PRINCIPLES & PRACTICE
A Model for Postpartum Smoking
Resumption Prevention for Women
Who Stop Smoking While Pregnant
Pamela K. Pletsch
Behavior change models and theories have
been useful in our efforts to help people stop smoking. However, models that were developed for the
general population do not always fit special populations such as pregnant women. Many women stop
smoking while pregnant, but most resume smoking
after giving birth. To help women who stop smoking
while pregnant to stay smoke-free, a model for tailoring a smoking resumption–prevention intervention to
the special needs of pregnant and postpartum women
is proposed. The intervention begins during pregnancy, continues postpartum, and addresses pregnancy and parenting contextual factors in women’s
lives. The model is based on motivational theory and
includes conducting patient assessments, developing
risk profiles, triaging women to different levels of intervention intensity, and matching intervention strategies to women’s risk profiles. JOGNN, 35, 215-222;
2006. DOI: 10.1111/J.1552-6909.2006.00036.x
Keywords: Smoking and Pregnancy—Smoking
Relapse Prevention—Sources of motivation—SteppedCare and Matching Model
and postpartum women (Curry, McBride, Grothaus,
Lando, & Pirie, 2001). A particularly thorny problem is the substantial number of women who stop
smoking for several months while they are pregnant
but resume after giving birth (Kahn, Certain, &
Whitaker, 2002). The author is in the process of
testing a model for tailoring a smoking resumption–
prevention intervention to the special needs of pregnant and postpartum women.
Accepted: July 2005
Pregnancy and Postpartum
Smoking Patterns
Cognitive behavioral theories and models are
good frameworks for tobacco control interventions,
and public health campaigns and pharmacologic
therapies have been useful intervention strategies
(Fiore et al., 2000; Windsor, Boyd, & Orleans,
1998). Ecologic models have also been useful for understanding the multiple factors that influence people’s smoking behavior (Green, Richard, & Potvin,
1996; Stokols, 1996). However, many theories and
models that were developed for the general population are less useful for tobacco control with pregnant
A substantial number of pregnant women stop
smoking while they are pregnant, but up to 70% resume by 12 months postpartum (DiClemente, DolanMullen, & Windsor, 2000; Hajek et al., 2001; Kahn
et al., 2002; Lelong, Kaminski, Saurel-Cubizolles, &
Bouvier-Colle, 2001; McBride et al., 1999; Mullen,
Richardson, Quinn, & Ershoff, 1997; Quinn, Mullen,
& Ershoff, 1991). Although pregnancy is an opportune time for smoking cessation (McBride, Emmons,
& Lipkus, 2003), the factors that contribute to the
high rates of postpartum resumption are complex
A
substantial number of pregnant
women stop smoking while they are
pregnant, but the majority resume
by 12 months postpartum.
© 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
JOGNN 215
and there is no one apparent path that women follow in
their return to smoking (Bottorff, Johnson, Irwin, &
Ratner, 2000; Scheibmeir & O’Connell 1997). On the
surface, it seems that women who have abstained from
smoking for many months and moved beyond the physical, psychological, and social withdrawal associated with
not smoking have accomplished a long-lasting behavior
change. However, the majority of women resume smoking
during the 1st postpartum year.
Hajek, Stead, West, and Jarvis (2005) in a recent
Cochrane Database review concluded that brief, skillsbased interventions were not effective relapse-prevention
strategies for women who stopped smoking during pregnancy. The proposed model addresses these issues in several ways. The intervention is individualized based on the
context of women’s lives. Postpartum, women are usually
in the same environments that supported smoking before
they were pregnant and have the additional joys and
stresses of caring for and mothering an infant. It is reasonable that women might return to a familiar behavior that
was pleasurable and helped them manage their lives before
they were pregnant. It is likely that parenting and nonparenting issues account for women’s return to smoking.
