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Motivational interviewing to prevent postpartum relapse

Institution: Kaiser Foundation Research Institute
Investigator(s): Virginia Quinn, MPH
Award Cycle: 1997 (Cycle 6) Grant #: 6KT-0206 Award: $282,502
Subject Area: Tobacco-Use Prevention and Cessation
Award Type: New Investigator Awards

Initial Award Abstract
The goal of this study is to develop and test an innovative relapse prevention program for women who stop smoking during pregnancy. Pregnancy offers women one of the best opportunities to stop smoking. Nearly half of the women who were smoking prior to pregnancy take advantage of this time of change and quit smoking, mainly to protect the health of their unborn child. Unfortunately, rates of relapse after delivery are high with as many as 70% of the quitters returning to smoking within 6 months of delivery.

Cigarette smoking is associated with many serious illnesses, especially those related to heart and lung disease. Although smoking carries additional risks for women of reproductive age, more than 25% of US women between the ages of 18 and 44 continue to smoke. Postpartum relapse re-exposes women to the health dangers of smoking. Further harm is done by exposing infants and children to passive smoke. Numerous studies have documented increased rates of respiratory infections, including pneumonia, bronchitis, and ear infections. More recently, passive smoke has been implicated in Sudden Infant Death Syndrome.

To develop an effective program we will adapt the principles and techniques of motivational interviewing to the context of postpartum relapse. Motivational interviewing is a supportive, non-judgmental counseling style that appears to be especially useful with behaviors that are difficult to change. It helps clients weigh the benefits and costs of their behaviors. The counseling will be delivered over the telephone by trained health educators in 4 to 6 brief calls. The literature identifies the influence of powerful barriers to maintenance such as being around other smokers, having a partner who smokes, and lack of confidence in the ability to stay off cigarettes. Counselors will help women identify their personal threats to maintenance, including lack of motivation to stay off cigarettes, and will assist women in developing effective coping strategies. The content of the program will be developed from telephone interviews and focus groups conducted among white, black, and Latino women who quit smoking during pregnancy. Subjects will be recruited from the diverse population of Southern California Kaiser Permanente. The effectiveness of the motivational interviewing program will be measured by comparing the bio-chemically confirmed 6-month postpartum abstinence rates among women who received the counseling program and women who did not.

An effective postpartum relapse prevention program would make a significant contribution to the health of young women, their newborn infants, and other family members.

Final Report
Pregnancy offers a special opportunity for smoking cessation and in response to strong beliefs about the dangers to fetal health, approximately half of the women smoking before pregnancy report quitting. Unfortunately, these health gains are eroded by high rates of postpartum relapse. In addition to re-exposing women to the harm of smoking, passive smoke endangers infant and child health. To promote healthy smokefree families, we developed and tested a proactive telephone-based motivational counseling program to help prenatal quitters remain abstinent after delivery.

Methods: Data were obtained from telephone interviews at baseline in the 8th month of pregnancy and at 6 months postpartum. Women who reported 7-day abstinence in the follow-up interview were mailed a saliva collection kit for biochemical verification of smoking status. We randomly assigned 270 women who reported they had stopped smoking for pregnancy to either usual care (C-group) or the experimental group (E-group) (usual care and the counseling program). After attrition, 233 women remained eligible for analysis. No significant differences were found between study groups by rates or reasons for attrition, or for baseline characteristics. Slightly more than half the subjects were white, a third were Latino, and 14% were another racial/ethnic group. The average age was 26 and they had completed 13 years of education. At recruitment subjects reported they had been quit for >5 months. Most (98%) held strong beliefs about the harmful effect of maternal smoking on fetal health and the majority (81 %) planned to "stay off cigarettes for good."

Results: E-group women received on average 5 calls that began late in pregnancy and extended through the 6th month postpartum. Women gave high ratings on items that assessed rapport building and confidence in the counselor's ability to help. Fewer E-group women reported smoking at 6 months postpartum than controls (22% v. 41%, p<.01). Importantly, fewer E-group women returned saliva samples for biochemical validation (66% v. 75%, NS) and more often test positive for smoking (9% v. 6%, NS). When women without samples or with positive samples were classified as relapsers, the difference in relapse rates between groups became nonsignificant (53% v. 58%). Of note, in the subgroup of women who lacked postpartum social support for their efforts to remain abstinent, the counseling helped (60% of E-group relapsed v. 81 % of C-group, -p<.01).

Logistic regression analysis revealed women with many smokers in their social network were more than six times as likely to relapse (OR=6.21, p<.01). Women exposed to postpartum passive smoke were twice as likely to relapse (OR=2.01, p<.05). And, women with stronger temptations to smoke due to addiction also were more likely to relapse (OR=1.33, p<.01). In addition, we found two protectors against return to smoking. Women who breast fed their infants were half as likely to relapse (OR=.45, p<.05) and women with a great deal of postpartum smoking-specific social support also relapsed less often (OR=.45, p<.01).

Conclusions: Results demonstrate the importance of biochemical verification of self-reported postpartum abstinence. Despite high ratings from participants, the telephone-based counseling program was ineffective overall. However, those women without a great deal of smoking-specific social support after delivery appear to have been helped. Study results highlight the importance of the social environment for postpartum maintenance. While perinatal smoking experts continue to learn more about the special characteristics of pregnant smokers and quitters, the challenge remains to translate this knowledge into effective interventions.