Helping women who quit smoking during pregnancy to stay quit postpartum is a key public health goal. The present study aimed to determine whether depressive, anxiety, and stress symptoms were associated with postpartum smoking among women who had stopped smoking during pregnancy. To our knowledge, this is the first study to explore the relationship between depressive, anxiety, and stress symptoms assessed repeatedly after delivery and smoking status by 24 weeks postpartum. Women who were smoking by 24 weeks postpartum had a higher score of combined depressive, anxiety, and stress symptoms compared with women who were nonsmokers. Depressive and stress symptoms were significantly associated with risk of relapse.
Previous research has shown a relationship between mood and postpartum relapse to smoking among women who met clinical criteria for depression (Whitaker et al., 2007
), but our work suggests that a relationship exists between postpartum depressive symptoms and postpartum relapse. Solomon et al. (2007)
showed an association between end-of-pregnancy depressive symptoms (BDI
6.0 for nonsmokers and 8.9 for smokers) and postpartum relapse. We found that changes in postpartum depressive symptoms, even among our sample of women with low levels of depressive symptoms at delivery (mean BDI at delivery
5.7 for nonsmokers and 5.3 for smokers), were associated with postpartum relapse by 24 weeks. Nonsmokers’ depressive symptoms decreased, whereas smokers’ depressive symptoms increased. Women who relapsed mentioned depressive symptoms when describing their episodes.
Our findings also suggest that a relationship exists between prepregnancy or prenatal mood and postpartum smoking. Women who relapsed by 24 weeks were more likely to report a history of ever having struggled with depression and having antenatal counseling for depression or anxiety, compared with women who did not relapse. Some clinical implications can be drawn about this subgroup of women with a depressive history who are at risk for postpartum relapse. First, clinicians should take care to address depressive symptoms during pregnancy and to prepare women for mood changes postpartum. Second, these women should be monitored postpartum to help them cope with mood changes or challenges as they occur; referrals for psychological support might be beneficial.
We found evidence that changes in perceived stress over 12 weeks postpartum were associated with smoking status at 24 weeks. Smokers’ perceived stress symptoms increased, whereas nonsmokers’ stress symptoms decreased. Women's qualitative descriptions of their relapse experiences highlighted the influence of stress and a dearth of skills needed to manage stress. Our findings are similar to a qualitative study (Letourneau et al., 2007
) conducted with inner-city women, in which stress was the most commonly cited reason for postpartum return to smoking. Clinicians might consider helping women to monitor their stress levels postpartum; women could benefit from being taught strategies to cope with elevated stress.
We did not detect a significant effect of anxiety on 24-week smoking status, although the slope of anxiety symptoms decreased more among nonsmokers at 24 weeks than it did among women who smoked. Some women admittedly smoked due to being “nervous” or “anxious,” but smokers described being affected by stress rather than anxiety.
In the present study, as in others (McBride & Pirie, 1990
; Solomon et al., 2007
), approximately half of women who returned to smoking did so within the initial 6 weeks postpartum. Future studies might explore whether there are different risk factors for “early” (within 6 weeks) versus “late” (6 weeks to 6 months) relapse. For example, some women relapsed early on in the postpartum period due to the stress of having a newborn, whereas others who relapsed around 12 weeks attributed their relapses to stress due to concerns about returning to work. Postpartum relapse prevention interventions for these women would have a different focus and timing.
We observed a relationship between these emotions and postpartum smoking, even though study participants were light smokers (prepregnancy average daily smoking rate was 8.4 cigarettes). As a comparison, Solomon et al. (2007)
found that end-of-pregnancy BDI scores were related to 6-month smoking relapse and that the mean daily prepregnancy smoking rate was 15.2 cigarettes for smokers versus 10.1 cigarettes for abstainers. However, the relapse rate in our study was similar to previous studies, so the low rate of prepregnancy smoking was not salient in this work.
Study limitations should be noted. First, we relied on self-report to assess smoking status. Second, the sample size limited the power of our analysis to detect differences in BDI, BAI, and PSS scores between smokers and nonsmokers. Therefore, we cannot rule out a small effect of anxiety symptoms on postpartum smoking. The sample size also precluded our ability to adjust for potential confounders in the relationship between BDI, BAI, and PSS symptoms and postpartum smoking (e.g., smoking addiction, low social support, and weight gain concerns). Finally, although we assessed depressive, anxiety, and stress symptoms repeatedly, more frequent quantitative and qualitative assessments using an ecological momentary assessment technique (Shiffman et al., 2007
) would provide further insights into the relationship between these symptoms and postpartum smoking, as well as the context-specific triggers of relapse.
Three areas deserve further exploration with this population to inform clinical interventions. First, specifically which emotional symptoms are the most salient in this relationship? For example, within depression, is it irritability or a sense of worthlessness associated with relapse? Although we measured the BDI and BAI multiple times postpartum, we did not have a large enough sample size to examine which symptoms, or cluster of symptoms, were associated with postpartum relapse. A postpartum stressors scale is needed to assess the prominence and effects of specific stressors. Second, what are women's emotional coping processes? Qualitative descriptions of relapse episodes suggested that these women might struggle with affect regulation. They did not seem to know how to cope with negative feelings, so they reverted to smoking. Third, what is the relationship between emotions and other relapse risk factors? For example, are women more vulnerable to depressive symptoms when they are particularly sleepy?
In summary, the present study found that a composite of depressive, anxiety, and stress symptoms in the 24 weeks following delivery was associated with postpartum smoking among women who quit smoking during pregnancy. Larger, in-depth studies are needed to elucidate these associations and target risk factors to prevent postpartum relapse to smoking.