Objective: Review and examine existing research, current strategies, and directions for future research on smoking cessation relapse and relapse prevention in pregnancy and postpartum.Methods: A MEDLINE/PubMed search in 2002 and 2003 for articles containing the key words "smoking," "pregnancy," "cessation," and "cessation relapse prevention" and references of retrieved papers yielded a review of more than 500 articles. Only 14 of these addressed program-based strategies to increase cessation among pregnant women through relapse prevention programs.Conclusion: Although there is much information on the rationale and strategies for smoking cessation for pregnant women, fewer studies exist on how to prevent relapse. Throughout the past decade, tobacco use has remained the single most important modifiable cause of poor pregnancy outcome in the United States. Smoking accounts for 20% of deliveries of infants with low birth weights, 8% of preterm births, and 5% of all perinatal deaths. Smoking during pregnancy and in postpartum contributes to sudden infant death syndrome and changes in brain and nervous system development. The direct medical costs of a complicated birth for a smoker are 66% higher than for nonsmokers. 1 Relapse rates range from 70% to 85% among women who smoke but quit at some time during their pregnancy. A recent 10-year study (1987 to 1996) of 8808 pregnant women and 178,499 nonpregnant women of childbearing age indicated that the prevalence of current smoking has decreased significantly among both pregnant (16.3% to 11.8%) and nonpregnant women (26.7% to 23.6%).2 This drop in smoking over time among pregnant women was primarily caused by the overall decline in smoking initiation rates among women of childbearing age, not by an increased rate of smoking cessation related to pregnancy.Although one fifth of pregnant smokers spontaneously quit by the time of their first antenatal visit, 3 and pregnant women are half as likely as nonpregnant women to be smokers, 2 an estimated 20.4% of women smokers continue smoking throughout their pregnancies. 4 For women who do quit during pregnancy and who received a planned intervention, between 6.2% and 37.2% remained smoke-free. The range of relapse rates is broad because of the varying success of the cessation intervention strategy. Between 29% and 85% of women who get a planned intervention relapse after delivery. 5-16Although there is much information on why and how pregnant women should quit, fewer data exist on how to prevent relapse. This article is a literature review on relapse and relapse prevention in pregnancy; we looked at existing research, current strategies, and directions for future research.

This qualitative study explores smoking cessation during pregnancy and the factors that contribute to remaining smoke-free and relapsing. Ninety-four women attending prenatal clinics in central North Carolina who had quit smoking before 30 weeks gestation were enrolled in an observational study that included a face-to-face interview at 4 months postpartum. Results were analyzed for common themes in the two groups: those who remained smoke-free and those who had relapsed. Fetal health motivated pregnant women to quit smoking, while stress, socializing with smokers, cravings, and easy access to cigarettes tempted women to smoke. Women who remained smoke-free postpartum overcame temptations by continuing to acknowledge the health benefits of not smoking and having a strong internal belief system, significant social support, negative experiences with renewed exposure to cigarettes, and concrete strategies for dealing with temptations. For women who relapsed postpartum, factors having the greatest influence on relapse included easy access to cigarettes, lack of social and financial support, insufficient resources for coping with the challenges of childrearing, physical addiction, reliance on cigarettes as a primary form of stress management, and feelings of regret, shame, or low self-esteem. Recommendations for relapse prevention include assessing women who quit during pregnancy for low or high risk of relapse and offering comprehensive interventions and case management for those at higher risk to address the physical, mental, behavioral, and social contexts leading to relapse.