Postpartum Smoking Relapse - A thematic synthesis of qualitative studies

Dr Caitlin Notley*Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich Norfolk, NR4 7TJ. Tel: 01602 521275. Email: c.notley@uea.ac.uk

Ms Annie Blyth, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich Norfolk, NR4 7TJ. Email: a.blyth@uea.ac.uk

Dr Jean Craig, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich Norfolk, NR4 7TJ. Email: j.craig@uea.ac.uk

Ms Alice Edwards, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich Norfolk, NR4 7TJ. Email: Alice.Edwards@uea.ac.uk

Professor Richard Holland, Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich Norfolk, NR4 7TJ. Email: r.holland@uea.ac.uk

*Corresponding Author

Running head:

A systematic review of postpartum relapse

Word count: 3999

Declaration of Interests:

The authors declare no competing interests

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Abstract

Background and aims: Many women quit smoking during pregnancy but relapse after the baby is born. To understand why and identify ways of preventing this, this study reviewed the qualitative literature on women’s experience of postpartum smoking relapse.Methods: A systematic review of qualitative studies and process evaluations of trials. We undertook a thematic synthesis of published qualitative data.Results: We screened 1,336 papers. Twenty-two papers reporting on 16 studies were included, reporting on the views of 1,031 postpartum women. Factors affecting relapse and barriers and facilitators to relapse prevention were identified around the key themes of beliefs, social influences, motivation, physiological factors and identity. Women’s beliefs about smoking as a means of coping with stress, and the need for social support, especially from a partner, emerged as important. Extrinsic motivation to quit during the pregnancy (for the health of the foetus) appeared to be a factor prompting relapse after the baby was born. During the immediate postpartum period women believed that physiological changes influence cigarette cravings. The stress of caring for a newborn, sleeplessness, and adjusting to a new mothering identity were also reported to be important.Conclusions: Among women who quit smoking during pregnancy, those who relapse postpartum commonly talk about no longer needing to protect the baby, and the effects of stress. Partner support and a sense of changed identity, are cited as factors preventing relapse.

Introduction:

More women quit smoking during pregnancy than at any other time – up to 45% of pregnant smokers ‘spontaneously quit’ during pregnancy (1). This may be due to focusing on the health of the foetus, social expectation, physical aversion to cigarette smoke (2) and decreased withdrawal symptoms (3). Continued abstinence following pregnancy (postpartum) has health benefits for the mother and reduces children’s exposure to second hand smoke (SHS) with its associated health risks (4, 5). Postpartum women are a priority group for research, both in the interests of their own health, and as smoking behaviours may be transmitted to children. However, postpartum relapse rates (defined as a return to regular smoking following a period of smoking cessation (6) within one year of the delivery (4)) are high, ranging from 70% to 85% among women who quit during pregnancy (7). 75% of these women return to smoking within six months postpartum (8). It is estimated that by 12 months postpartum 80%-90% of women who quit during pregnancy will have relapsed (9). Relapse rates are also disproportionately spread, being much higher in women from lower socioeconomic groups (10, 11).

Two Cochrane systematic reviews included sub-sections on relapse prevention for pregnant women (1, 12). These reviews, and an updated review (13) found no effective relapse prevention approaches, or guidelines, for this population. A subsequent NICE review summarised Cochrane findings and included 4 further outcome studies and 17 studies providing other information (qualitative and descriptive studies). The review supported Cochrane findings but also illuminated barriers to the implementation of smoking relapse prevention from the perspectives of healthcare professionals (14). The review did not seek to report on patient experiences of interventions, as this review specifically focuses on.

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This review systematically synthesised studies with a qualitative component, to identify patient reported facilitators and barriers to maintaining abstinence, and views of trialled interventions, to inform the development of relapse prevention interventions for this group.

The protocol was initially registered and published in PROSPERO (15).

Review questions were:

1: What do women report to be factors affecting smoking relapse in the postpartum period?

2: What are the reported barriers and facilitators to smoking relapse prevention?

3: For interventions aiming to prevent post-partum smoking relapse that have been trialled, what are the reasons given by women as to why these interventions are effective or not?

Methods:

Inclusion criteria:Participants:

Women of any age in the postpartum period (up to 12 months after birth) who reported having quit smoking either during or in the 12 months prior to pregnancy.

Interventions:

Non-interventional and interventional studies.

Outcomes:

Patient reported experiences of smoking relapse and relapse prevention, and qualitative patient evaluations of smoking relapse prevention interventions.

Studies:

Qualitative or mixed-methods studies, reporting qualitative patient data, and published in English. We included journal articles, book chapters, reports, theses and conference abstracts.

Exclusion criteria:Where a study included ≥ 30% of participants outside our inclusion criteria (e.g. smokers, those who had reduced smoking but not quit or pre-partum women), we excluded the study, unless we were able to extract data only for eligible participants. Studies that focused on cessation only in pregnant women were not included unless an element of the study focused on relapse prevention.

