Journal of Adolescent Health xxx (2014) 1e6
www.jahonline.org Original article
Smoking Cessation, Maintenance, and Relapse Experiences Among Pregnant and Postpartum Adolescents: A Qualitative Analysis Norman A. Constantine, Ph.D. a, b, *, Jana Kay Slater, Ph.D. c, Julie A. Carroll, M.P.H., M.S.W. d, and Tamar M.J. Antin, Dr.P.H. a a
Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, California School of Public Health, University of California, Berkeley, California c Samaritan Health Services, Center for Health Research and Quality, Corvallis, Oregon d Department of Psychology, Emory University, Atlanta, Georgia b
Article history: Received July 26, 2013; Accepted December 24, 2013 Keywords: Tobacco; Smoking; Cessation; Relapse; Pregnant; Postpartum; Qualitative research
A B S T R A C T
Purpose: To understand the experiences and processes of smoking cessation, maintenance, and relapse for pregnant and postpartum adolescents, whose perspectives and needs might be different from other age groups. Methods: We conducted in-depth semistructured interviews with 52 pregnant and postpartum adolescents using tools of grounded theory analysis. Results: Spontaneous smoking cessation during pregnancy was reported by most participants. This was generally explained as resulting from knowledge about the harmful effects of tobacco on the fetus, intense emotional reactions to this knowledge, or unpleasant tobacco- and pregnancyrelated physical symptoms. Relapses were common, however. Most participants experienced guilt when they relapsed during pregnancy. Postpartum relapse was less fraught, as many participants no longer considered their smoking to negatively affect their infants. This was found even among adolescents who were breastfeeding. Participants who did maintain cessation postpartum typically reported support from smoke-free families and environments. Conclusions: The results of this study suggest a constellation of protective factors that contribute to smoking cessation and maintenance during and after pregnancy, as well as risk factors that contribute to temporary or permanent relapses. These results can inform future research and interventions on tobacco prevention among pregnant and postpartum adolescents. Several promising strategies for intervention development are discussed. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Smoking during and after pregnancy significantly increases health risks for mother and child. Prenatal and postpartum smoking are associated with premature birth, intrauterine growth retardation, low birth weight, infant mortality, sudden infant death syndrome, and childhood respiratory, behavioral, and cognitive problems [1e5]. The Centers for Disease Control * Address correspondence to: Norman A. Constantine, Ph.D., Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, CA. E-mail address: [email protected] (N.A. Constantine).
IMPLICATIONS AND CONTRIBUTION
Results will inform future research on tobacco prevention and cessation among pregnant and postpartum adolescents to help refine and expand research questions, methods, and measures; inform development and testing of plausible rival hypotheses; and help provide a foundation for developing and testing new interventions for this age group.
and Prevention estimate that 18.5% of pregnant adolescents smoke during pregnancy, the second highest rate of all age groups [6]. Low income further increases adolescents’ risk of prepartum and postpartum smoking [7e10]. Multiple factors have been found to predict cessation and relapse among pregnant and postpartum adult women [11e15]. Factors associated with cessation include health concerns for mother and baby, breastfeeding, decision to remain quit, social support, adverse physical reactions to smoking, and concrete strategies to resist temptation [31,34]. Factors associated with
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2013.12.027
2
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
relapse include marital status, easy access to cigarettes, lack of social and financial support, addiction, stress of dealing with a newborn, and use of cigarettes for stress reduction [15,30,34,35]. Several types of cessation support that interventions have demonstrated effectiveness across mixed-age pregnant populations, including consistent clinical support [16], educational brochures [32], cognitive behavioral approaches [36], and combinations of strategies [9,16,17]. Less is known about effective interventions for preventing postpartum relapse [33], although some evidence supports the effectiveness of individualized assessments related to intention to remain quit and an anticipatory guidance strategy [35], as well as taking into account reason for quitting (for a healthy lifestyle, for the baby, or both), expectation about staying quit, existing social support, incentives for staying quit, plans to avoid relapse, and stressors [28,29]. Most research on cessation and relapse prevention related to pregnancy is focused on mixed-age adult populations. It is not clear to what extent such research findings can be generalized to adolescents. To better understand factors related to cessation and relapse prevention for adolescents, two primary questions were addressed in this study: 1. What are the key processes and experiences of smoking cessation, maintenance, and relapse for pregnant and postpartum adolescents? 2. Which individual and environmental factors and interactions of factors influence smoking cessation and relapse among pregnant and postpartum adolescents? Addressing these questions provides important information about differences and similarities between adult and adolescent women regarding smoking prevention and intervention strategies during and after pregnancy. This information can help guide future cessation strategies and programing for pregnant and postpartum adolescents. Methods This study’s protocol was approved by the Public Health Institute’s Institutional Review Board. Eligible adolescents consisted of low-income pregnant and postpartum adolescents between the ages of 15 and 19 years, who had (1) lifetime use of 100 or more cigarettes; (2) smoked at least 10 cigarettes during the 3 months prior to discovery of pregnancy; and (3) abstained from smoking for at least 30 consecutive days during pregnancy. Recruitment brochures and flyers were used, and many participants selfreferred. In addition, educators and staff in alternative schools and community-based organizations assisted with recruitment and referral. In some cases, participants informed their peers about the opportunity to participate in the study. Referring individuals received $20 for each successful referral, and participants received a $20 honorarium. Fifty-two eligible adolescents were interviewed between 3 months before expected delivery and 2 years after delivery. No adolescents declined to participate. Interviews were semistructured and included open-ended questions and prompts. Topics included personal, family, and educational circumstances; tobacco initiation and prepregnancy use; pregnancy experiences; quitting during pregnancy; and current use. The primary tools of grounded theory analysis were facilitated by the use of ATLAS.ti qualitative analysis software [18]. Interviews were audio recorded and transcribed by a professional service. Each transcript was coded by the researcher
who conducted the interview. We used an emergent rather than a priori code list and held monthly meetings to review coding and e-merging themes. Results Nineteen percent of participants were interviewed while pregnant, and 81% were interviewed postpartum. Most were Latina (38.5%) or white (34.6%). Ages ranged from 14 to 19 years, with a median age of 17 (Table 1). Most participants came from challenging life situations. Many had tenuous relationships with family members and boyfriends, and some had experiences with physical and sexual abuse. Many had struggled in school, engaged in substance use or witnessed siblings’ and parents’ substance use, and lived in economically disadvantaged households. Some were involved with the criminal justice system or had incarcerated partners. Many participants attended alternative continuation high schools [19], having voluntarily transferred after becoming pregnant. Several participants described the alternative school as a more supportive environment than traditional high schools. For example: I like the classes and I like how the teachers act and help out. I like the work here. The teachers here talk to you when you need help and you raise your hand and they come help you. In [previous school] they just all, “well you got to figure it out yourself” you know, they never even helped. (Participant 38) Analyses revealed similarities across participants in life circumstances, maturity levels, lifestyle characteristics, risk-taking behaviors, and the unplanned nature of adolescent pregnancies. Several major themes related to cessation and relapse were particularly prominent. Pregnancy was a powerful motivator for life change: “It wasn’t just me anymore” Participants often considered their lives before pregnancy negatively, and many described pregnancy or parenting as a powerful motivator for change. For example, a Latina mother described her life before pregnancy as a time of fighting, drinking, and smoking cigarettes and marijuana. After pregnancy, she felt that she had to change: Table 1 Participant characteristics Characteristic
