Naturalistic changes in the readiness of postpartum women to quit smoking

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Abstract

Background

This study involves a long-term examination of the natural behavioral changes in postpartum women undergoing smoking cessation. The analysis was based on the readiness to quit smoking as assessed using the Transtheoretical Model of intentional behavioral change. This is a secondary data analysis of a randomized controlled trial.

Methods

Between May 2002 and March 2003, all women in the maternity wards of six hospitals in the German state of Mecklenburg-West Pomerania were screened for smoking before or during pregnancy. Of the women who answered in the affirmative, 871 (77%) participated in the study. We utilized a questionnaire to classify 345 women into stages of progress regarding their motivation to change their smoking behavior 4–6 weeks postpartum (T0). Participants were followed-up after 6 (T1), 12 (T2), and 18 months (T3). In addition to the descriptive analysis, latent transition analysis was applied as a statistical method to test models of patterns of change and to evaluate transitions in the stages of change over time.

Results

During the time interval between consecutive follow-up surveys, 59.1% (T0/T1), 72.3% (T1/T2), and 67.9% (T2/T3) of women remained at the same stage of motivation to change. Most relapses into earlier stages occurred 6 months postpartum (T1) (31.5% of the stage transition). The patterns of change across the first three time points were best described by a model that includes stability, one-stage progressions, and one-to-four-stage regressions.

Conclusions

Readiness to quit smoking in study participants did not substantially change over the span of 18 months postpartum.

Introduction

Pregnant women and mothers who smoke form a unique population of smoking women in general. The percentage of mothers who smoke during pregnancy in Germany and the United States is between 20% and 25% (Hannöver et al., 2008, Röske et al., 2008, Thyrian et al., 2005, U.S. Department of Health and Human Service, 2001, Voigt et al., 2001). In addition to negative effects on the mother's health, smoking during and after pregnancy can also affect unborn children and infants. These negative effects include premature delivery, reduced birth height and weight, and sudden infant death. In addition, children may suffer from respiratory tract diseases and parotitis due to maternal smoking or infantile second-hand smoke inhalation (U.S. Department of Health and Human Service, 2001). Therefore, it can be assumed that women are highly motivated to give up smoking during and after pregnancy. The rates of smokers who quit by the time of delivery vary according to socio-demographic factors, including education and age (Röske et al., 2008).

Women give up smoking during pregnancy predominantly to protect their unborn children (Edwards and Sims-Jones, 1998, Stotts et al., 1996). Smoking cessation is also linked to a loss of taste for tobacco and pregnancy nausea (Edwards and Sims-Jones, 1998, Johnson et al., 2000, O’Campo et al., 1992). However, these external motivational factors often result in a suspension of smoking behavior rather than a permanent cessation (DiClemente et al., 2000, Stotts et al., 1996, Stotts et al., 2000). Some women even state an intention to resume smoking (IRS) and do not intend to pursue life-long abstinence (Röske et al., 2006, Stotts et al., 2000). Of the women who quit smoking during pregnancy in the United States, France, and Germany, 50–70% resume smoking within 1 year postpartum (Colman and Joyce, 2003, Fingerhut et al., 1990, Lelong et al., 2001, Röske et al., 2006, Thyrian et al., 2005).

Little is known about the process underlying a pregnant woman's intentions to quit or continue smoking, especially regarding individual stages of psychological processes that occur while deliberating change. Two studies found that women who quit smoking during pregnancy applied less cognitive-affective and behavioral processes than non-pregnant women (Ruggiero et al., 2000, Stotts et al., 1996). Consequently, it seems plausible to assume that smoking women differ from the average smoker with regard to the process of behavioral change in this particular phase of their life. This would suggest the need to develop a special strategy for relapse prevention (Dolan-Mullen, 2004, Lawrence et al., 2005; Lawrence and Haslam, 2007, Lancaster et al., 2006, Redding et al., 2007, Ruggiero et al., 2003). In a study by Lancaster et al. (2006), the efficacy of relapse prevention programs after successful smoking cessation was analyzed. They found that no effective programs exist for preventing relapses after delivery.

The Transtheoretical Model of Health Behavior Change (TTM) has core constructs that include “stages of change”, “processes of behavioral change”, “decisional balance”, and “self efficacy” and offers a suitable theoretical basis for an investigation (Prochaska and Velicer, 1997). The applicability of TTM for smoking cessation and smoking prevention has been critically analyzed in various studies (Peipert and Ruggiero, 1998, Schumann et al., 2002, Schumann et al., 2006, Spencer et al., 2002, Sutton, 2001). Assumptions regarding the behavioral change process are made within the TTM (Martin et al., 1996). These are:

  • (1)

    The behavioral change process is, in most cases, not a temporal ordering process, which means that regressions to earlier (and already passed) stages may occur. The proposed stages are: precontemplation, contemplation, preparation, action and maintenance.