Search Strategy:Following searches from the Cochrane (11, 12) and NICE reviews (14), a draft search strategy using subject and topic terms for pregnancy and smoking relapse was developed in Medline. We did not specify the study types of interest to ensure a broad search as per CRD guidance (16). Following testing against a sample of relevant papers, searches were finalised and adapted to run in other databases (see supplementary file). MEDLINE, CINAHL, EMBASE, PsyINFO, COCHRANE, ASSIA & WEB OF SCIENCE were searched from inception to March 2015.

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Study selectionFollowing removal of duplicates, a detailed title and abstract screen was undertaken independently by two reviewers. An initial test screen of 20 abstracts confirmed that the eligibility criteria were sufficiently detailed, unambiguous and consistently applied by both reviewers. Where there was disagreement abstracts were discussed to check for systematic screening differences. Where disagreement persisted following discussion, abstracts were screened by a 3rd reviewer who arbitrated. Full text articles were retrieved for all potentially eligible articles. Reviewer 3 undertook a random (10%) check of the references in which reviewers 1 and 2 had agreed and concurred 100% with their decisions.

For phase two, two reviewers independently screened the full texts. Of the 111 full text articles assessed, there were 11 in which the reviewers disagreed. The 3rd reviewer reviewed these and disagreements were resolved by consensus.

Assessment of Study QualityThe CASP Qualitative Research checklist (17), developed specifically for use in qualitative systematic reviews and recommended in CRD guidance (16), was applied by two reviewers, independently. Disagreements were resolved by discussion and reporting of an aggregate ‘score’ was given as a mean of the two reviewers’ assessments. Scores were assigned as 1 if a criterion was met, 0 if not met and 0.5 if partially met. Studies were included in the review regardless of quality score.

Data extractionTwo reviewers independently extracted data from all the included studies, and discrepancies were agreed through discussion. A third reviewer independently extracted data from 10% of the included papers, and this extraction was compared to reviewer’s 1 and 2 extraction.

Qualitative synthesis

Qualitative data were analysed thematically, as per CRD guidance (16), culminating in a qualitative thematic synthesis of review findings (18, 19)(20). CN extracted data by coding all the findings in each paper relevant to the review questions. This involved detailed inductive coding to generate ‘first level’ codes summarising the meaning of the text or captured the original language of the author (‘in-vivo’ codes). A second reviewer independently verified all coding. Coded data was entered into NVivo 10 software. Coding was identified as arising from original data cited in papers or as ‘author interpretation’ of data. Differences in interpretation of codes were discussed at team meetings until consensus was reached. Additional codes identified by the 2nd or 3rd reviewers were included in the analysis at this stage. A second level of coding entailed the development of ‘descriptive themes’ that summarised first level codes but remained close to the primary studies, and the third stage involved developing ‘analytical themes’ whereby we ‘went beyond’ the primary studies to generate new interpretative constructs that synthesised the findings across all the included studies (20) (reported below).

Results:

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Following removal of duplicates, 1,336 records were screened. 1,225 records were excluded at abstract screening (Figure 1). 111 full text articles were assessed for eligibility. In total 16 studies, reported in 22 papers, were included (Table 1), all of which were American or Canadian. Only one study (21) reported patient views of a smoking relapse prevention intervention, reporting only very brief qualitative findings. The remaining 15 studies were qualitative only studies or sub-studies of larger studies. Most studies were judged to be of high quality according to the critical appraisal checklist (Table 1), but researcher reflexivity and potential for bias was often missing or poorly described.

In total 362 first level codes were identified, and organised into 33 interpretative codes. First level codes were initially organised around the review questions before being synthesised into the five analytical themes reported below. Moving the synthesis beyond the level of summarising previous study findings, the coding diagram (Figure 2) illustrates the frequency of reporting categories, taken as a marker of relevance of coding categories to the postpartum population. Based on this, the key findings of this review can be summarised in terms of personal beliefs, social influences, motivation, how physiological changes are experienced, and individuals’ identity. Underlined text denotes review coding.

Personal Beliefs

Women’s reported beliefs about smoking were a major barrier to relapse prevention, particularly harm reduction beliefs. Women who had relapsed felt that smoking postpartum was acceptable provided they protected their babies from second hand smoke ( 22 ) :

“It's important, but it's not one of the biggest things for me personally not to smoke. It's just a big thing not to smoke around him [indicating baby]”. (original data cited in (23))

Where women associated smoking as a form of stress relief ( 24 ) or as their way of coping with stress ( 25 ) , there seemed a tendency to relapse:

‘‘I found [caring for her baby] very stressful, and so the first thing I did was to light a cigarette; that’s what I usually tend to do when I am under stress.’’(Original data, cited in (26))

Correa et al (27) identified stress as the most commonly cited reason for relapse. Also clearly linked were views that smoking was a coping response to negative mood (28) including loneliness, tiredness, a lack of tolerance to distress (29) and aggravation (exacerbated by difficulties in dealing with new-born behaviour, particularly persistent crying).