Age (years) 14 15 16 17 18 19 Race/ethnicity African-American Asian/Pacific Islander Latina Native American/ Alaska Native White Unknown
Full sample (n ¼ 52)
Pregnant (n ¼ 10)
Postpartum (n ¼ 42)
f
%
f
%
f
%
1 4 10 18 12 7
1.9 7.7 19.2 34.6 23.1 13.5
0 2 0 3 2 3
0.0 20.0 0.0 30.0 20.0 30.0
1 2 10 15 10 4
2.4 4.8 23.8 35.7 23.8 9.5
7 3 20 1
13.5 5.8 38.5 1.9
3 1 3 1
30.0 10.0 30.0 10.0
4 2 17 0
9.5 4.8 40.5 0.0
18 3
34.6 5.8
2 0
20.0 0.0
16 3
38.1 7.1
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
[Pregnancy] really hit me hard. I’m going to be a mommy now. I can’t be dumb anymore, because it’s not just going to be me anymore. And I think that (getting pregnant) was the best thing that could have happened to me. (Participant 4) Most described their lives before pregnancy as troubled with little hope for a promising future. With pregnancy, however, the motivation to complete school and prepare for a more financially stable future grew in many of these adolescent mothers. I didn’t care about my work or anything. I wasn’t expecting to be anything in life, because I didn’t think it mattered. . And then when I got pregnant, it wasn’t just me anymore. So now I know I have to go to school. I have to get my grades up. I have to pass high school. (Participant 5) For most teens, cessation during pregnancy was spontaneous and for the baby: “I did not have another cigarette, not one single puff” None of the teens indicated that they had intentionally become pregnant, and none had plans in place to quit smoking before becoming pregnant. Most described cessation as spontaneous and entirely for the sake of the baby. And the day that I thought I might have been pregnant I quit smoking. I just quit until I knew. for sure if I was or wasn’t. So if I wasn’t, then I would have continued on smoking. But if I was, then I would stop. So I stopped. (Participant 6) It was easy for me. Like before when I tried to quit, it felt so hard. But I think it was knowing that I had a baby inside of me. (Participant 29) Spontaneous cessation was generally motivated by the teen’s knowledge of the harmful effects of smoking on the fetus and their emotional response to this knowledge. I had gone to the library and got a bunch of books and one of them. had like a 2-page chapter on smoking when you’re pregnant and I was crying, it was terrible. After I read that, I did not have another cigarette, not one single puff for the rest of the time I was pregnant. (Participant 39) Most adolescents were acutely aware that smoking during pregnancy was harmful for the fetus. Participants mentioned public health media including television and pamphlets as vivid and important knowledge sources. Other sources included classes at school, prenatal classes, friends, parents or other relatives, doctors or healthcare providers, and books. Participants also expressed how negative physical reactions to smoking, such as smell, taste, or sickness experienced during pregnancy, triggered and facilitated cessation. I didn’t really decide to quit, it kind of happened just because I couldn’t stand that smell of the cigarettes no more, it made me want to gag. And I couldn’t take a drag of my cigarette; I’d start coughing and choking. And it just made me want to throw up, so I just quit. (Participant 42) Regardless of their motivations, most adolescents directly stated or implied that quitting during pregnancy was not especially challenging.
3
Prepartum relapse was strongly resisted: “I hit a cigarette, and now I hate myself for it” Although most participants quit easily and many maintained cessation throughout their pregnancies, relapsesdboth during pregnancy and especially after pregnancydwere not uncommon. Prepartum relapse was consistently described by participants as a temporary lapse, consisting of a single puff to only a few cigarettes, triggered by stress or a particular event and accompanied by guilt and remorse. I remember one time in my pregnancy, a friend of mine committed suicide. and I went over to my friend’s house, and I hit a cigarette, and now I hate myself for it. (Participant 9) I always wanted a cigarette in my pregnancy. But it wasn’t that bad, I only had one once, and that was when my aunt passed away. (Participant 1) . a couple of times when I was pregnant, I had a couple of cigarettes, which I totally admit to. .. But then I was like, ’Ooh, I can’t.’ And I would feel guilty afterwards. (Participant 26)
Postpartum relapse was typically described as a matter of fact return to smoking: “I’m not pregnant anymore so I can smoke again” In contrast to prepartum relapse, postpartum relapse was typically a more stable return to participants’ nonpregnant level of smoking. Most participants described postpartum return to smoking in a matter of fact manner, without reference to guilt. Many mothers reported little motivation to maintain cessation postpartum, in part because they no longer viewed their smoking as damaging to their infants. Some waited until after breastfeeding to resume smoking, whereas others reported smoking immediately after discharge, and several immediately after delivery. Right after I had [my son]. right when I got out of the hospital, I went to go hit a cigarette. I was like, ’I’m not pregnant, so I can smoke again. (Participant 13) I asked for a cigarette right after he was born, right in the hospital. They said if I could get up and walk, I could go have one. I tried and I fell. (Participant 35) In the hospital when he was born. I ran out I had to go outside and smoke. When they told me I wasn’t supposed to leave, I got in this big trouble because I was still under the hospital’s signature. I just left to smoke and got in trouble. (Participant 34) Two additional factors associated with postpartum relapse emergeddstress and social influences. Many participants referred to the stress of motherhood or postpartum depression as contributing to their return to smoking. I get really stressed out, taking care of [my daughter]. I’ll just go there and have a cigarette by myself. So it kind of relaxes me. It does, too, because I’ll go [back] in, I’ll be all nice to her. (Participant 24) Right after [my daughter] was born. Yeah. I was frustrated. I was having so much depression. it was bad. I was upset over everything. (Participant 4) For other participants, relapses occurred because they no longer had social support for cessation postpartum, in many
4
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
cases due to living with smokers or starting to go out again, often involving gatherings where their friends were smoking. It’s so hard because my mom smokes, my dad smokes, my boyfriend smokes, everybody smokes around me. And so even though I wanted to quit right now, I know I wouldn’t be able to, just because my mom and dad smoke, and they let me smoke. So it was like, I wish they didn’t and I wish they didn’t like it, it would be a lot easier to quit, because then I would have to hide or something. (Participant 1) Although many participants reported having support from family and friends for cessation during pregnancy, this support often broke down after birth, or in some cases after breastfeeding, when smoking was no longer considered hazardous. For example, when asked about her postpartum relapse, one participant explained: Well, my sister just said, ’I’m going to have a cigarette.’ I’m like, ’Could I join you?’ She’s like, ’Oh, yeah, sure. You stopped breast-feeding, right?’ (Participant 7) Although most participants recognized that infants should not be exposed to tobacco smoke, they also felt self-efficacy for protecting them from this smoke. Nobody smokes around the baby, not even me. when people smoke, I make them put a sweatshirt on, and then take it off when they get inside. Because even if [my son] doesn’t smell the smoke, he smells the smoke off your clothes and it still does the same thing. (Participant 2)
