prenatal
care beyond the medical model in order to respond to the
complex health risks of minority populations during
pregnancy.
Acknowledgments The authors wish to thank the field work staff, the interviewers, and data management staff. We wish to thank the
participants who welcomed us into their lives in hopes of helping
themselves and their children. This work was supported by grants no.
3U18HD030445; 3U18HD030447; 5U18HD31206; 3U18HD031919;
5U18HD036104, Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Center on Minority
Health and Health Disparities, National Institutes of Health, Depart-
ment of Health and Human Services. These analyses were supported,
in part, by the intramural program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Conflict of interest None of the authors have any conflict of interests to declare.
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