Thus, the sources of motivation for abstaining or smoking
might differ during pregnancy and postpartum. The proposed intervention spans pregnancy and postpartum to allow for changes in motivation during this transition.
Motivational interviewing (MI) is the primary approach
used in the intervention. With MI counseling, women create strategies that fit their lives and are feasible for them to
accomplish rather than having the counselor teach them
skills. Because pregnancy and the postpartum experience
include many changes, our intervention includes more than
“brief” counseling. It includes one in-depth in-person
counseling session and several telephone counseling sessions over several months. It is proposed that the resumption-prevention model and intervention will be more
effective than previous interventions.
E
ffective resumption-prevention interventions
may decrease women’s return to smoking and
prevent many tobacco-related chronic illnesses.
Sources of Motivation for Becoming a
Nonsmoker
From previous research, the characteristics of women
and their environments associated with smoking resumption are noted in Table 1. These characteristics provide
216 JOGNN
insight about the multiple sources of motivation associated
with smoking or abstinence in pregnant and postpartum
women. Many behavior change models include the following concepts: degree of addiction, readiness to change, selfefficacy, and support. These are useful concepts, and we
have included them in our model. However, we have added
contextual concepts that are appropriate for pregnant and
postpartum women, specifically, concerns for the fetus and
baby, body weight concerns, and mental health. Grouping
these characteristics according to their motivational sources
was useful in developing the intervention model.
Deci and Ryan (1985, 2002) in their discussion of selfdetermination theory did some of the seminal work on
intrinsic and extrinsic sources of motivation as a way to
understand people’s behavior. Deci and Ryan (2002) describe development as a process in which people are motivated and shaped by social norms and values. Intrinsic
motivation comes from within the self and is expressed as
the need to be competent and self-determining. Extrinsic
motivation comes from the social environment and values. People adopt behaviors, values, and attitudes that
are useful for acceptable functioning in the social world.
In their study of pregnant smokers, Curry et al. (2001)
reported that pregnancy and parenthood-related motivational factors were useful in understanding women’s
smoking behavior. They studied pregnant women’s reasons for quitting smoking using a modified Reasons for
Quitting questionnaire (RFQ). The original RFQ was developed for the general smoking population and included
two dimensions of intrinsic motivation (health concerns
and self-control) and two dimensions of extrinsic motivation (immediate reinforcement and social influence.) They
modified the RFQ by adding pregnancy- and parentingrelated reasons for quitting. Their findings indicated that
both recent quitters and continuing smokers have high
pregnancy motivational scores early in pregnancy and that
at 8 weeks postpartum, women who had continued abstinence compared to those who had resumed smoking had
a significantly higher intrinsic to extrinsic motivational
ratio. These findings suggest that both general and pregnancy-specific (PS) motivational factors are important in
understanding postpartum smoking (Curry et al.).
Model Structure
The model was adapted from one proposed by Abrams
et al. (1996) as a guide for matching smoking cessation
counseling to patient characteristics. The purpose of Abrams
et al.’s model was to develop a stronger link between clinical and public health approaches. The 1st phase included
screening, diagnosis, and triage plus biobehavioral (BB) and
comorbidity assessments. Based on people’s dependence
and comorbidity ratings, they were assigned to one of three
levels of intervention intensity: minimal care (self-help),
moderate care (essentially Agency for Healthcare Quality
Volume 35, Number 2
TABLE 1
Characteristics Associated With Postpartum Smoking Resumption
Degree of Dependence
Readiness or stage of change
Self-efficacy for smoking abstinence
Concerns for the baby’s health
Partner or household member smoking
Social influences or support
Mental health
Body weight concerns
Hajek et al. (2001); Ratner et al. (2000)
Curry et al. (2001); Klesges, Johnson, Ward, & Barnard (2001); Stotts et al. (2002)
Severson, Andrews, Lichtenstein, Wall, & Akers (1997); Van’t Hof et al. (2000)
McBride et al. (1999); Van’t Hof et al. (2000)
Severson et al. (1997); Van’t Hof et al. (2000)
Klesges et al. (2001); Van’t Hof et al. (2000)
Kahn et al. (2002)
Pomerleau, Brouwer, et al. (2000); Pomerleau, Zucker, et al. (2001)
and Research’s Clinical Practice Guideline steps of Ask, Advise, Assess, Assist, Arrange) (Fiore et al., 2000), and maximal specialized care (outpatient or inpatient treatment)
(Abrams et al., 1996, p. 294). Abrams et al.’s stepped-care
and matching model was developed for smoking cessation
in the general population, and we have adapted it for resumption prevention with pregnant women. The proposed
model is more tailored than Abrams et al.’s and includes
assessment, development of a risk profile, triaging women
to different levels of intervention intensity, and matching
the timing and content of the intervention to women’s risk
profiles (see Figure 1). All the steps of the model are initiated during the last trimester of pregnancy, but intervention
contacts continue for 3 months postpartum.