Successful postpartum cessation maintenance was often due to lifestyle changes: “I want a better life for my son” While most teens returned to smoking after the birth of the baby, some did maintain cessation postpartum. Among those who did not return to smoking, several common factors emerged. Many maintaining mothers were Latina, who tended to be lighter smokers prior to pregnancy and often felt that motherhood necessitated a transition away from reckless behaviors, including smoking. Some talked about the support they received from their families in helping maintain smoking cessation. Others talked about wanting to protect their baby from tobacco smoke or an environment that normalizes smoking and were willing to go to great lengths to do so. For example, one mother wanted to keep her son away from smokers and therefore disassociated herself from old friends who smoked: I still have the same best friend. But, I don’t really kick it with [my old friends] no more because I don’t want people like that around my son. Like smoking cigarettes and smoking marijuana. I want a better life for my son. (Participant 24) In some cases, breastfeeding also appeared to be protective for maintaining cessation postpartum. For some mothers, it served to motivate a temporary postpartum cessation maintenance plan; for others, it helped with long-term cessation. I thought that I would probably have one or two after he was born, but then I started breastfeeding, and so then I couldn’t again. And then I thought, ’Oh, well, I don’t need to smoke,’ but I just never picked the habit back up. (Participant 18)
Discussion Adolescent motherhood is an experience typically discussed in relation to a greater risk for a variety of health and social problems, including low birth weight deliveries, drug and alcohol abuse, child neglect and abuse, poverty, and a lack of family and employment stability [20e22]. Nevertheless, adolescent pregnancy and motherhood can serve as an important turning point in the lives of some adolescents [23e25]. Our study helps illustrate this other side of adolescent pregnancy and motherhood, as a period of transition to adulthood that can support changes in young women’s lifestyles as they consider the health consequences of their behaviors. Many of our pregnant and postpartum adolescents reported intense emotional reactions and connections to knowledge about the harmful effects of tobacco to their infants. In many cases, this served as the necessary impetus to quit and, in some cases, to maintain cessation postpartum. Yet, once they delivered and felt that their bodies were no longer directly tied to the well-being of their children, many simply resumed smoking. Spontaneous cessation of smoking defined the experiences of a majority of adolescents in this study, yet many relapsed, usually briefly, one or more times during their pregnancy. In spite of those relapses, most continued to define their pregnancy as a nonsmoking period. Because of deeply felt knowledge and beliefs about smoking’s detrimental effect on the fetus, most experienced significant guilt when they relapsed. Some rationalized that the stress relief they experienced from smoking justified the relapse. Smoking relapse was far less fraught after birth, even when relapse occurred among breastfeeding mothers. After birth, many participants no longer considered their smoking to negatively affect their infants, provided that they took necessary steps to protect against direct exposure. The few mothers who did maintain tobacco cessation postpartum tended to be supported by smoke-free families and environments. This study has revealed a number of similarities between adult and adolescent mothers related to motivations to quit smoking and to stay quit. Adult mothers tend to view pregnancy as a reason to quit, are susceptible to environmental events and stressors that can trigger relapse, and tend to benefit from social influences for staying quit [15]. These same themes emerged for adolescent mothers. This suggests that interventions developed for mixed-age adult women might be effective for adolescents. In light of the findings from this study, several promising intervention strategies specific to adolescents are suggested. First, given the significance of health information in motivating quitting during pregnancy, prevention initiatives could maximize the use of media, especially television public service announcements and health pamphlets, to distribute specific compelling information and emotionally engaging stories about the harmful effects of tobacco on infant health and development [32]. To avoid exacerbating the guilt and shame many pregnant teens experience as a result of relapses, these materials should be developed to increase teens’ knowledge in sensitive nonstigmatizing ways. Second, encouraging pediatricians and other health care providers to play an active role in supporting postpartum cessation maintenance could help to maintain cessation during the relapse-prone postpartum period. For example, emphasizing the risk of environmental tobacco smoke for fetal and infant health, the inadequacy of measures taken by smokers to minimize mother and infant exposure to tobacco smoke, and how mothers’ bodies remain connected to those of their children
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
after delivery could be effective strategies for providers to employ. Third, because many pregnant and postpartum adolescents attend alternative high schools and report their experiences there as positive and supportive, cessation support groups could be particularly effective in these environments. Strategies might include interventions to improve maternal-infant bonding, which have been suggested to promote tobacco cessation among mothers of mixed ages [26], or programs designed to increase family support in smoking cessation efforts. Finally, adolescent mothers generally lead complicated lives and, like their adult counterparts, may benefit from individualized assessment and guidance for maintaining postpartum cessation [28,29,36]. The findings of this study should be interpreted in light of several limitations. First, adolescents were interviewed between 3 months before delivery and 2 years after delivery. Recall accuracy related to tobacco use and pregnancy experiences might have been affected by time since delivery. Second, the attribution of motivations to individuals based solely on their interview responses might be influenced by participants’ personal biases. Third, the boundaries of generalizability of these results must be noted. All participants were from Northern California, an area that has received a substantial amount of tobacco control promotion messaging and activities for more than two decades [27]. As such, the experiences of these participants could differ from experiences of similar adolescents in other states, and replication in regions where anti-tobacco messaging has not been as widely promoted might provide additional insights. In addition, eligible adolescents met the criteria of smoking at least 10 cigarettes in the 3 months prior to their knowledge of their pregnancy. Although we did elicit smoking histories to confirm eligibility, we did not quantify prepregnancy smoking levels. The range of smoking levels in the sample may have affected findings, specifically with respect to ease of cessation. Finally, our sample involved by design only those who had successfully quit during pregnancy (abstained at least 30 days). As such, these results are not meant to generalize to teens who continued smoking during pregnancy. Despite these limitations, the consistent issues and themes uncovered across a diverse sample of pregnant and postpartum adolescents provide potentially useful insights. In conclusion, this study illustrates a common maternal ebb and flow of intrinsic and extrinsic motivations to quit and to maintain cessation. Its findings suggest a constellation of protective factors that contribute to smoking cessation and maintenance during and after an adolescent’s pregnancy, as well as risk factors that contribute to relapses. Many but not all these factors are common across other age groups. These results can inform future research to help refine and expand research questions, methods, and measures, to inform development and testing of plausible rival hypotheses, and to help provide a foundation for the development and testing of new interventions for this age group. References [1] Jaakkola JJK, Gissler M. Maternal smoking in pregnancy, fetal development, and childhood asthma. Am J Public Health 2004;94:136e40. [2] Lee W, Galant S. Effects of maternal smoking during pregnancy and environmental tobacco smoke on asthma and wheezing in children. Pediatrics 2002;110(suppl 2):445e6. [3] Suellentrop K, Morrow B, Williams L, D’Angelo D. Monitoring progress toward achieving Maternal and Infant Healthy People 2010 objectivesd19 states, pregnancy risk assessment monitoring system (PRAMS), 2000e2003. MMWR Surveill Summ 2006;55:1e11.
