Research article
Weight Concerns, Mood, and Postpartum Smoking Relapse

https://doi.org/10.1016/j.amepre.2010.05.023Get rights and content

Background

The majority of women who quit smoking as a result of pregnancy will resume smoking during the first 6 months postpartum. Evidence suggests that changes in depressive symptoms, perceived stress, and concerns about weight may relate to postpartum smoking relapse.

Purpose

This study was designed to prospectively evaluate the relationship of mood and weight concerns to postpartum smoking among women who quit smoking during pregnancy.

Methods

Pregnant women who had quit smoking (N=183) were recruited between February 2003 and November 2006. Women completed assessments of mood (depressive symptoms, perceived stress, positive and negative affect) and weight concerns during the third trimester of pregnancy and at 6, 12, and 24 weeks postpartum. Self-reported smoking status was verified by expired-air carbon monoxide and salivary cotinine at each assessment. Cox regression analyses in which mood and weight concerns were treated as time-dependent covariates were conducted in 2007 and 2009.

Results

By 24 weeks postpartum, 65% of women had resumed smoking. Smoking-related weight concerns increased risk of relapse, and positive affect and self-efficacy for weight management without smoking decreased risk of relapse postpartum. Moreover, after controlling for variables previously related to postpartum relapse, weight concerns remained significantly related to smoking relapse.

Conclusions

Smoking-related weight concerns and positive affect increase the likelihood that a woman will resume smoking postpartum. Moreover, weight concerns appear to be salient even in the context of other factors shown to affect postpartum smoking. This study suggests that interventions may need to address women's weight concerns and mood to help sustain smoking abstinence after childbirth.

Introduction

The majority of women who quit during pregnancy will resume smoking following childbirth, thereby exposing their young children to tobacco smoke. By 6 months postpartum, at least 60% of women who had quit during pregnancy will have returned to tobacco smoking.1, 2, 3, 4 In addition to the negative health consequences of smoking for the women themselves,5, 6, 7, 8, 9, 10 the effects of second-hand exposure on children are substantial. Tobacco smoke exposure has been linked to many childhood medical problems, including sudden infant death syndrome, ear infections, respiratory illness, and asthma,11, 12 as well as to deficits in cognitive and behavioral performance among children.13, 14, 15 Given the importance of preventing postpartum smoking, a greater understanding of factors associated with postpartum smoking relapse, particularly factors that are modifiable, will inform efforts to sustain smoking abstinence and thereby positively affect the health of women and children.

To date, studies have identified several demographic and situational factors related to smoking. The use of alcohol,16 minority race,17, 18 higher levels of nicotine dependence,4, 17, 19 and lower levels of education18 have been associated with a resumption of smoking after pregnancy. In addition, having a partner who smokes has received consistent support2, 4, 16, 19, 20, 21 as a correlate of postpartum smoking. In contrast, support2, 4, 20, 22 for another hypothesized risk factor, bottle- rather than breast-feeding the baby, has been inconsistent.

Mood changes and concerns about shape and weight also may relate to postpartum smoking23 and would represent modifiable targets for prevention interventions. Many women experience depressive symptoms postpartum,24, 25 and depressive symptoms have been associated with smoking relapses,26, 27, 28, 29 independently of nicotine dependence.30 Moreover, major depressive disorder31, 32 and depressive symptoms during pregnancy33 have been linked to postpartum smoking, as have depressive symptoms during the first 6 months postpartum34 and the self-report of lifetime depression.35 Stress also relates to postpartum smoking relapse.33, 35, 36

Similarly, maladaptive eating attitudes, dieting behaviors, and concerns about shape or weight increase postpartum,37, 38 suggesting that weight concerns are common during the postpartum period. Weight concerns affect smoking, particularly among women,39, 40 and initial evidence suggests that this may be true for postpartum smoking as well. For example, concerns about weight,2, 19 having gained more than an average amount of weight during pregnancy,17 and the use of snacking as a strategy to cope with prenatal smoking urges19 have been related to postpartum relapse. Remaining abstinent from smoking has been associated with increased confidence in preventing weight gain,41 and self-efficacy to manage weight has been linked to greater motivation for maintaining postpartum abstinence.42

In summary, although available evidence suggests that mood and weight can increase vulnerability to smoking relapse postpartum, previous studies have often relied on single-item assessments of complex mood and weight concern variables and cross-sectional, retrospective comparisons. Prospective data, using validated assessment instruments to investigate the roles that changes in mood and weight concerns play in postpartum smoking relapse, are lacking. Systematic evaluation of these variables is particularly important because weight concerns and mood are modifiable and may make important targets for interventions to prevent relapse. Accordingly, the present study was designed to examine the relationship of weight concerns and mood experienced during pregnancy in the context of other demographic and situational factors that may affect postpartum smoking relapse. Specifically, it was hypothesized that women who reported mood symptoms, stress, or concerns about weight over the course of the first 6 months postpartum would be more likely to return to smoking.

Section snippets

Procedure

The current study was conducted at a large, urban hospital in Pittsburgh, PA, and was reviewed and approved annually by the local IRB. Participants were recruited through advertisements in local media that targeted pregnant women in outpatient obstetric and gynecologic clinics as well as agencies serving women and children between February 2003 and November 2006. Women who contacted the study were screened for eligibility by phone, and interested women who were not currently in the third

Relapse Rates

Rates of biochemically verified abstinence from smoking at 6, 12, and 24 weeks postpartum were 53.5% (n=98); 37.7% (n=69); and 34.7% (n=44), respectively. On average, relapse to smoking occurred 43.8 (SD=45.2) days after delivery for women who resumed smoking by 24 weeks.

Discussion

The current study provides the first prospective documentation of the relationship between weight concerns and postpartum smoking relapse, and augments previous data suggesting the role of mood symptoms in relapse by using established measures of mood, affect, and stress. Findings also suggest new targets for intervention to minimize smoking relapse postpartum. Specifically, these data suggest that positive affect and weight concerns relate to the resumption of smoking in the postpartum period.

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