Assessment
The 1st step in the model is assessment, which occurs
when women are between 28 and 32 weeks of pregnancy.
The assessment has three dimensions, all of which have
been demonstrated to be associated with smoking behavior: BB, PS, and coconditions (CC). The assessment instruments are listed in Table 2. The BB dimension consists of
intrinsic sources of motivation. The PS dimension includes
extrinsic source of motivation. The CC dimension consists
of both intrinsic and extrinsic sources of motivation (see
Figure 2).
Biobehavioral Dimension. The BB assessment characteristics are those that have been most predictive of resumption in previous studies. The characteristics are degree
of dependence, readiness or stage of change, and selfefficacy. Degree of dependence is an indicator of how
embedded smoking is in a person’s life (Hajek et al., 2001;
Ratner, Johnson, Bottorff, Dahinten, & Hall, 2000). The
more dependent people are on tobacco, the more challenging it is for them to become nonsmokers. In addition, people with high dependence often benefit from the use of
pharmacotherapies and require more intensive intervention and cessation attempts to be successful.
Readiness to change a behavior has been conceptualized in several ways. The transtheoretical model (TTM)
stages of change have been extensively used to assess people’s readiness to change smoking behavior (DiClemente
et al., 1991; Prochaska & Velicer, 1997). According to
this model, women in earlier stages of change are less
likely to be ready to become nonsmokers than women in
later stages. There is some evidence that the standard TTM
model does not fit the special circumstances of pregnancy
and postpartum. Stotts, DiClemente, Carbonari, and
Mullen (1996) reported that processes of change were
expressed differently among pregnant and nonpregnant
groups, suggesting that motivation and coping during
pregnancy are different from that at other times. The same
Assessment Dimensions
BIOBEHAVIORAL
Intrinsic Motivation
Dependence
Readiness/stage
Self -efficacy
PREGNANCY SPECIFIC
Extrinsic Motivation
Concerns for the fetus
Sensory changes to tobacco
COCONDITIONS
Intrinsic
Extrinsic
Depression
Body weight
concerns
Partner/household
smokers
& support
FIGURE 1
Risk assessment.
March/April 2006
JOGNN 217
TABLE 2
Risk Assessment Instruments
Biobehavioral
Instrument
Source
Dependence
Readiness
Self-efficacy
Fagerstrom test for nicotine dependence
Likelihood of resumption
Self-efficacy for smoking abstinence
Heatherton et al. (1991)
Stotts et al. (2000)
Becona et al. (1988)
Pregnancy specific
Reasons for not smoking
Researcher developed, baby focused
Researcher developed, sensory aversion
Concerns for baby, concerns for secondhand smoke
and children
Cigarettes smell bad, lost the taste for cigarettes
Edinburgh postpartum depression scale
Williamson’s body image assessment
Partner interaction questionnaire
Cox et al. (1996)
Williamson et al. (2000)
Cohen & Lichtenstein (1990)
Coconditions
Depression
Body weight concerns
Partner/family support
team (Stotts, DiClemente, & Dolan-Mullen, 2002) found
that women’s reports of the likelihood of resuming smoking by 6 months postpartum were the best predictors
of future smoking behavior. Although the usefulness of
the standard staging algorithms and processes of change
is questionable with pregnant women, the concepts
of readiness and self-efficacy remain good predictors of
postpartum smoking behavior (Stotts, DiClemente, &
Dolan-Mullen; Van’t Hof, Wall, Dowler, & Stark, 2000).