5
[4] Centers for Disease Control and Prevention. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: Centers for Disease control and Prevention; 2006. [5] DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004;113(suppl 4):1007e15. [6] Centers for Disease Control and Prevention. Table 5 Prevalence of smoking during pregnancy during the last 3 months of pregnancy among 2008 PRAMS participants, by selected demographic characteristics, for all sites combined. Available at: http://www.cdc.gov/prams/DATA-TobaccoTables. htm#table5. Accessed April 17, 2013. [7] Cluss PA, Levine MD, Landsittel D. The Pittsburgh STOP program: Disseminating an evidence-informed intervention for low-income pregnant smokers. Am J Health Promot 2011;25(suppl 5):75e81. [8] Kendrick JS, Zahniser SC, Miller N, et al. Integrating smoking cessation into routine public prenatal care: The smoking cessation in pregnancy project. Am J Public Health 1995;85:217e22. [9] McBride CM, Curry SJ, Lando HA, et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:706e11. [10] Windsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: Its behavioral impact and cost benefit. Am J Public Health 1993; 83:201e6. [11] Curry SJ, McBride C, Grothaus L, et al. Motivation for smoking cessation among pregnant women. Psychol Addict Behav 2001;15:126e32. [12] DiClemente C, Dolan-Mullen P, Windsor R. The process of pregnancy smoking cessation: Implications for interventions. Tob Control 2000;9(suppl 3):16e21. [13] McBride CM, Pirie PL. Postpartum smoking relapse. Addict Behav 1990;15: 165e8. [14] Woodby LL, Windsor RA, Snyder SW, et al. Predictors of smoking cessation during pregnancy. Addiction 1999;94:283e92. [15] Ripley-Moffit CE, Goldstein WLF, Butzen AY, et al. Safe babies: A qualitative analysis of the determinants of postpartum smoke-free and relapse states. Nicotine Tob Res 2008;10:1355e64. [16] Baxter S, Everson-Hock E, Messina J, et al. Factors relating to the uptake of interventions for smoking cessation among pregnant women: A systematic review and qualitative synthesis. Nicotine Tob Res 2010;12: 685e94. [17] Lando HA, Valanis BG, Lichtenstein E, et al. Promoting smoking abstinence in pregnant and postpartum patients: A comparison of 2 approaches. Am J Manag Care 2001;7:685e93. [18] ATLAS.ti [computer program]. Version 5.0. Berlin, Germany: ATLAS.ti Scientific Software Development GmbH; 2004. [19] Perez LG, Johnson JF. California continuation high schools: A descriptive study. Available at: http://www.ncust.org/docs/Lynnes%20paper%20for% 20Irvine.pdf. Accessed April 17, 2013. [20] Chuang J, Santelli J, Soren K. Pregnancy in adolescence. In: Brown BB, Prinstein MJ, eds. Encyclopedia of adolescence. San Diego, CA: Academic Press; 2011:231e7. [21] Hoffman SD, Maynard RA, eds. Kids having kids: Economic costs & social consequences of teen pregnancy. 2nd edition. Washington, DC: Urban Institute Press; 2008. [22] Furstenberg Jr FF, Brooks-Gunn J, Morgan SP. Adolescent mothers in later life. New York, NY: Cambridge University Press; 1987. [23] Hunt G, Joe-Laidler K, MacKenzie K. Moving into motherhood: Gang girls and controlled risk. Youth Soc 2005;36:333e73. [24] Lesser J, Koniak-Griffin D, Anderson NL. Depressed adolescent mothers’ perceptions of their own maternal role. Issues Ment Health Nurs 1999;20: 131e49. [25] Anderson NL. Pregnancy resolution decisions in juvenile detention. Arch Psychiatr Nurs 1990;4:325e31. [26] Phillips RM, Merritt TA, Goldstein MR, et al. Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. J Perinatol 2012;32:374e80. [27] Rogers T. The California Tobacco Control Program: Introduction to the 20year retrospective. Tob Control 2010;19(suppl 1):i1e2. [28] Fang WL, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: A review of postpartum relapse prevention strategies. J Am Board Fam Pract 2004;17:264e75. [29] Pletsch PK. A model for postpartum smoking resumption prevention for women who stop smoking while pregnant. J Obstet Gynecol Neonatal Nurs 2006;35:215e22. [30] Prady SL, Kiernan K, Bloor K, Pickett KE. Do risk factors for post-partum smoking relapse vary according to marital status? Matern Child Health J 2012;16:1364e73. [31] Pletsch PK, Pollak KI, Peterson BL, et al. Olfactory and gustatory sensory changes to tobacco smoke in pregnant smokers. Res Nurs Health 2008;31: 31e41. [32] Brandon TH, Simmons VN, Meade CD, et al. Self-help booklets for preventing postpartum smoking relapse: A randomized trial. Am J Public Health 2012;102:2109e15.
6
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
[33] Hannover W, Thyrian JR, Ebner A, et al. Smoking during pregnancy and postpartum: Smoking rates and intention to quit smoking or resume after pregnancy. J Womens Health 2008;17:631e40. [34] Schneider S, Huy C, Schutz J, Diehl K. Smoking cessation during pregnancy: A systematic literature review. Drug Alcohol Rev 2010;29:81e90.