  • (2)

    The probability of progression towards the aim of smoking cessation is higher than regression.

  • (3)

    The probability of transition to a neighboring stage is higher than the transition to a non-neighboring stage.

In summary, smoking cessation during pregnancy seems to differ from smoking in general. To develop effective (stage-based) interventions, more research is needed to understand the process of behavioral change in women postpartum.

In this study, the process of natural behavioral changes toward smoking cessation was longitudinally examined in a sample of postpartum women. As such, we examined those women that had been assigned to the control group only. The assumptions of the TTM regarding the behavioral change process form the basis of the analysis in this study. In accordance with Martin et al. (1996), we generated our first hypothesis: (1) regressions occur in the behavioral change process of women postpartum. Diverting from Martin et al. (1996), we hypothesized that, (2) taking the high relapse rate and the findings of Ruggiero et al. (2000) and Stotts et al. (1996) into account, regressions will be observable more often than progressions and that (3) the probability for a change into a non-neighboring stage (e.g. from the stage of action to the stage of precontemplation) is higher than a change into a neighboring stage, since some of the women showed an intention to resume smoking (Röske et al., 2006, Stotts et al., 2000). Therefore, we analyzed the distribution of smokers by stage and assessed the stage transition longitudinally. We also sought to find a suitable model for the description of stage transition and also estimate the rates of naturalistic changes in readiness for smoking cessation. Martin et al. (1996) and Velicer et al. (1996) illustrated the use of latent transition analysis (LTA) as a special statistical technique for this purpose.

Section snippets

Design

The study we analyzed, “Smoking Cessation and Relapse Prevention Postpartum”, was a controlled randomized study with four follow-up examinations over a time period of 2 years (Thyrian et al., 2004). The aim was to test the effectiveness of an intervention based on the Transtheoretical Model of Behavior Change and motivational interviewing to prevent smoking relapse and provide support for abstinence in postpartum women (Thyrian et al., 2006).

On the maternity ward of each of six hospitals in

Longitudinal analysis of stage distribution

After analysis of the distribution of the stages at the different times of measurement 4–6 weeks after delivery (T0), most women were assigned to the maintenance stage (42.1%), and 36.7% of women were placed in the precontemplation stage. Six months after delivery (T1), the opposite was observed. Most women were assigned to the precontemplation stage (49.1%), followed by women in the maintenance stage (33.1%).

At 12 (T2) and 18 months postpartum (T3), more than half of the women interviewed were

Discussion

This study examined the natural intention to alter smoking behavior of women after delivery on the basis of the Transtheoretical Model of Health Behavior Change utilizing longitudinal data. The assumptions of the behavioral change process within the Transtheoretical Model were assessed. The distribution of the stages, models for stage transitions, and probabilities of transition of stage within the behavioral change process were analyzed over a period of 18 months. In accordance to our

Funding source

This study is part of the Research Collaboration in Early Substance use Intervention (EARLINT), has been funded by the German Federal Ministry of Education and Research (grants # 01EB0120, 01EB0420) and the Social Ministry of the State of Mecklenburg-West Pomerania (grant #. IX311a 406.68.43.05).

Role of the contributors

Grit Händel wrote the manuscript, oversaw all co-author-comments and edited all versions of the manuscript. She carried out all statistical analyses. Wolfgang Hannöver planned and carried out the study “Smoking cessation and relapse prevention in women postpartum” that constitutes the sample described in this manuscript. He conducted screenings on maternity wards and contributed to statistical analyses. Kathrin Röske conducted screenings for the study “Smoking cessation and relapse prevention

Conflict of interest

Conflicts of interest either financial or of any other nature are not existent for all authors of this manuscript.

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      Specifically, older age, lower education level, lower income, being unmarried, not having private medical insurance, being pregnant for the second or more time(s), higher smoking level before pregnancy, quitting smoking later during pregnancy, higher alcohol consumption, and living with people or having a partner who smokes have all been shown to be related to continued smoking or relapse after quitting (e.g., Colman and Joyce, 2003; Fingerhut et al., 1990; Kahn et al., 2002; McLeod et al., 2003; Severson et al., 1995). Additionally, there is evidence that internal psychological processes (i.e., intention or readiness to resume smoking) play a role in the process of relapse (Händel et al., 2009a,b; Röske et al., 2006). For example, women with the intention to resume smoking returned to smoking more often within 12 months postpartum than women without the intention to resume smoking, although both groups were at risk for relapse (Röske et al., 2006).

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