3. Engage in relapse prevention

Helping pregnant women to quit or reduce smoking is different from helping other smokers. Pregnant smokers have unique cessation issues (e.g., social pressures to quit, high rates of relapse, physiological changes, brief time period) compared to other women. High postpartum relapse rates demonstrate that we need to treat pregnant and postpartum women differently than other smokers. Pregnant women often appear to experience the “quitting” process, but end up returning to smoking behaviour.

Given the high likelihood of relapse after the baby is born, it is very important to continue to engage with women regarding their smoking throughout pregnancy and in the postpartum period. Things to consider:

  • Cessation during pregnancy may really be a temporary abstinence from smoking, rather than a permanent behaviour change.
  • Some women may be experiencing a “suspended identity” as a non-smoker.
  • No actual shift in identity from smoker to non-smoker may have occurred, particularly if cessation is externally motivated (i.e., for the fetus/baby).
  • Relapse is often viewed as a reward after pregnancy and may have been planned.

Practice Tips

  • Normalize cessation as a journey or process

    For women who have "slipped," tell them you understand that it is hard to quit and stay quit.
  • Re-visit women’s reasons for smoking and quitting

    Focus on the woman’s health and the continued benefits of staying quit. Discuss the additional stressors in her life after the birth. Discuss the harmful effects of ETS to the baby’s health and to the woman’s own health.
  • Monitor and support  "spontaneous quitters," especially in the postpartum period

    The majority of women who quit during pregnancy report doing so on their own without formal intervention. Spontaneous quitters tend to be older, more highly educated, less addicted, and less likely to have partners who smoke.
  • Encourage women to continue breastfeeding

    even if they smoke or are using NRTs to aid their cessation. Health Canada recommendations state that smoking is not a contraindication to breastfeeding.
  • If a woman has relapsed, ask her about her goals

    For example,  
    1. At this time, which of the following best describes your personal goal with regard to smoking after pregnancy?
      1. To stay off cigarettes;
      2. To control where and when you smoke;
      3. To go back to smoking;
      4. You are not sure what your goal is right now)
    2. How likely are you to smoke in the first six months after the baby is born?
      1. Extremely likely to smoke;
      2. Very likely;
      3. Somewhat likely;
      4. Not very likely;
      5. Not at all likely to smoke.
    3. Since your prenatal visit, have you smoked a cigarette, even a puff?
      1. Yes
      2. No
  • From: Stotts, A. L., DiClemente, C. C., Carbonari, J. P., & Mullen, P. D. (2000). Postpartum return to smoking: Staging a "suspended" behavior. Health Psychology, 19(4), 324-332.

    Resources

    Your Body Will Forgive You

    My World without Smoking

    The I’m a STAR! Journal for moms who smoke and want to protect their kids from secondhand smoke

    Further Reading

    Fang, W. L., Goldstein, A. O., Butzen, A. Y., Hartsock, S. A., Hartmann, K. E., Helton, M., & Lohr, J. A. (2004). Smoking cessation in pregnancy: A review of postpartum relapse prevention strategies. Journal of the American Board of Family Practice 17(4), 264-275.  PMID: 15243014 Free full-text»

    Mullen, P.D., (2004). How can more smoking suspension during pregnancy become life long abstinence? Lessons learned about predictors, interventions, and gaps in our accumulated knowledge. Nicotine and Tobacco Research 6(Suppl. 2), 217-238. doi: 10.1080/14622200410001669150

    Back to 5 ways to Change Your Practice

  • Resources for Health Care Providers
  • Physical discomfort due to pregnancy or following birth

    Pregnant women experiencing discomfort may have exhausted all their usual coping strategies. By viewing smoking as the only thing that “keeps them sane,” pregnant women may cling to smoking. Tell women that you appreciate how hard it is to quit and stay quit.

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