[35] Roske K, Hannover W, Grempler J, et al. Post-partum intention to resume smoking. Health Ed Res 2006;21:386e92. [36] Reitzel LR, Vidrine JI, Businelle MS, et al. Preventing postpartum smoking relapse among diverse low-income women: A randomized clinical trial. Nicotine Tob Res 2010;12:326e35.
www.jahonline.org Original article
Smoking Cessation, Maintenance, and Relapse Experiences Among Pregnant and Postpartum Adolescents: A Qualitative Analysis Norman A. Constantine, Ph.D. a, b, *, Jana Kay Slater, Ph.D. c, Julie A. Carroll, M.P.H., M.S.W. d, and Tamar M.J. Antin, Dr.P.H. a a
Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, California School of Public Health, University of California, Berkeley, California c Samaritan Health Services, Center for Health Research and Quality, Corvallis, Oregon d Department of Psychology, Emory University, Atlanta, Georgia b
Article history: Received July 26, 2013; Accepted December 24, 2013 Keywords: Tobacco; Smoking; Cessation; Relapse; Pregnant; Postpartum; Qualitative research
A B S T R A C T
Purpose: To understand the experiences and processes of smoking cessation, maintenance, and relapse for pregnant and postpartum adolescents, whose perspectives and needs might be different from other age groups. Methods: We conducted in-depth semistructured interviews with 52 pregnant and postpartum adolescents using tools of grounded theory analysis. Results: Spontaneous smoking cessation during pregnancy was reported by most participants. This was generally explained as resulting from knowledge about the harmful effects of tobacco on the fetus, intense emotional reactions to this knowledge, or unpleasant tobacco- and pregnancyrelated physical symptoms. Relapses were common, however. Most participants experienced guilt when they relapsed during pregnancy. Postpartum relapse was less fraught, as many participants no longer considered their smoking to negatively affect their infants. This was found even among adolescents who were breastfeeding. Participants who did maintain cessation postpartum typically reported support from smoke-free families and environments. Conclusions: The results of this study suggest a constellation of protective factors that contribute to smoking cessation and maintenance during and after pregnancy, as well as risk factors that contribute to temporary or permanent relapses. These results can inform future research and interventions on tobacco prevention among pregnant and postpartum adolescents. Several promising strategies for intervention development are discussed. Ó 2014 Society for Adolescent Health and Medicine. All rights reserved.
Smoking during and after pregnancy significantly increases health risks for mother and child. Prenatal and postpartum smoking are associated with premature birth, intrauterine growth retardation, low birth weight, infant mortality, sudden infant death syndrome, and childhood respiratory, behavioral, and cognitive problems [1e5]. The Centers for Disease Control * Address correspondence to: Norman A. Constantine, Ph.D., Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, CA. E-mail address: [email protected] (N.A. Constantine).
IMPLICATIONS AND CONTRIBUTION
Results will inform future research on tobacco prevention and cessation among pregnant and postpartum adolescents to help refine and expand research questions, methods, and measures; inform development and testing of plausible rival hypotheses; and help provide a foundation for developing and testing new interventions for this age group.
and Prevention estimate that 18.5% of pregnant adolescents smoke during pregnancy, the second highest rate of all age groups [6]. Low income further increases adolescents’ risk of prepartum and postpartum smoking [7e10]. Multiple factors have been found to predict cessation and relapse among pregnant and postpartum adult women [11e15]. Factors associated with cessation include health concerns for mother and baby, breastfeeding, decision to remain quit, social support, adverse physical reactions to smoking, and concrete strategies to resist temptation [31,34]. Factors associated with
1054-139X/$ e see front matter Ó 2014 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2013.12.027
2
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
relapse include marital status, easy access to cigarettes, lack of social and financial support, addiction, stress of dealing with a newborn, and use of cigarettes for stress reduction [15,30,34,35]. Several types of cessation support that interventions have demonstrated effectiveness across mixed-age pregnant populations, including consistent clinical support [16], educational brochures [32], cognitive behavioral approaches [36], and combinations of strategies [9,16,17]. Less is known about effective interventions for preventing postpartum relapse [33], although some evidence supports the effectiveness of individualized assessments related to intention to remain quit and an anticipatory guidance strategy [35], as well as taking into account reason for quitting (for a healthy lifestyle, for the baby, or both), expectation about staying quit, existing social support, incentives for staying quit, plans to avoid relapse, and stressors [28,29]. Most research on cessation and relapse prevention related to pregnancy is focused on mixed-age adult populations. It is not clear to what extent such research findings can be generalized to adolescents. To better understand factors related to cessation and relapse prevention for adolescents, two primary questions were addressed in this study: 1. What are the key processes and experiences of smoking cessation, maintenance, and relapse for pregnant and postpartum adolescents? 2. Which individual and environmental factors and interactions of factors influence smoking cessation and relapse among pregnant and postpartum adolescents? Addressing these questions provides important information about differences and similarities between adult and adolescent women regarding smoking prevention and intervention strategies during and after pregnancy. This information can help guide future cessation strategies and programing for pregnant and postpartum adolescents. Methods This study’s protocol was approved by the Public Health Institute’s Institutional Review Board. Eligible adolescents consisted of low-income pregnant and postpartum adolescents between the ages of 15 and 19 years, who had (1) lifetime use of 100 or more cigarettes; (2) smoked at least 10 cigarettes during the 3 months prior to discovery of pregnancy; and (3) abstained from smoking for at least 30 consecutive days during pregnancy. Recruitment brochures and flyers were used, and many participants selfreferred. In addition, educators and staff in alternative schools and community-based organizations assisted with recruitment and referral. In some cases, participants informed their peers about the opportunity to participate in the study. Referring individuals received $20 for each successful referral, and participants received a $20 honorarium. Fifty-two eligible adolescents were interviewed between 3 months before expected delivery and 2 years after delivery. No adolescents declined to participate. Interviews were semistructured and included open-ended questions and prompts. Topics included personal, family, and educational circumstances; tobacco initiation and prepregnancy use; pregnancy experiences; quitting during pregnancy; and current use. The primary tools of grounded theory analysis were facilitated by the use of ATLAS.ti qualitative analysis software [18]. Interviews were audio recorded and transcribed by a professional service. Each transcript was coded by the researcher
who conducted the interview. We used an emergent rather than a priori code list and held monthly meetings to review coding and e-merging themes. Results Nineteen percent of participants were interviewed while pregnant, and 81% were interviewed postpartum. Most were Latina (38.5%) or white (34.6%). Ages ranged from 14 to 19 years, with a median age of 17 (Table 1). Most participants came from challenging life situations. Many had tenuous relationships with family members and boyfriends, and some had experiences with physical and sexual abuse. Many had struggled in school, engaged in substance use or witnessed siblings’ and parents’ substance use, and lived in economically disadvantaged households. Some were involved with the criminal justice system or had incarcerated partners. Many participants attended alternative continuation high schools [19], having voluntarily transferred after becoming pregnant. Several participants described the alternative school as a more supportive environment than traditional high schools. For example: I like the classes and I like how the teachers act and help out. I like the work here. The teachers here talk to you when you need help and you raise your hand and they come help you. In [previous school] they just all, “well you got to figure it out yourself” you know, they never even helped. (Participant 38) Analyses revealed similarities across participants in life circumstances, maturity levels, lifestyle characteristics, risk-taking behaviors, and the unplanned nature of adolescent pregnancies. Several major themes related to cessation and relapse were particularly prominent. Pregnancy was a powerful motivator for life change: “It wasn’t just me anymore” Participants often considered their lives before pregnancy negatively, and many described pregnancy or parenting as a powerful motivator for change. For example, a Latina mother described her life before pregnancy as a time of fighting, drinking, and smoking cigarettes and marijuana. After pregnancy, she felt that she had to change: Table 1 Participant characteristics Characteristic