Self-efficacy is the confidence a person has that she can
engage in a new behavior. Strong self-efficacy is a demonstrated predictor of success in adopting a new behavior
such as quitting smoking (Condiotte & Lichtenstein,
1981). The concept of self-efficacy has been incorporated
into many behavior change models (Condiotte &
Lichtenstein; Gwaltney et al., 2002; Velicer, DiClemente,
Rossi, & Prochaska, 1990). The relationship between the
BB characteristics and smoking behavior have been well
substantiated in the literature with both pregnant and
nonpregnant populations.
Pregnancy-Specific Assessment. The presence of unique
motivators and experiences related to pregnancy led us
to include a PS dimension to the risk assessment. The
Matching Strategies
Assessment
Biobehavioral
Pregnancy specific
Coconditions
Anticipate & plan for changes
Increase readiness & self-efficacy
Anticipate & plan for risky situations
Shift motivation from baby to woman
Plan for loss of aversion
Skills for social support/resisting social pressure
Referral for specialized services for depression and
weight management
Risk Profile
Intervention Intensity & Timing
Low BB/Low PS
Low BB/High PS
High BB/Low PS
High BB/High PS
Minimal # contacts - pregnancy & postpartum
Moderate # contacts - concentrated during pregnancy
Moderate # contacts - concentrated during postpartum
Maximal # contacts - pregnancy & postpartum
FIGURE 2
Model (BB = biobehavioral; PS = pregnancy specific).
218 JOGNN
Volume 35, Number 2
characteristics assessed in this dimension are concerns for
the fetus and sensory changes in the taste and smell of
cigarettes. Both sources of motivation are time limited to
pregnancy, disappear after women give birth, and likely
contribute to some women’s return to smoking (Pletsch,
2001, 2002).
A woman’s concern for the health of her fetus is a
strong motivator for stopping smoking and many women
stop smoking just for the pregnancy (McBride et al., 1999;
Van’t Hof et al., 2000). A finding from an earlier study
indicated that most women were trying to be good mothers and protect their babies from harm by not exposing
them to tobacco smoke (Pletsch, 2001). During pregnancy,
when the baby was inside their bodies, the women either
stopped smoking or reduced the amount smoked in an effort to protect the baby. However, after giving birth, when
the baby was outside their bodies, women could protect
their babies by restricting smoking in the home and keeping their babies away from secondhand smoke. Postpartum women believed they could be good mothers by
restricting their baby’s exposure to tobacco smoke, but
still smoke themselves. In addition, many of the circumstances, such as life stressors, that led women to smoke
before they became pregnant were present postpartum
and women returned to the familiar behavior of smoking.
In the same studies, we found that many women developed an aversion to the taste or smell of tobacco smoke
while they were pregnant; this aversion was a primary
motivator for their stopping smoking, and women attributed the aversion to being pregnant (Pletsch & Kratz,
2004). In this study, 73% of women who stopped smoking were smoking again by 3 months postpartum (Pletsch
& Kratz). Several other studies on gustatory and olfactory changes in pregnancy (Tepper & Seldner, 1999)
included anecdotal descriptors of women’s aversion to
the smell and taste of tobacco smoke (Kolble, Hummel,
von Mering, Huch, & Huch, 2001). Thus, women who
stop smoking because they lose the taste for cigarettes
or because the smell has become aversive are likely to
return to smoking when they return to a nonpregnant
physiological state.