After the births of their babies, many of the women experienced fatigue, isolation, and stress. These intensified over time, and smoking was viewed as a way to buffer or alleviate these feelings when they became intolerable. (Author interpretation, cited in (30))

Sometimes beliefs were utilised to justify the return to smoking. For example, three papers reported that women believed that they could ‘control their smoking’, by returning to smoking at a lower level or only smoking in certain social situations. This belief acted as permission to resume smoking:

Ginny thought that as long as she didn't buy any cigarettes she wasn't really smoking. She reflected, “Well I can just smoke one here and there” (Author interpretation and direct data,

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cited in (31)

However, beliefs also acted as facilitators for avoidance of relapse. The way in which addiction was conceptualised, for example as an incurable disease by which a single cigarette puff could trigger a full smoking relapse, seemed to be influential in enabling some women to resist cravings:

"I was really addicted to smoking ... I could never turn smoking off.” … Trying to quit smoking during pregnancy changed her beliefs about smoking as an addiction and gave her resolve to engage in the ongoing struggle not to smoke. (Author interpretation and original data, cited in (31))

Motivation

Many women suggested that their intention to quit had been for the pregnancy only ( 32 ) :

Quitting for good was presented as an unlikely possibility. Although the women were confident they could stop smoking again for a time-limited period, their narratives did not include a vision of life without smoking. (Author interpretation, cited in (30)

Thus women’s initial motivation to quit smoking was linked directly to their pregnancy status. Kennison et al (31, 33) conceptualise this motivation status as pausing, suggesting that some women ceased smoking during pregnancy with the explicit intention of resuming postpartum. For others, motivation to continue to be smoke free extended beyond the immediate postpartum period, into the time of breastfeeding the infant:

Women commonly related re-starting smoking after breastfeeding or even terminating breastfeeding earlier than they desired in order to smoke. Breastfeeding is time limited; though it may extend the pause after birth, it does not assure continued smoking cessation. (Author interpretation, cited in (31)).

Relapse seemed almost inevitable where women admitted that they didn’t really quit for themselves; where motivation to quit was extrinsic, not intrinsic:

‘‘I didn’t think of myself when I quit smoking, I thought of the baby first and that is what motivated me.’’ (Original data, cited in(26))

In this sense, pregnancy provided the motivation to quit smoking but, given pregnancy was time limited, so too was the quit attempt. This was confirmed by findings of the only process evaluation study of a trialled intervention identified by this review (21), which found that women felt interventions would only be effective if the motivation to stay quit from smoking came from ‘within’. However, others had managed to re-motivate themselves to continue smoke-free. For these women, a process of ‘renewing the quit’, focusing on reasons to continue to stay quit, had occurred. The motivation came from within rather than being related to the pregnancy; these individuals perhaps had a particularly strong internal belief system enabling them to maintain the quit:

‘‘I’m pretty strong-willed. I don’t feel like I would be pressured into doing something that I didn’t decide to do myself. And I wouldn’t decide to smoke again.’’ (Original data, cited in (34))

The new role as Mother was motivational too, with women wanting to protect their children from second-hand smoke. However, Correa et al ( 27 ) , who collected women’s thoughts over time,

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reported that motivation to remain smoke free increasingly declined during the first year postpartum.

The lived experience of Physiological realities

Women experience a range of physiological changes while recovering from childbirth and adjusting to breastfeeding. For some, knowledge of these changes was positive:

"Well, it goes straight through your breast milk, everything does ... and I'm not an abusive parent. To me that is abuse." (Original data, cited in (31))

So for some women breastfeeding facilitated smoking abstinence, whereas others weaned early specifically to initiate a return to smoking (35). Some women expressed a renewed concern for, and desire to protect, their own and their children’s health following childbirth, which acted as a facilitator for continued abstinence:

I want to live a longer life to be around my children. I want to see my kids grow up… I don't want to miss it over no cancer so, right now I'm so done with smoking cigarettes. (Original data, cited in (23))

However, others were overwhelmed with a return of craving for nicotine ; the physiological experience of pregnancy had lessened or removed craving, but as soon as the pregnancy had ended, the craving returned (36):

I said to myself, it would be really nice to sit down and have a cup of coffee and a cigarette, and it was just, oh my God, what did I do? It was basically the craving just came back. (Original data, cited in (26)

Others reported they had been able to resist urges during pregnancy, whereas postpartum, the incentive to abstain was gone:

‘‘Throughout my whole pregnancy I had craved cigarettes but I did not smoke, and then after I smoked that one, I got hooked all over again…my main thing was I craved them so bad.’’ (Original data, cited in (34))