Age (years) 14 15 16 17 18 19 Race/ethnicity African-American Asian/Pacific Islander Latina Native American/ Alaska Native White Unknown
Full sample (n ¼ 52)
Pregnant (n ¼ 10)
Postpartum (n ¼ 42)
f
%
f
%
f
%
1 4 10 18 12 7
1.9 7.7 19.2 34.6 23.1 13.5
0 2 0 3 2 3
0.0 20.0 0.0 30.0 20.0 30.0
1 2 10 15 10 4
2.4 4.8 23.8 35.7 23.8 9.5
7 3 20 1
13.5 5.8 38.5 1.9
3 1 3 1
30.0 10.0 30.0 10.0
4 2 17 0
9.5 4.8 40.5 0.0
18 3
34.6 5.8
2 0
20.0 0.0
16 3
38.1 7.1
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
[Pregnancy] really hit me hard. I’m going to be a mommy now. I can’t be dumb anymore, because it’s not just going to be me anymore. And I think that (getting pregnant) was the best thing that could have happened to me. (Participant 4) Most described their lives before pregnancy as troubled with little hope for a promising future. With pregnancy, however, the motivation to complete school and prepare for a more financially stable future grew in many of these adolescent mothers. I didn’t care about my work or anything. I wasn’t expecting to be anything in life, because I didn’t think it mattered. . And then when I got pregnant, it wasn’t just me anymore. So now I know I have to go to school. I have to get my grades up. I have to pass high school. (Participant 5) For most teens, cessation during pregnancy was spontaneous and for the baby: “I did not have another cigarette, not one single puff” None of the teens indicated that they had intentionally become pregnant, and none had plans in place to quit smoking before becoming pregnant. Most described cessation as spontaneous and entirely for the sake of the baby. And the day that I thought I might have been pregnant I quit smoking. I just quit until I knew. for sure if I was or wasn’t. So if I wasn’t, then I would have continued on smoking. But if I was, then I would stop. So I stopped. (Participant 6) It was easy for me. Like before when I tried to quit, it felt so hard. But I think it was knowing that I had a baby inside of me. (Participant 29) Spontaneous cessation was generally motivated by the teen’s knowledge of the harmful effects of smoking on the fetus and their emotional response to this knowledge. I had gone to the library and got a bunch of books and one of them. had like a 2-page chapter on smoking when you’re pregnant and I was crying, it was terrible. After I read that, I did not have another cigarette, not one single puff for the rest of the time I was pregnant. (Participant 39) Most adolescents were acutely aware that smoking during pregnancy was harmful for the fetus. Participants mentioned public health media including television and pamphlets as vivid and important knowledge sources. Other sources included classes at school, prenatal classes, friends, parents or other relatives, doctors or healthcare providers, and books. Participants also expressed how negative physical reactions to smoking, such as smell, taste, or sickness experienced during pregnancy, triggered and facilitated cessation. I didn’t really decide to quit, it kind of happened just because I couldn’t stand that smell of the cigarettes no more, it made me want to gag. And I couldn’t take a drag of my cigarette; I’d start coughing and choking. And it just made me want to throw up, so I just quit. (Participant 42) Regardless of their motivations, most adolescents directly stated or implied that quitting during pregnancy was not especially challenging.
3
Prepartum relapse was strongly resisted: “I hit a cigarette, and now I hate myself for it” Although most participants quit easily and many maintained cessation throughout their pregnancies, relapsesdboth during pregnancy and especially after pregnancydwere not uncommon. Prepartum relapse was consistently described by participants as a temporary lapse, consisting of a single puff to only a few cigarettes, triggered by stress or a particular event and accompanied by guilt and remorse. I remember one time in my pregnancy, a friend of mine committed suicide. and I went over to my friend’s house, and I hit a cigarette, and now I hate myself for it. (Participant 9) I always wanted a cigarette in my pregnancy. But it wasn’t that bad, I only had one once, and that was when my aunt passed away. (Participant 1) . a couple of times when I was pregnant, I had a couple of cigarettes, which I totally admit to. .. But then I was like, ’Ooh, I can’t.’ And I would feel guilty afterwards. (Participant 26)
Postpartum relapse was typically described as a matter of fact return to smoking: “I’m not pregnant anymore so I can smoke again” In contrast to prepartum relapse, postpartum relapse was typically a more stable return to participants’ nonpregnant level of smoking. Most participants described postpartum return to smoking in a matter of fact manner, without reference to guilt. Many mothers reported little motivation to maintain cessation postpartum, in part because they no longer viewed their smoking as damaging to their infants. Some waited until after breastfeeding to resume smoking, whereas others reported smoking immediately after discharge, and several immediately after delivery. Right after I had [my son]. right when I got out of the hospital, I went to go hit a cigarette. I was like, ’I’m not pregnant, so I can smoke again. (Participant 13) I asked for a cigarette right after he was born, right in the hospital. They said if I could get up and walk, I could go have one. I tried and I fell. (Participant 35) In the hospital when he was born. I ran out I had to go outside and smoke. When they told me I wasn’t supposed to leave, I got in this big trouble because I was still under the hospital’s signature. I just left to smoke and got in trouble. (Participant 34) Two additional factors associated with postpartum relapse emergeddstress and social influences. Many participants referred to the stress of motherhood or postpartum depression as contributing to their return to smoking. I get really stressed out, taking care of [my daughter]. I’ll just go there and have a cigarette by myself. So it kind of relaxes me. It does, too, because I’ll go [back] in, I’ll be all nice to her. (Participant 24) Right after [my daughter] was born. Yeah. I was frustrated. I was having so much depression. it was bad. I was upset over everything. (Participant 4) For other participants, relapses occurred because they no longer had social support for cessation postpartum, in many
4
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
cases due to living with smokers or starting to go out again, often involving gatherings where their friends were smoking. It’s so hard because my mom smokes, my dad smokes, my boyfriend smokes, everybody smokes around me. And so even though I wanted to quit right now, I know I wouldn’t be able to, just because my mom and dad smoke, and they let me smoke. So it was like, I wish they didn’t and I wish they didn’t like it, it would be a lot easier to quit, because then I would have to hide or something. (Participant 1) Although many participants reported having support from family and friends for cessation during pregnancy, this support often broke down after birth, or in some cases after breastfeeding, when smoking was no longer considered hazardous. For example, when asked about her postpartum relapse, one participant explained: Well, my sister just said, ’I’m going to have a cigarette.’ I’m like, ’Could I join you?’ She’s like, ’Oh, yeah, sure. You stopped breast-feeding, right?’ (Participant 7) Although most participants recognized that infants should not be exposed to tobacco smoke, they also felt self-efficacy for protecting them from this smoke. Nobody smokes around the baby, not even me. when people smoke, I make them put a sweatshirt on, and then take it off when they get inside. Because even if [my son] doesn’t smell the smoke, he smells the smoke off your clothes and it still does the same thing. (Participant 2)