Cocondition Assessment. Depression and body weight
concerns can be lifelong issues for women and are associated
with tobacco use. Depression and smoking often occur
together; thus, people’s mental health can have an impact
on their cessation efforts (Kahn et al., 2002; Pomerleau,
Zucker, & Stewart, 2003). Ratner et al. (2000) found that
women with good mental health were less likely to resume
smoking postpartum. In her review article, Mullen (2004)
noted that depression in new mothers was higher among
women who smoked prior to pregnancy, and there was a
strong association between depression and smoking among
nonpregnant women. Therefore, it is important to assess
women for symptoms of depression.
March/April 2006
Smoking is a strategy used by many women to control
their body weight, and many women are concerned about
the potential weight gain associated with smoking cessation (Levine, Perkins, & Marcus, 2001; Pomerleau,
Zucker, Namenek Brouwer, Pomerleau, & Stewart, 2001).
Pregnancy presents a unique situation in which women are
expected to gain weight for a healthy pregnancy, but most
women hope to lose the extra weight after giving birth.
Pomerleau, Brouwer, and Jones (2000) note that pregnant
women who stop smoking but have serious concerns about
body image and weight are in particular need of early
identification and relapse-prevention interventions.
The final CC assessment characteristic is partner or
household member smoking and support. Smoking or
support for not smoking among significant people in
women’s lives have substantial effects on women’s smoking behavior. Having a nonsmoking partner, living in a
smoke-free household, and having family members and
friends who support nonsmoking positively influence
women’s ability to become a nonsmoker (Lelong et al.,
2001; Ratner et al., 2000; Van’t Hof et al., 2000). Conversely, being surrounded by smokers makes it much more
difficult for women to abstain permanently. Women who
have this risk factor need skills to help them resist social
pressure and temptations to smoke so they can be more
successful in becoming lifelong nonsmokers.
Risk Profiles and Triaging
The 2nd step in the model is to develop a risk profile for
each woman. Women are assessed on the three risk dimensions and would be categorized into one of four profiles
based on the BB and PS dimensions: low BB and low PS,
low BB and high PS, high BB and low PS, high BB and high
PS (see Table 1). Because motivation for behavior is complex, each dimension includes several concepts. The BB
and PS dimensions are most relevant for determining the
number and timing of intervention contacts. The CC
dimension is related to specific intervention strategies.
Women would have a high BB score if they had one of the
following: (a) a score of 6 or greater on the Fagerstrom test
for nicotine dependence (Heatherton, Kozlowski, Frecker,
& Fagerstrom, 1991), (b) a score of 2 or less on Stott’s readiness to become a nonsmoker screener (Stotts, DiClemente,
Carbonari, & Mullen, 2000), or (c) a score of 5 or less on
Condiotte and Lichtenstein’s self-efficacy for abstinence
scale (Becona, Frojan, & Lista, 1988; Colletti, Supnick, &
Payne, 1985). Women would have a high PS score if they
reported one of the following reasons for not smoking:
(a) lost the taste for cigarettes, (b) the smell of cigarettes
was aversive, (c) concerns for the baby, or (d) pressure from
family and friends to not smoke during pregnancy.
Referrals would be used for specialized services for depression and weight management from the CC dimension.
Depression is assessed by the Edinburgh Postnatal Depression Scale with a score of 12 or greater indicating risk for
JOGNN 219
depression (Cox, Chapman, Murray, & Jones, 1996). The
Williamson’s Body Image Assessment (BIA-O) is used to assess women’s risk for resuming smoking for weight control
(Williamson et al., 2000). Women with a significant BIA-O
discrepancy score and who use smoking for weight control
would be referred to weight management programs.
Once women are risk assessed and their profiles created, they are triaged to different levels of intervention intensity. All women receive one in-person intervention
contact and one or two telephone contacts while pregnant.