Finally, the physiological effects of a smoking lapse in the postpartum period were influential. For some, a smoking lapse was pleasant, which increased vulnerability to a full smoking relapse. However, for others, negative physiological effects of a smoking lapse positively reinforced non-smoking behaviour:

many women in the smoke-free group reported negative physical reactions to cigarette smoke or unpleasant experiences when trying a cigarette again. Negative reactions were related to smell, taste, nausea, and gagging, all of which increased the desire to remain smoke-free. (Author interpretation, cited in (34)

Social Influences

Social influences were important, and were particularly influential, perhaps, in the post-partum period, when social interaction is especially valued. For some, their social groups expected a return to smoking postpartum:

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One woman described how she went back to smoking after each of her other pregnancies because friends in her social network started handing her cigarettes assuming she would want to smoke. (Author interpretation, cited in (37))

For others, the social influence on relapse was more circumstantial – they would be offered cigarettes by a friend, or have drunk alcohol, (associated with smoking), or had easy social access to cigarettes, perhaps due to family members smoking. Quinn (38) found that simply being around other smokers was an important factor affecting relapse. Women highlighted that social influence was multi-faceted, encompassing behavioural influence, ‘peer pressure’, and positive associations with the smell and taste:

‘‘Everybody around me smoking, peer pressure. Temptation to see it all the time, smell it.’’ (Original data, cited in (34))

Women also reported stress and influences such as relationship problems as influential on their relapse status. Social support for remaining abstinent dropped away suddenly following pregnancy:

When I got pregnant she's (supportive relative) always on me all the time and if you don't quit smoking that's my godbaby you're carryin, da da da this 'n that, but she basically helped me to quit when I was pregnant. . . . After I had her, and I don't know, maybe she was just so excited that the baby was there and she ain't have to worry about me no more, ya know, and she had her godbaby and that she didn't care what I did basically after that. (Original data, cited in (31))

Of particular importance was partner smoking status. It was extremely difficult for women to remain smoke free when their partners smoked. This may partly relate to the integral role of smoking within some relationships (39):

Although during pregnancy her husband encouraged her to quit—even reducing his own smoking to just one cigarette a day to offer support—after delivery they began to smoke together while drinking and after meals as a way of spending time together. (Author interpretation, cited in (40))

Conversely, partner smoking status and support emerged as potentially a powerful way to assist women in remaining smoke free post-partum:

The majority of abstinent women noted the support of their partner was a strong factor in remaining smoke free. Many women reported that their spouses had altered their own smoking behaviors in some ways, to help them remain quit. (Author interpretation, cited in (41))

a non-smoking partner might be really dedicated to maintaining a smoke-free household and so offer tremendous support. (Author interpretation, cited in (42))

Qualitative findings from the included process evaluation study (21) found that women valued social support and personalised praise from health professionals.

Individual Identity

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The social and culturally influenced concept of identity was an important emergent theme. During and immediately after pregnancy, women experience changes to their role, their sense of themselves and their place in society, requiring adjustments to establish their own sense of themselves as a ‘Mother’. For some women, this was difficult; there was a desire to rekindle a sense of themselves as individuals prior to the pregnancy. Where this pre-pregnancy identity included smoking, relapse seemed likely:

“I miss my life when I was a smoker. Smoking is associated with happy times, friends, and the freedom to do what I want. Smoking helps me recapture my ‘old self’ as I was before I had the baby.” (Original data, cited in (30))

Linked to the discussion above around motivation to quit and the possibility of pregnancy as pausing, some women seemed to retain smoking as part of their identity. Thus women who retained a positive smoker identity seemed more likely to return to smoking:

“Even though I quit I will always be a smoker. I was able to quit for a while but then I had to have a cigarette and that was it.” (Original data, cited in (30))

The retention of a positive smoker identity may relate to a conflicted new parent identity. However, positive adjustment to the mothering identity could conversely be seen to act as a facilitator to relapse prevention, as for some smoking was seen as incompatible with the new mothering role:

Choosing to be a good mother with all the responsibilities of creating a healthy, safe family environment and role modelling positive behaviors was experienced as incompatible with continued smoking. (Author interpretation, cited in (31))

Social and morally influenced discourses about what constitutes a ‘good mother’ are apparent in the interpretation above. Identification with these discourses, i.e. a belief that good mothers don’t smoke, seemed to facilitate continued non-smoking status.

Discussion

This qualitative synthesis has summarised the available literature on women’s experiences of continued smoking abstinence and relapse postpartum. Figure 3, depicting the overall qualitative synthesis, shows that themes of particular importance are misinformed beliefs (e.g. associating smoking as a coping mechanism and believing that harm reduction ‘rules’ make a return to smoking permissible); factors motivating the initial quit attempt (quitting for pregnancy); physiological realities of the postpartum period (craving, breastfeeding); social support (from friends, family and especially a partner) and women’s sense of identity (adjusting to the new mothering role). These themes are specific to women in the postpartum period. Relapse prevention interventions must specifically address the uniqueness of this population.