Successful postpartum cessation maintenance was often due to lifestyle changes: “I want a better life for my son” While most teens returned to smoking after the birth of the baby, some did maintain cessation postpartum. Among those who did not return to smoking, several common factors emerged. Many maintaining mothers were Latina, who tended to be lighter smokers prior to pregnancy and often felt that motherhood necessitated a transition away from reckless behaviors, including smoking. Some talked about the support they received from their families in helping maintain smoking cessation. Others talked about wanting to protect their baby from tobacco smoke or an environment that normalizes smoking and were willing to go to great lengths to do so. For example, one mother wanted to keep her son away from smokers and therefore disassociated herself from old friends who smoked: I still have the same best friend. But, I don’t really kick it with [my old friends] no more because I don’t want people like that around my son. Like smoking cigarettes and smoking marijuana. I want a better life for my son. (Participant 24) In some cases, breastfeeding also appeared to be protective for maintaining cessation postpartum. For some mothers, it served to motivate a temporary postpartum cessation maintenance plan; for others, it helped with long-term cessation. I thought that I would probably have one or two after he was born, but then I started breastfeeding, and so then I couldn’t again. And then I thought, ’Oh, well, I don’t need to smoke,’ but I just never picked the habit back up. (Participant 18)
Discussion Adolescent motherhood is an experience typically discussed in relation to a greater risk for a variety of health and social problems, including low birth weight deliveries, drug and alcohol abuse, child neglect and abuse, poverty, and a lack of family and employment stability [20e22]. Nevertheless, adolescent pregnancy and motherhood can serve as an important turning point in the lives of some adolescents [23e25]. Our study helps illustrate this other side of adolescent pregnancy and motherhood, as a period of transition to adulthood that can support changes in young women’s lifestyles as they consider the health consequences of their behaviors. Many of our pregnant and postpartum adolescents reported intense emotional reactions and connections to knowledge about the harmful effects of tobacco to their infants. In many cases, this served as the necessary impetus to quit and, in some cases, to maintain cessation postpartum. Yet, once they delivered and felt that their bodies were no longer directly tied to the well-being of their children, many simply resumed smoking. Spontaneous cessation of smoking defined the experiences of a majority of adolescents in this study, yet many relapsed, usually briefly, one or more times during their pregnancy. In spite of those relapses, most continued to define their pregnancy as a nonsmoking period. Because of deeply felt knowledge and beliefs about smoking’s detrimental effect on the fetus, most experienced significant guilt when they relapsed. Some rationalized that the stress relief they experienced from smoking justified the relapse. Smoking relapse was far less fraught after birth, even when relapse occurred among breastfeeding mothers. After birth, many participants no longer considered their smoking to negatively affect their infants, provided that they took necessary steps to protect against direct exposure. The few mothers who did maintain tobacco cessation postpartum tended to be supported by smoke-free families and environments. This study has revealed a number of similarities between adult and adolescent mothers related to motivations to quit smoking and to stay quit. Adult mothers tend to view pregnancy as a reason to quit, are susceptible to environmental events and stressors that can trigger relapse, and tend to benefit from social influences for staying quit [15]. These same themes emerged for adolescent mothers. This suggests that interventions developed for mixed-age adult women might be effective for adolescents. In light of the findings from this study, several promising intervention strategies specific to adolescents are suggested. First, given the significance of health information in motivating quitting during pregnancy, prevention initiatives could maximize the use of media, especially television public service announcements and health pamphlets, to distribute specific compelling information and emotionally engaging stories about the harmful effects of tobacco on infant health and development [32]. To avoid exacerbating the guilt and shame many pregnant teens experience as a result of relapses, these materials should be developed to increase teens’ knowledge in sensitive nonstigmatizing ways. Second, encouraging pediatricians and other health care providers to play an active role in supporting postpartum cessation maintenance could help to maintain cessation during the relapse-prone postpartum period. For example, emphasizing the risk of environmental tobacco smoke for fetal and infant health, the inadequacy of measures taken by smokers to minimize mother and infant exposure to tobacco smoke, and how mothers’ bodies remain connected to those of their children
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
after delivery could be effective strategies for providers to employ. Third, because many pregnant and postpartum adolescents attend alternative high schools and report their experiences there as positive and supportive, cessation support groups could be particularly effective in these environments. Strategies might include interventions to improve maternal-infant bonding, which have been suggested to promote tobacco cessation among mothers of mixed ages [26], or programs designed to increase family support in smoking cessation efforts. Finally, adolescent mothers generally lead complicated lives and, like their adult counterparts, may benefit from individualized assessment and guidance for maintaining postpartum cessation [28,29,36]. The findings of this study should be interpreted in light of several limitations. First, adolescents were interviewed between 3 months before delivery and 2 years after delivery. Recall accuracy related to tobacco use and pregnancy experiences might have been affected by time since delivery. Second, the attribution of motivations to individuals based solely on their interview responses might be influenced by participants’ personal biases. Third, the boundaries of generalizability of these results must be noted. All participants were from Northern California, an area that has received a substantial amount of tobacco control promotion messaging and activities for more than two decades [27]. As such, the experiences of these participants could differ from experiences of similar adolescents in other states, and replication in regions where anti-tobacco messaging has not been as widely promoted might provide additional insights. In addition, eligible adolescents met the criteria of smoking at least 10 cigarettes in the 3 months prior to their knowledge of their pregnancy. Although we did elicit smoking histories to confirm eligibility, we did not quantify prepregnancy smoking levels. The range of smoking levels in the sample may have affected findings, specifically with respect to ease of cessation. Finally, our sample involved by design only those who had successfully quit during pregnancy (abstained at least 30 days). As such, these results are not meant to generalize to teens who continued smoking during pregnancy. Despite these limitations, the consistent issues and themes uncovered across a diverse sample of pregnant and postpartum adolescents provide potentially useful insights. In conclusion, this study illustrates a common maternal ebb and flow of intrinsic and extrinsic motivations to quit and to maintain cessation. Its findings suggest a constellation of protective factors that contribute to smoking cessation and maintenance during and after an adolescent’s pregnancy, as well as risk factors that contribute to relapses. Many but not all these factors are common across other age groups. These results can inform future research to help refine and expand research questions, methods, and measures, to inform development and testing of plausible rival hypotheses, and to help provide a foundation for the development and testing of new interventions for this age group. References [1] Jaakkola JJK, Gissler M. Maternal smoking in pregnancy, fetal development, and childhood asthma. Am J Public Health 2004;94:136e40. [2] Lee W, Galant S. Effects of maternal smoking during pregnancy and environmental tobacco smoke on asthma and wheezing in children. Pediatrics 2002;110(suppl 2):445e6. [3] Suellentrop K, Morrow B, Williams L, D’Angelo D. Monitoring progress toward achieving Maternal and Infant Healthy People 2010 objectivesd19 states, pregnancy risk assessment monitoring system (PRAMS), 2000e2003. MMWR Surveill Summ 2006;55:1e11.
