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Original Investigation
April 2016

Preventing Postpartum Smoking RelapseA Randomized Clinical Trial

Author Affiliations
  • 1Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 2Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 4Duquesne University School of Nursing, Pittsburgh, Pennsylvania
JAMA Intern Med. 2016;176(4):443-452. doi:10.1001/jamainternmed.2016.0248

Importance  Most women who quit smoking during pregnancy will relapse postpartum. Previous efforts to prevent postpartum relapse have been unsuccessful at increasing rates of sustained abstinence.

Objective  To evaluate the relative efficacy of 2 different approaches to prevent postpartum smoking relapse.

Design, Setting, and Participants  Pregnant women who recently had quit smoking were recruited before the end of pregnancy. Intervention sessions were conducted through a combination of telephone calls and in-person visits beginning at delivery and continuing through 24 weeks postpartum. Participants completed assessments at the prenatal baseline and at 12, 24, and 52 weeks postpartum. Participants were recruited between March 2008 and December 2012. The dates of the analysis were April 2014 to February 2015.

Interventions  Women received postpartum-adapted, behavioral smoking relapse prevention intervention and were randomly assigned to an enhanced cognitive behavioral intervention that included additional specialized strategies and content focused on women’s postpartum concerns about mood, stress, and weight (Strategies to Avoid Returning to Smoking [STARTS]) or a supportive, time and attention–controlled comparison (SUPPORT). Intervention began before delivery and continued through 24 weeks postpartum.

Main Outcomes and Measures  The primary outcome was biochemically confirmed sustained tobacco abstinence at 52 weeks postpartum. Secondary outcomes were self-reported mood, levels of perceived stress, and degree of concern about smoking-related weight gain.

Results  The study cohort comprised 300 participants (150 randomly assigned to each group). Their mean (SD) age was 24.99 (5.65) years. Overall, 38.0% (114 of 300), 33.7% (101 of 300), and 24.0% (72 of 300) of the sample maintained abstinence at 12, 24, and 52 weeks’ postpartum, respectively. There were no differences between the intervention groups in abstinence or time to relapse. Self-reported depressive symptoms and perceived stress significantly improved over time, and improvements were similar for both intervention groups. Women with more depressive symptoms and higher levels of perceived stress were more likely to relapse (hazard ratio, 1.02; 95% CI, 1.00-1.04; P = .04 for depressive symptoms and hazard ratio, 1.04; 95% CI, 1.01-1.07; P = .003 for stress).

Conclusions and Relevance  An intervention designed to address women’s concerns about mood, stress, and weight did not differentially improve rates of sustained tobacco abstinence postpartum compared with a time and attention–controlled comparison. Women in STARTS and SUPPORT reported postpartum improvements in mood and stress, and the experience of fewer depressive symptoms and less perceived stress was related to sustained abstinence. Given that most pregnant quitters will relapse within 1 year postpartum and that postpartum smoking has negative health consequences for women and children, effective interventions that target postpartum mood and stress are needed.

Trial Registration  clinicaltrials.gov Identifier: NCT00757068