The themes interacted in complex ways. For example, motivation may act as a barrier to continued abstinence, as the initial quit reason was motivated specifically by pregnancy. This finding supports work on intrinsic and extrinsic motivations for smoking cessation (43, 44) and intentions to resume smoking (45). Conversely, motivation can facilitate relapse prevention where women have a strong

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desire to remain quit (46) and where motivation is renewed post-partum to refocus on protecting children from second-hand smoke.

The review also found that stress, particularly caused by struggling with the new mothering role, was perceived as impacting on smoking relapse, confirming other studies’ findings (47), but that the mothering role prevented relapse for others. So the transition to motherhood itself is pivotal. There is clearly scope to intervene with information and support at this important time. Considering the theme of identity (women’s struggle to identify with the new mothering role), review findings suggest that some ex-smokers may strongly associate smoking with their ‘old life’ and therefore see smoking as integral to regaining a valued sense of individual identity postpartum. This complements work in the general population finding that identity may be associated with longer term smoking status (48-50).

Motivational factors, including planned return to smoking post-partum (30), also may need reconceptualising. Our dominant model for understanding smoking relapse (51) may require adaptation to account for social and motivational influences that are particularly relevant to postpartum women, as we know that people understand health risks, yet this understanding is often not enough to contribute to behaviour change. Social support, particularly the support of a partner, was identified as critical. Whilst this finding is not novel (52), few interventions have specifically included the partner.

It was problematic to apply the CASP critical appraisal checklist. Reviewers found it to be inaccurate and non-specific. Assigning an aggregate critical appraisal score was not a recommendation of the CASP tool, but a measure used by the authors for ease of reporting. Therefore scoring gives an indication of our assessment of study quality but is not definitive – this imperfect method of assessment clearly requires further development.

Conclusions / implications

This review has found a lack of patient evaluation of trials, with only one included process evaluation study reporting qualitative data. There is clearly a gap in research understanding as trial findings do not routinely publish qualitative process evaluation data, enabling us to unpick possible reasons underlying the null result.

All of the studies included are American or Canadian. This is problematic for intervention development in other settings, where differing healthcare systems, for example the UK specialist stop smoking service, make findings less transferable. Clearly, there is a need for us to understand the postpartum experience of smoking relapse in other contexts.

Critical appraisal within qualitative research synthesis is problematic. It is technically difficult to compare quality of research studies utilising differing study designs. Currently, available tools for qualitative critical appraisal are difficult to apply and do not give a depth understanding of the methodological issues apparent within each study.

Findings across this review are nonetheless important and useful for future intervention development. Post-partum women should be recognised as a specific at risk population, for whom interventions need to be carefully tailored. For example by addressing stressors relevant to the immediate post-partum period, such as sleeplessness and infant crying/irritability (30). The specific

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needs of this population centre on inaccurate beliefs about returning to smoking, and motivation to continue to remain abstinent from smoking, implying that ‘renewing the quit’ or re-motivating women postpartum is very important. Social and physiological factors are also particular to this population, who are especially in need of social support due to their postpartum status, alongside support to continue to stay quit. It is appears that support from a partner is particularly important, but personalised support from a health professional was also valued (21). Critically, the individual’s sense of past, current and future identity must be integrated within future relapse prevention interventions.

Acknowledgements

Dr Caitlin Notley Receives Research Fellowship funding from the Society for the Study of Addiction

The team was supported by a small amount of Research Capability Funding from NHS South Norfolk Clinical Commissioning Group

Team roles: Reviewers 1 and 2 are experts in smoking cessation and reviewer 2 also in qualitative methods; reviewer 3 is an expert in systematic review methodology.

