Risk Factors for Smoking Cessation Relapse After Pregnancy

1. Risk Factors for Smoking Cessation Relapse After Pregnancy Elizabeth Clark, MD, MPH (1,2) Kenneth D. Rosenberg, MD, MPH (1, 3) (1) Oregon Health & Science University, Portland, Oregon (2) University of Iowa College of Medicine, Iowa City, Iowa (3) Oregon DHS Office of Family Health, Portland, Oregon 9th Annual Maternal and Child Health Epidemiology Workshop, Tempe, AZ December 10, 2003

2. Introduction • Maternal smoking associations: • Effects during Pregnancy • Low Birth Weight (growth retardation) • Effects in Infancy • Increased SIDS • Effects in Childhood and Adolescence • Increased hyperactivity (ADHD) • Increased alcohol & drug use as adolescent • Decreased child IQ • Increased asthma

3. Methods • Oregon PRAMS (Pregnancy Risk Assessment Monitoring System), 1998-99 Stratified random sample of Oregon women a few months after live birth (from birth certificates) • Response Rate = 64.0% (1867/2917) • Questions: Smoking Before Pregnancy Smoking During Pregnancy (in the third trimester) Smoking After Pregnancy (at the time of the PRAMS survey)* * Days after birth: mean=106.5; Standard deviation=27.2

4. Results • 1867 women in sample • 454 women (24.3%) smoked before pregnancy • 229 (50.4% of the smokers) successfully quit during pregnancy • Among the 229 who successfully quit during pregnancy • 91 (39.7%) of the quitters relapsed after delivery • 135 (59.0%) of the quitters did not smoke after pregnancy (stayed quit)

5. Results: Risk Factors for Relapse • Among the women who quit smoking during pregnancy, risk factors for relapse (Odds Ratio, 95% CI): Bivariate Multivariate • Living with other smokers 3.32 (1.38, 8.00) 3.13 (1.28, 7.65) • Multiparous 2.60 (1.10, 6.14) 2.28 (0.94, 5.58) • Medicaid (at L&D) 2.24 (0.96, 5.23) • Unmarried 1.83 (0.78, 4.32) • Black race 1.55 (0.63, 3.80) • Teen mother (<20 yrs) 0.86 (0.31, 2.40)

6. Conclusions • Half of smoking women successfully quit smoking during pregnancy • 60% of women who quit smoking during pregnancy were still quit at time of survey • Women who lived with other smokers were less likely to stay quit

7. Discussion • We found that living with other smokers is the strongest risk factor for relapse. • Programs to decrease smoking among pregnant women should include partners • Women are more likely to stay quit for their first baby than for subsequent babies.

8. Discussion • Pregnant women who are internally motivated to quit (for themselves) are more likely to stay quit postpartum than women who are externally motivated to quit (for their baby)* *Stotts AL et al. Pregnancy smoking cessation: a case of mistaken identity. Addictive Behaviors. 1996;21;459-471.

9. Discussion • Limitations • Mean time from delivery to survey is less than 4 months (106.5 days) so stay-quit rate is higher than 6-month stay-quit rates (e.g., Mullen PD, et al. Maintenance of non-smoking postpartum by women who stopped smoking during pregnancy. Am J Public Health 1990;80:992-994). • Recall bias • Strengths • Survey method better than birth certificate or face-to-face interview

10. Public Health Implications • More federal support for programs that help pregnant women quit and stay quit. • Women who live with other smokers need extra social support to quit and stay quit. • Replicate 5As Screening for prenatal care providers: Ask, Advise, Assess, Assist, Arrange [www.smokefreefamilies.org]. • Use of 5As can cause lower relapse rates at one year postpartum.* *Secker-Walker RH, et al. Amer J Prev Med;1998:25-31

11. Acknowledgments • Alfredo P. Sandoval • Lesa Dixon-Gray