Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review

Abstract

Aims In pregnant smoking cessation trial participants, to estimate (1) among women abstinent at the end of pregnancy, the proportion who re-start smoking at time-points afterwards (primary analysis) and (2) among all trial participants, the proportion smoking at the end of pregnancy and at selected time-points during the postpartum period (secondary analysis). Methods Trials identified from two Cochrane reviews plus searches of Medline and EMBASE. Twenty-seven trials were included. The included trials were randomized or quasi-randomized trials of within-pregnancy cessation interventions given to smokers who reported abstinence both at end of pregnancy and at one or more defined time-points after birth. Outcomes were validated biochemically and self-reported continuous abstinence from smoking and 7-day point prevalence abstinence. The primary random-effects meta-analysis used longitudinal data to estimate mean pooled proportions of re-starting smoking; a secondary analysis used cross-sectional data to estimate the mean proportions smoking at different postpartum time-points. Subgroup analyses were performed on biochemically validated abstinence. Results The pooled mean proportion re-starting at 6 months postpartum was 43% [95% confidence interval (CI) = 16-72%, I 2 = 96.7%] (11 trials, 571 abstinent women).The pooled mean proportion smoking at the end of pregnancy was 87% (95% CI = 84-90%, I 2 = 93.2%) and 94% (95% CI = 92-96%, I 2 = 88%) at 6 months postpartum (23 trials, 9262 trial participants). Findings were similar when using biochemically validated abstinence. Conclusions In clinical trials of smoking cessation interventions during pregnancy only 13% are abstinent at term. Of these, 43% re-start by 6 months postpartum.

Large multi-centre pilot randomized controlled trial testing a low-cost, tailored, self-help smoking cessation text message intervention for pregnant smokers (MiQuit)

“…Although the trial did not include a formal cost–utility analysis, it is highly likely that, if cessation is maintained in the longer term, the calculated ‘cost‐per‐quitter’ will translate into longer‐term cost‐effectiveness. One can assume that ‘quitters’ gain 1.94 quality‐adjusted life years (QALYs) across their life‐time 42, 43, so by multiplying this value by the seven additional quitters generated by MiQuit the incremental QALYs would be 13.58, making the incremental cost per additional QALY £69.06—even after inflating this figure to take into account relapse to smoking 44, this would remain securely within most accepted cost‐effectiveness benchmarks. Finally, it is noteworthy that the ‘non‐text‐message’ costs of MiQuit are fixed, and so ‘per‐user’ costs fall as the numbers using the intervention increase.…”

Smoking Behavior of Women Before, During, and after Pregnancy: Indicators of Smoking, Quitting, and Relapse

“…Moreover, postpartum relapse rates of women who quit smoking during pregnancy are also high. A meta-analysis showed that 43% of women who stopped smoking during pregnancy began smoking again at 6 months postpartum [12]. In addition, subgroup analyses of this meta-analysis revealed that the rate of women who relapsed at 6 months postpartum increased to 74% when only studies with biochemically validated abstinence data were included [12].…”

“…In contrast, postpartum relapse prevention interventions have shown limited effects [2,17]. It seems that many women and their offspring do not receive the maximum health benefits of smoking cessation [12]. Therefore, there is still considerable room for improvement with regard to cessation and relapse-prevention interventions in pregnancy.…”

The importance of permanent cessation for pregnant smokers

“…Jones et al [1] have clarified the present evidence regarding postnatal relapse to smoking. Future research must improve the quit rate by the end of pregnancy [15], but must also improve long-term cessation.…”

“…Future research must improve the quit rate by the end of pregnancy [15], but must also improve long-term cessation. Future trials must have a postnatal component, as most relapse has happened by 6 months after birth, after which time cessation is likely to be long-lasting [1]. Permanent cessation will provide the maximum return for investment on effective smoking cessation interventions during pregnancy [14].…”