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35. Goldade KN, Mimi;Nichter, Mark;Adrian, Shelly;Tesler, Laura;Muramoto, Myra. Breastfeeding and Smoking among Low-Income Women: Results of a Longitudinal Qualitative Study. Birth. 2008;35(3):230-40.36. Pletsch PK, Kratz AT. Why do women stop smoking during pregnancy? Cigarettes taste and smell bad. Health Care Women Int. 2004;25(7):671-9.37. Nguyen SVK, Isabelle;Schulman-Green, Dena;Colson, Eve. The Importance of Social Networks on Smoking: Perspectives of Women Who Quit Smoking During Pregnancy. Matern Child Health J. 2012;16(6):1312-8.38. Quinn G, Ellison BB, Meade C, Roach CN, Lopez E, Albrecht T, et al. Adapting smoking relapse-prevention materials for pregnant and postpartum women: formative research. Matern Child Health J. 2006;10(3):235-45.39. Bottorff JL, Kalaw C, Johnson JL, Stewart M, Greaves L, Carey J. Couple dynamics during women's tobacco reduction in pregnancy and postpartum. Nicotine & Tobacco Research. 2006;8(4):499-509.40. Nichter MA, S.;Goldade, K.;Tesler, L.;Muramoto, M. Smoking and harm-reduction efforts among postpartum women. Qual Health Res. 2008;18(9):1184-94.41. Simmons VN, Cruz LM, Brandon TH, Quinn GP. Translation and adaptation of smoking relapse-prevention materials for pregnant and postpartum Hispanic women. J Health Commun. 2011;16(1):90-107.42. Park ER, Chang, Y, Quinn, V.P, Ross, K, Rigotti, N.A. Perceived support to stay quit: what happens after delivery? Addict Behav. 2009;34(12):1000-4.43. Curry S, Wagner, E, Grothaus, L. Intrinsic and Extrinsic Motivation for Smoking Cessation. Journal of Consulting and Clinical Psychology. 1990;58(3):310-6.44. Stotts AL, DiClemente, C, Carbonari, J.P, Mullen, P.D. Pregnancy smoking cessation: A case of mistaken identity. Addict Behav. 1996;21(4):459-71.45. Röske K, Hannöver, W, Grempler, J, Thyrian, J.R, Rumpf, H, John, U, Hapke, U. Post-partum intention to resume smoking. Health Educ Res. 2006;21(3):386-92.46. Heppner WL, Ji, L, Reitzel, L.R, Castro, Y, Correa-Fernandez, V, Vidrine, J, Li, Y, Dolan-Mullen, P, ;Velasquez, M.M, Cinciripini, P.M, Cofta-Woerpel, L, Greisinger, A, Wetter, D.W. The role of prepartum motivation in the maintenance of postpartum smoking abstinence. Health Psychol. 2011;30(6):736-45.47. Hauge LJ, Torgersen, L, Vollrath, M. Associations between maternal stress and smoking: findings from a population-based prospective cohort study. Addiction. 2012;107(6):1168-73.48. Tombor I, Shahab, L, Brown, J, West, R. Positive smoker identity as a barrier to quitting smoking: findings from a national survey of smokers in England. Drug Alcohol Depend. 2013;133(2):740-5.49. Vangeli E, West, R. Transition towards a ‘non-smoker’ identity following smoking cessation: An interpretative phenomenological analysis. British Journal of Health Psychology. 2012;17(1):171-84.50. Vangeli E, Stapleton, J, West, R. Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation. Patient Education and Counseling. 2010;81(2):267-71.51. Marlatt GA, George, W. H. Relapse Prevention: Introduction and Overview of the Model. British Journal of Addiction. 1984;79(3):261-73.52. Ma Y, Goins KV, Pbert L, Ockene JK. Predictors of smoking cessation in pregnancy and maintenance postpartum in low-income women. Matern Child Health J. 2005;9(4):393-402.

Table 1 – Overview of included studies

Figure 2 – Prisma diagram

13

Figure 3 – Coding diagram

14

Table 1 : Study characteristics

Lead author. Publication year.Reference.

Aims / focus.Study design and analysis.

Sample size and approach.

Participant demographics: Country, study setting, timing of interview(s) according to number of weeks/months postpartum (pp), socio-economic status, education.

Women's smoking history: level of dependence prior to pregnancy or delivery. Smoking status at time of interview.

Partner and household smoking status.

Quality rating.

Bottorff et al. (2000). (30)

Women’s experiences of postpartum smoking relapse.Narrative research and narrative analysis.

n=27.(n=24: subgroup from a prior trial, selected on basis of having relapsed; n=3: respond to advertisement.

Canada.Urban setting.Interviewed at 6 months pp.

1-20 cigarettes/day.Relapsed by time of interview: 100%.

Partner smokes: 10/27 (37%).

8

Bottorff et al. (2006). (39)

Couple dynamics in tobacco reduction, cessation, or relapse.Grounded Theory approach to data collection and analysis.

n=28. Canada.Urban setting.Interviewed at 2-4 weeks and 3-6 months pp. Majority had some post-secondary education 22/28 (79%).

Mean Fagerstrom score 2.0, i.e. low/medium nicotine addiction.Mean years smoked n=14 (range 6 to >21 years).Relapsed by time of final interview: 8/17 (47%) .

Partner smokes: 18/28 (64%).

8.75

Correa et al. (2014)(27)

Attributions for resuming smoking or maintaining abstinence postpartum. Open ended survey responses. Thematic content analysis.

N=472(Subgroup from a larger study population).

Florida, USA.Surveyed at 1, 8 and 12 months pp.41.6% had household income ≤$30,000.Majority educated to HS diploma level or had ‘some college or tech school’ education (36% & 44.7%)

Pre-cessation Fagerstrom score 3.7 (2.6) [M (SD)]No. of cigarettes per day 15.2 (6.6) [M (SD)].No. or participants smoking/abstinent at 1, 8 & 12 months: 116/326, 154/261, 156/244.

