Adapting Smoking Relapse Prevention Materials for Pregnant and

Adapting Smoking Relapse Prevention Materials for Pregnant and Postpartum Women Gwendolyn P. Quinn, Ph. D.

Pregnancy and Smoking The majority of pregnant women (except for this one in the photo) are aware that smoking has deleterious effects on unborn children

Pregnancy and Smoking is associated with ectopic pregnancy, premature birth, low-birth weight and placental complications Health risks to the unborn child of a smoker remain a factor after birth – postpartum smoking is linked to sudden infant death syndrome, ear infections, and asthma

Pregnancy and Smoking While most mothers are aware of the dangers of smoking during pregnancy, less are aware of how these health risks prevail after the birth of their child. Pregnant women are often highly motivated to quit smoking during the pregnancy and tend to report an easier time quitting than non-pregnant women

Pregnancy and Smoking Because pregnant women report having an easier time quitting (higher motivation and reduced cravings and withdrawal symptoms) they tend to quit spontaneously and without a plan. This lack of planning may account for the relapse rate of 70 -85% among postpartum women

Pregnancy and Smoking The purpose of this study was to gain formative research data on the barriers and facilitative factors of using existing, theoretically based, empirically supported relapse prevention materials, as they were adapted to meet the unique needs of pregnant and postpartum women.

Forever Free The Forever Free relapse prevention program is a series of eight empirically based booklets, validated in two clinical trials to reduce relapse among adult former smokers. Brandon, T. et al. Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: Dismantling the effects of content versus contact. J consult Clin Psychol 2004; 72 (5) 797 -808.

Forever Free The Forever Free materials are distinct in that their focus is not on smoking cessation, but rather on preventing relapse among former smokers who have already quit or attempted to.

Methods Semi-structured interviews were conducted with 38 women who were: l l l 18 or older A smoker for at least a year Stopped smoking before or during pregnancy Been abstinent at least two months during pregnancy No sooner than 5 months pregnant and no more than 8 months postpartum

Recruitment Recruiting women for the study was a challenge. We placed ads in newspapers, posted flyers in grocery and baby stores, worked through local health depts. , OB and pediatrician offices. Women were reluctant to admit to being a smoker at any time during the pregnancy

Participants The resulting sample was comprised of 22 white, 5 Asian, and 10 black women who represented the three categories of: l l l (PA) Pregnant Abstinent – at least 6 months pregnant and not smoking (PPA) Postpartum Abstinent – within 8 months postpartum and not smoking (PPR) Postpartum Relapsed – within 8 months postpartum and relapsed to smoking

Semi-structured interviews Qualitative interviews were conducted in private rooms of the research office, or at the participants homes. Child care and $25 compensation was provided The interview guide was developed based on common cessation and relapse factors in the literature as well as a review of the Forever Free booklets. One of the goals of the project was to ask the women for input in adapting the existing materials to meet the needs of pregnant and postpartum women

Data Analysis Verbatim transcripts of interviews were initially hand coded and later managed with Ethnograph Content analysis, using a template analysis plan, was performed to identify key themes in the women’s beliefs and experiences Data were used to edit and restructure the existing Forever Free materials and create tailored messages for pregnant and postpartum women

Results Findings showed varied results across the three groups in terms of the definition of “quitting smoking” versus making a decision to quit Overall, women in all groups experienced conflict about their identities as new parents or parents to be in relation to their new social roles and a smoke-free life.

Results Feedback about needed changes to the booklets did not vary across the three groups. Suggested names for the new booklets included: Baby’s Breath, New Beginnings, Forever Free for Baby and Me The majority said they would expect to be offered the booklets by their health care provider and would be reluctant to use them if distributed from another source

Sample Results Issues (PA) Pregnant Abstinent (n=6) (PPA) Postpartum Abstinent (n= 8) Stress Physical, financial Adjusting to staying at home or returning to work Financial, looking for work, in ability to quit smoking “Being able to get a job in my field while pregnant is impossible” “Keeping a balance between work and the baby and everything else is a challenge. Quitting smoking has been a huge challenge too” “I can’t afford to go back to work and I can’t afford to stay home” (PPR) Postpartum Relapse (n=8)

Results Issue PA PPA Timing of Quitting When pregnancy Decided to quit was confirmed when pregnancy was confirmed, serious effort a few months later Decision to quit when pregnancy confirmed, cut down on # of cigarettes “The minute my doctor said I was pregnant, I threw out my cigarettes” “I quit as soon as I found out and lowered by cigarettes to one a day for the first trimester “ “It took me about six weeks after I found out I was pregnant” PPR

Results Issue PA PPR Barriers Being around other smokers Other smokers, alcohol, coffee, driving Daily life stress “I go out with my old friends and they have their ashtrays and I don’t have that anymore” “When my husband goes outside to smoke I think ‘there goes my old life’ and I miss it” “When I get into an argument I really want a cigarette”

Results Issue PA PPR Spouse/Partner Support Spouse quitting was helpful Spouse quit for pregnancy resumed after Spousal comments often negative and unhelpful “My husband smokes outside and not around me. . It’s helpful” “At first he put the window down if he smoked in the car or went outside to smoke, now he doesn’t and it drives me crazy” “He said ‘look honey, if you’re going to smoke at least try to lose some weight. You can’t be fat and a smoker”

Results All women liked the layout of the booklets and found content useful Respondents requested additional information about weight gain, dealing with social situation, moodiness, cravings Women said that information specific to each trimester and the postpartum period would be helpful – the issues are different at each stage Women requested personal stories or case histories of other pregnant women who were successful at remaining smoke free

Results The most appealing messages included information about Costs of smoking l Behavioral and mental coping skills l Preparing for “triggers” to smoking l Preparing for differences in withdrawal during pregnancy and postpartum period l Reminders of reasons to quit smoking for their own health as well as the child l

Conclusions Results underscore those found in other studies – women often “suspend” smoking during pregnancy Women tend to not make a plan for long-term smoking cessation, either intending to resume after baby is born or assuming that the ease of remaining smoke-free during pregnancy will continue through postpartum period

Conclusions The focus of the project is on preventing relapse among this population and adapting the Forever Free materials for this group To this end, attention must be paid to the language and definitions used by women describe to “quitting” The role of the spouse/partner is also a key factor Preparing women for the different potential relapse situations they may encounter in the postpartum period is also essential

End A clinical trial to test the efficacy of the booklets with this population is on-going. Results will be available by mid 2007 The research was supported by NCI grant RO 1 CA 94256. Copies of the Forever Free for Baby and Me booklets may be requested from Dr. Thomas Brandon: brandont@moffitt. usf. edu This presentation is based on the article:

Quinn, G. , Ellison, B. , Meade, C. , Roach, N. , Lopez, E. , Albrecht, T. , Brandon, T. (2005). Adapting Smoking Relapse Prevention Materials for Pregnant and Postpartum Women: Formative Research For details about this presentation or the article please contact : Gwendolyn P. Quinn, Ph. D. H. L. Moffitt Cancer Center and Research Institute University of South Florida, College of Medicine quinng@moffitt. usf. edu