5
[4] Centers for Disease Control and Prevention. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: Centers for Disease control and Prevention; 2006. [5] DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004;113(suppl 4):1007e15. [6] Centers for Disease Control and Prevention. Table 5 Prevalence of smoking during pregnancy during the last 3 months of pregnancy among 2008 PRAMS participants, by selected demographic characteristics, for all sites combined. Available at: http://www.cdc.gov/prams/DATA-TobaccoTables. htm#table5. Accessed April 17, 2013. [7] Cluss PA, Levine MD, Landsittel D. The Pittsburgh STOP program: Disseminating an evidence-informed intervention for low-income pregnant smokers. Am J Health Promot 2011;25(suppl 5):75e81. [8] Kendrick JS, Zahniser SC, Miller N, et al. Integrating smoking cessation into routine public prenatal care: The smoking cessation in pregnancy project. Am J Public Health 1995;85:217e22. [9] McBride CM, Curry SJ, Lando HA, et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:706e11. [10] Windsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: Its behavioral impact and cost benefit. Am J Public Health 1993; 83:201e6. [11] Curry SJ, McBride C, Grothaus L, et al. Motivation for smoking cessation among pregnant women. Psychol Addict Behav 2001;15:126e32. [12] DiClemente C, Dolan-Mullen P, Windsor R. The process of pregnancy smoking cessation: Implications for interventions. Tob Control 2000;9(suppl 3):16e21. [13] McBride CM, Pirie PL. Postpartum smoking relapse. Addict Behav 1990;15: 165e8. [14] Woodby LL, Windsor RA, Snyder SW, et al. Predictors of smoking cessation during pregnancy. Addiction 1999;94:283e92. [15] Ripley-Moffit CE, Goldstein WLF, Butzen AY, et al. Safe babies: A qualitative analysis of the determinants of postpartum smoke-free and relapse states. Nicotine Tob Res 2008;10:1355e64. [16] Baxter S, Everson-Hock E, Messina J, et al. Factors relating to the uptake of interventions for smoking cessation among pregnant women: A systematic review and qualitative synthesis. Nicotine Tob Res 2010;12: 685e94. [17] Lando HA, Valanis BG, Lichtenstein E, et al. Promoting smoking abstinence in pregnant and postpartum patients: A comparison of 2 approaches. Am J Manag Care 2001;7:685e93. [18] ATLAS.ti [computer program]. Version 5.0. Berlin, Germany: ATLAS.ti Scientific Software Development GmbH; 2004. [19] Perez LG, Johnson JF. California continuation high schools: A descriptive study. Available at: http://www.ncust.org/docs/Lynnes%20paper%20for% 20Irvine.pdf. Accessed April 17, 2013. [20] Chuang J, Santelli J, Soren K. Pregnancy in adolescence. In: Brown BB, Prinstein MJ, eds. Encyclopedia of adolescence. San Diego, CA: Academic Press; 2011:231e7. [21] Hoffman SD, Maynard RA, eds. Kids having kids: Economic costs & social consequences of teen pregnancy. 2nd edition. Washington, DC: Urban Institute Press; 2008. [22] Furstenberg Jr FF, Brooks-Gunn J, Morgan SP. Adolescent mothers in later life. New York, NY: Cambridge University Press; 1987. [23] Hunt G, Joe-Laidler K, MacKenzie K. Moving into motherhood: Gang girls and controlled risk. Youth Soc 2005;36:333e73. [24] Lesser J, Koniak-Griffin D, Anderson NL. Depressed adolescent mothers’ perceptions of their own maternal role. Issues Ment Health Nurs 1999;20: 131e49. [25] Anderson NL. Pregnancy resolution decisions in juvenile detention. Arch Psychiatr Nurs 1990;4:325e31. [26] Phillips RM, Merritt TA, Goldstein MR, et al. Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. J Perinatol 2012;32:374e80. [27] Rogers T. The California Tobacco Control Program: Introduction to the 20year retrospective. Tob Control 2010;19(suppl 1):i1e2. [28] Fang WL, Goldstein AO, Butzen AY, et al. Smoking cessation in pregnancy: A review of postpartum relapse prevention strategies. J Am Board Fam Pract 2004;17:264e75. [29] Pletsch PK. A model for postpartum smoking resumption prevention for women who stop smoking while pregnant. J Obstet Gynecol Neonatal Nurs 2006;35:215e22. [30] Prady SL, Kiernan K, Bloor K, Pickett KE. Do risk factors for post-partum smoking relapse vary according to marital status? Matern Child Health J 2012;16:1364e73. [31] Pletsch PK, Pollak KI, Peterson BL, et al. Olfactory and gustatory sensory changes to tobacco smoke in pregnant smokers. Res Nurs Health 2008;31: 31e41. [32] Brandon TH, Simmons VN, Meade CD, et al. Self-help booklets for preventing postpartum smoking relapse: A randomized trial. Am J Public Health 2012;102:2109e15.
6
N.A. Constantine et al. / Journal of Adolescent Health xxx (2014) 1e6
[33] Hannover W, Thyrian JR, Ebner A, et al. Smoking during pregnancy and postpartum: Smoking rates and intention to quit smoking or resume after pregnancy. J Womens Health 2008;17:631e40. [34] Schneider S, Huy C, Schutz J, Diehl K. Smoking cessation during pregnancy: A systematic literature review. Drug Alcohol Rev 2010;29:81e90.
[35] Roske K, Hannover W, Grempler J, et al. Post-partum intention to resume smoking. Health Ed Res 2006;21:386e92. [36] Reitzel LR, Vidrine JI, Businelle MS, et al. Preventing postpartum smoking relapse among diverse low-income women: A randomized clinical trial. Nicotine Tob Res 2010;12:326e35.