Partner smokes / Lives with smoker(s): not reported.

7.75

15

Edwards and Sims-Jones (1998). (26)

The meaning of smoking and smoking relapse to women during pregnancy and pp. Symbolic interactionist approach. Descriptive thematic analysis.

n=21(subgroup from a prior trial).

Canada.Interviewed at 3 months pp. Annual household income range ≤$20,000 to ≥$40,000 (mode ≥$40,000).

Relapsed by time of interview: 11/18 (61%).

Partner smokes: 3/21 (14%).

7.5

Gaffney et al. (2008). (25)

Infant irritability and postpartum tobacco use. Qualitative descriptive method. Thematic content analysis.

n=86(subgroup from a larger study).

Southern USA.≤3 months pp.'Low income’. Only a small minority had some post secondary education (19/86, 22.1%), remainder ≤ grade 12.

Relapsed by time of interview: 44/86 (51.2%).

Partner smokes / Lives with smoker(s): not reported.

7.5

Groner et al. (2005). *(21)

Patient acceptability of a smoking relapse prevention intervention. Process evaluation (some open-ended questions). Basic thematic analysis.

n=121. Ohio USA.Interviewed at 3 and 6 months pp. Predominantly low income; High school or higher education 41/121 (34%).

Not reported Lives with smoker(s): 103/121 (85%).

4.75

Hymowitz et al. (2003). (32)

Determine factors that influence postpartum relapse.Open ended structured interviews. Thematic analysis.

n=26(subgroup from a larger study population, selected on basis of having relapsed (group C, n=16), or remained abstinent (group D, n=10).

New Jersey, USA.Interviewed within 12 months postpartum. Only a small minority had some post secondary school education 4/26 (27%), all in group C)

Mean cigarettes/day: n=6.8 (group C), n=6.1 (group D). Relapsed by time of interview: 100% in group C (100% abstinent in group D).

Lives with smoker(s): 11/16 (69%) and 5/10 (50%) (groups C and D respectively).

5.75

Kennison (2004) & (2009)(31) (33)

Develop theory about how women make decisions to quit smoking during pregnancy, and then pp smoking status. Grounded theory – data collection and analysis.

n=17 . Florida, USA.Total annual household income <$20,000 8/17 (47%). Some post secondary education 8/17 (47%); high school diploma or less 9/17 (53%).

10/17 (59%) smoked ≥20 cigarettes/day (range 5-50).

Lives with smoker(s): 7/17 (41%).

9.5**

16

Nichter et al. (2008); Goldade et al. (2008)(40) (35)

How smoking status affected women’s decision making about breastfeeding.Ethnography. Thematic analysis of narratives.

n=14(subgroup from a larger study population).

South Western USA.Urban setting.Interviewed at 1, 3, & 6 months pp. All 'low income' (less than $30,000 per annum for a family of 4, or eligible for Medicaid).

Mean cigarettes/day n=18. Relapsed by time of final interview: 6/14 (43%).

Not reported for subsample.

8**

Nguyen et al. (2012). (37)

Understand what influences resumption of smoking.Grounded theory – data collection and analysis.

n=24 USA.Urban setting. Interviewed in hospital following delivery of baby.Majority had some college education (13/24, 63%).

Relapsed by time of interview: 0%.

Lives with smoker(s): 15/24 (63%).

8.5

Park et al. (2009a) & (2009b);Psaros et al. (2012) & (2008)(24) (42) (29) (28)

To explore attributions for smoking relapse. Content analysis.

n=25(subgroup from a larger study population).

USA.Urban hospital. Interviewed if had relapsed at 2, 6, 12, or 24 weeks postpartum.

Relapsed by time of final interview: 100%.

Not reported for subsample.

8.5**

Pletsch and Kratz (2004). (36)

Investigate smoking behaviours during pregnancy and the first three months pp to gain insight into the reasons women relapse. Qualitative, thematic content analysis.

n=15. Midwest USA.Urban academic centre.Interviewed at 36 weeks of pregnancy and 3 months pp. Mean annual household income $19,716. High school graduates 12/15 (89%).

Mean cigarettes/day n=13.8 (10.8 sd, range 3-40).Mean years smoked 9.1 (5.4 sd, range 4-22 years). Relapsed by time of final interview: 11/15 (73%).

Not reported. 6.5

Quinn, G., et al. (2006). (38)

Perceptions of quitting smoking during pregnancy and barriers and benefits associated with initiating and maintaining this change, for the purpose of modifying existing relapse-prevention materials for use pp. Formative evaluation.

n=22 (subgroup from a larger study population).

Florida, USA.Interviewed when at least 6 months pregnant, or ≤8 months postpartum.A variety of socioeconomic backgrounds.

Smoked for at least a year, and at least 10 cigarettes/day. Relapsed by time of interview: 8/16 (50%) pp women.