All of the postpartum contacts are by telephone with
women receiving three to six contacts, depending on their
risk profiles. For example, women who have high BB risk
are likely to need more assistance to stay smoke-free and
would receive more intervention contacts (nine contacts,
three during the last 6 weeks of pregnancy and six during
the first 3 postpartum months). Women with high PS risks
are likely to resume smoking shortly after giving birth, so
intervention contacts would be focused more on the antepartum than the postpartum period (six contacts, three
during the last 6 weeks of pregnancy and three during the
first 3 postpartum months).
Matching
The next step in the model is to match intervention
strategies to women’s risk assessments with women choosing intervention priorities. First, women’s risk profiles are
reviewed with them. Then, using an MI change plan worksheet (Deci & Ryan, 2002, p. 137), women identify at
least one tobacco-related goal, create an action plan for
that goal, and think of ways for other people to assist
them. In addition, women identify possible roadblocks to
achieving their goal and the ultimate results they hope to
see. Over the course of multiple intervention contacts,
women can identify new goals and action plans as they
transition from pregnancy to parenthood. If women ask
for advice from the interventionist, a variety of well-documented behavior change strategies are offered. Some typical strategies are anticipating and planning for changes in
the context of smoking, expectancies, and behavioral capabilities (Bandura, 1986), increasing self-efficacy (DiClemente et al., 1991), and anticipating and planning for
risky postpartum situations such as parenting stress, and
social and work environments that support smoking, and
methods for obtaining social support (Marlatt & Gordon,
1985). For example, a woman’s BB assessment indicates
that she has little confidence that she could refrain from
smoking with the stress of having a newborn to care for.
The MI change plan worksheet would be used to help her
devise a plan for stress management. If she asks the interventionist for additional suggestions, the interventionist
demonstrates deep breathing and relaxation techniques,
helps the woman identify stress management techniques
that have worked for her in the past, provides her with
220 JOGNN
written material about stress management and parenting,
and gives her a list of parenting support groups in her
community. The intervention is tailored for each woman
based on a combination of her own problem solving, expertise of the interventionist, and referral to community
resources.
Adoption into Practice
The proposed model of assessment, risk profiling, triaging, and matching addresses the common problems of people
being asked to participate in too few or too many intervention contacts, tailors intervention strategies to focus on personal risk factors, and uses referrals to existing programs for
services that women might need beyond tobacco control.
Telephone counseling is cost-effective and makes the integration into practice more feasible than in-person counseling
visits.
In the prenatal setting, a nurse case manager or a nurse
with additional tobacco control training could deliver the
intervention. Another option is a team approach. Women
could be risk assessed and profiles created by one team
member, such as a registered nurse; counseling and monitoring could be provided by a certified nurse-midwife, registered nurse, tobacco specialist, nurse case manager, or
outreach worker with specialized training; and referrals
managed by a discharge nurse or social worker. The process of using the model in practice would be similar to the
nationally developed smoking cessation guidelines (Fiore,
Bailey, & Cohen, 2000).
I
ndividualized interventions are likely to be
more successful than a one-dimensional
approach.
Summary
Pregnancy has been described as a “teachable moment”
(McBride et al., 2003) and identified as an opportune time
for families to change smoking behavior (DiClemente
et al., 2000). However, previous resumption-prevention
programs have not had a sustained impact on changing
women’s smoking.
The innovative model that has been described integrates
concepts from motivational and behavior change theories
and a practice model. The model is currently being evaluated to refine and modify it. Models such as this can contribute to our understanding of behavior change during
other significant life transitions for women.
Volume 35, Number 2
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Pamela K. Pletsch, PhD, RN, is a professor in the School of
Nursing at the University of Wisconsin, Madison, WI.
Correspondence: Pamela K. Pletsch, PhD, RN, School of Nursing
University of Wisconsin, Madison, Box 2455 Clinical Science
Center, K6/344, 600 Highland Ave., Madison, WI 53792.
E-mail: [email protected].
Volume 35, Number 2