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 9 th 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