Not reported. 9.25

17

Content analysis.Ripley-Moffitt, C. E., et al. (2008). (34)

Explore the factors involved in postpartum smoke-free and relapse states.Grounded theory data analysis.

n=94. North Carolina, USA.University clinics, health departments and community clinics. Interviewed at 1 week, 3 and 4 months postpartum. Majority low income, defined by reviewers as eligible for Medicaid insurance (66/94, 70.2%).

Mean cigarettes/day n=10.5; mean previous quit attempts n=2.6. Relapsed by time of interview: 51/94 (54%).

Lives with smoker(s): 48/94 (51.1%).

8.5

Simmons et al. (2011). (41)

Assess benefits, barriers, motivations to quitting smoking, support provided and sources of stress and relaxation in pregnant and pp Hispanic women; for the purpose of translating and adapting smoking-relapse prevention materials.Content analysis.

n=15(includes n=4 (27%) pregnant women).

Florida, USA.In employment 7/15 (47%); annual income ≤$20,000 8/15 (53%), >$20,000 7/15 (47%).Some college or university education 9/15 (60%); remainder ≤ 12th grade.

≥5 cigarettes/day 9/15 (60%); ≥5 years smoking 13/15 (87%). Relapsed by time of interview: 8/15 (53%).

Lives with smoker(s): 12/15 (80%).

7.5

Von Kohorn et al. (2012) &Von Kohorn (2011).(22) (23)

Determine why women return to smoking after prolonged abstinence during pregnancy by examining mothers' intention to smoke.Grounded theory data analysis.

n=24. Boston, USA.Inner city teaching hospital. Interviewed during postpartum hospital stay. Education level: At least high school education 21/24 (84%).

Relapsed by time of interview: 100%.

Partner smokes: 14/24 (58%).Lives with smoker(s):15/24 (63%).

9**

Notes:

*Study reporting on process evaluation of a smoking relapse prevention intervention

**Where more than 1 paper reports on the same study, the highest critical appraisal score across the included papers is cited. All critical appraisal scores for linked papers fell within 1 point.

Data on age and parity of participants were extracted from the studies, but are not shown here as we were unable to draw any conclusions about the impact of these contextual characteristics on the review findings.

18

Incomplete information within any table cell indicates that data were not reported, or could not be extracted for the subsample.

19

Figure 1: PRISMA 2009 Flow Diagram

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

For more information, visit www.prisma-statement.org.

20

Records identified through database searching

(n = 2904)

Scre

enin g

Incl

ude

dEl

igi

bilit

yId

entifi

catio

n

Additional records identified from other sources

(n = 23)

Records after duplicates (n=1591) removed (n = 1336)

Records screened (n = 1336)

Records excluded

(n = 1225)695 - title screen236 - no qual component229 - not relapse prevention65 - participants ineligible

Full-text articles assessed for eligibility

(n = 111)

Full-text articles excluded(n = 89)

57 - No qual component15 - Not relapse prevention17 - Participants ineligible

Studies included in qualitative synthesis

(n = 22 papers; 16 studies) )

Motivation

21

Association of smoking as coping mechanism /

smoking as coping. 49Smoking as stress

relief. 28

Belief that able to control

smoking. 14

‘Harm reduction’ efforts allow smoking to

continue / permissive rules allow return to smoking.

48

Aversion to repeating

the cessation process 8

Pregnancy as pausing. 26

Social network of smokers 10

Alcohol 13

Figure 2: Qualitative synthesis coding overviewKey:Blue = factors affecting relapse (13)Red = barriers to RP (7)Green = facilitators for RP (12)

Sizing of circles (indication of coding density): >10 refs = 2cm, 10-20 refs = 3cm, 21-30 refs = 4cm, 31-40 refs = 5cm, 41-50 refs = 6cm

Ide

ntit y

Soci al

infl

uen

ces

Phy

siol

ogic al

Mo

tiva

tion

Beli

efs

Lack of alternative

coping mechanisms

8

Acceptance of addiction as a disease

8Smoking as time

out. 17

Desire to protect children from

second-hand smoke 18

I didn’t do it for myself. 11

Intends to quit for

pregnancy only. 10

Belief that can maintain abstinence.

6

Strong desire to remain

smoke free 9

Physiological effects of trying smoking again experienced as

negative 12

Knowledge of nicotine in

breast milk. 7

Wish to protect own

health for children’s sake. 12

Craving 12

Social support for not smoking falls

away post-partum 16

Partner support. 15Easy social access 11

Partner smoking status. 8

Support from

family and friends. 9

Stress – boredom /infant crying /relationship

problems. 37

Being around others who were smoking.

26

22

Good mothers

don’t smoke. 4

Smoking incompatible

with new mothering role.

5

Desire to return to pre-pregnancy self

14

Smoking to feel

renewed. 8

Identity: continued

smoker or new parent

conflict.9