All informants were daily smokers prior to pregnancy, with a mean number of cigarettes smoked per day at 20. Although almost one half of informants were able to quit at some point in their pregnancy for 3 weeks or more, only 32% remained nonsmokers throughout their pregnancy. In a previous article on smoking during pregnancy among this sample, we identified three distinct patterns that emerged: quitters, harm reducers, and shifters (Nichter et al., 2007
). The first category, “quitters” (n
= 14, 32%), were women who successfully quit smoking through their pregnancy. “Harm reducers” (n
= 19, 43%) were women who engaged in significant harm-reduction efforts (defined as having reduced smoking during pregnancy by at least 50% of their prepregnancy smoking level and maintaining that reduction to the end of term). The third category, “shifters” (n
= 11, 25%), were women who, despite intermittent harm reduction and quit attempts, were unable to reduce their smoking by at least 50% of their prepregnancy level across the months of pregnancy. Their smoking trajectories across pregnancy were marked by short-term and erratic changes with both reductions and increases in smoking occurring. In terms of prepregnancy smoking levels of women in these three groups, the quitters had the lowest daily mean (18 cigarettes per day) compared to the harm reducers (20 cigarettes) and shifters (23 cigarettes).
By 6 months postpartum, considerable changes had occurred in the women’s smoking status. Of the 14 women who had quit smoking during pregnancy, 8 remained quit and 2 other women who had smoked during pregnancy quit. Among women who continued to smoke during pregnancy, by 6 months postpartum almost one half (n = 21, 48%) had reduced their smoking by 50% of their prepregnancy level. An additional 7 women (16%) had reduced their smoking by one third when compared to their prepregnancy levels. Notably, only 6 women (14%) of the sample returned to smoking at the same level as at prepregnancy.
Women Who Quit Smoking During Pregnancy: What Happened Postpartum?
Among those women who had quit smoking during pregnancy (n = 14), all remained quit for the first month postpartum. However, by Month 3 postpartum, 10 women (70%) remained quit, and by Month 6, 8 women (62%) remained quit. Of the 14 women (86%) who reported abstinence, 12 had cotinine levels of less than 50 ng/ml. Of the 8 women who remained quit, 4 were Hispanic and had been low-level smokers prior to becoming pregnant. The other women had developed strong nonsmoker identities during pregnancy and were motivated to stay quit for the health of the baby. Although 6 women did relapse postpartum, it is noteworthy that 6 months following delivery these women were smoking at one half of their prepregnancy level. Thus, these women were still engaging in significant harm-reduction efforts.
Women who had quit smoking during pregnancy and who remained quit postpartum were motivated to do so largely because of strong social support from their partners and friends. Another widely discussed motivation was a concern about being seen smoking by their children, even at very young ages. For example, when asked about her motivations for staying quit after delivery, a mother of three explained, “I don’t really want to start smoking again because it’s expensive but mostly it’s because of my daughter. I look at my baby and I don’t want her to be smoking. And my other kids are at an age when they can really see what I’m doing.”
Below, we discuss case studies of two women who had quit smoking during pregnancy and relapsed postpartum. These case studies allow us to highlight contextual factors that led to resuming smoking after delivery and provide data on how and why women engage in harm-reduction efforts.
Patricia, a 21-year-old multiethnic woman, was married and pregnant with her first child. Before pregnancy, she smoked half a pack to a pack a day. During pregnancy, she gradually reduced her cigarette consumption, and from Month 5 until delivery she was completely abstinent. By 3 months postpartum, Patricia had resumed smoking three cigarettes a day and felt comfortable with her smoking level. Compared to what she had smoked prepregnancy, she explained, she hardly felt like she was a smoker any-more. Having a cigarette helped her deal with boredom: “I have nothing else to do except take care of my son.” Smoking outside her home enabled her to take a much-needed break from the hard work of being a mom and helped her deal with feelings of anger and stress.
Although during pregnancy her husband encouraged her to quit—even reducing his own smoking to just one cigarette a day to offer support—after delivery they began to smoke together while drinking and after meals as a way of spending time together.
Patricia exclusively breast-fed her baby for more than 2 months. As a precaution, she waited some time after having a cigarette before she breast-fed so she would not smell like smoke. She did not think that smoking affected her breast milk, nor did she think that smoking three cigarettes a day would affect her own or her baby’s health if she continued to smoke outside. At the last interview at 6 months postpartum, Patricia’s smoking remained at that level.
Melissa was a single mom, aged 31, who worked full-time to support her three children. Prior to this pregnancy, Melissa smoked a pack or more a day, a number that markedly increased when she went for “girl’s night out.” During her previous two pregnancies, she had reduced her smoking to a half a pack a day. She attributed her success in quitting during this pregnancy to the encouragement and pleading of her two children (aged 10 and 12) who were concerned about her health and the baby’s and to coworkers who smoked but had encouraged her to quit.
Despite wanting to stay quit after delivery, Melissa recognized near the end of her pregnancy that resuming smoking would be a big temptation as a way of “getting her life back.” She explained,
I’m probably gonna socially smoke. I’m gonna go out and get drunk after I have the baby. I’m gonna smoke and I’m gonna drink. Because I’m not pregnant and I can…. I’ll want to put myself in a social environment. I need some adult interaction.
Two months postpartum, Melissa smoked with family members and then resumed smoking one cigarette a day. She initially rationalized her smoking by saying that it might help her reduce some weight but quickly realized that it was not effective. By 4 months postpartum, Melissa was smoking 6 to 8 cigarettes a day and by 6 months postpartum, was up to 10 cigarettes a day. Much of her smoking was done at work or in the evening when the kids fell asleep and she felt bored.
Melissa lived and worked in high-risk smoking environments. Aside from her two children, she had no social support for quitting, as her social network was entirely composed of smokers. At her job, she was offered cigarettes by coworkers as soon as she returned after delivery and pressed to join them for smoke breaks. Her mother was also a smoker, who even smoked around the baby. Melissa expressed concern about this but felt powerless to tell her to stop. Her friends who were smokers also smoked around their children. Melissa felt particularly ashamed when she smoked near the baby, especially while putting her in the car seat and carrying her outside while she smoked. “The baby just stares at me and watches the cigarette,” Melissa observed.
Despite her smoking, Melissa continued to exclusively breast-feed for 3 months and then introduced formula. Although initially she felt it was not good to start smoking again when she was breast-feeding because “at least some nicotine must get to her,” Melissa added, “When it really mattered [in utero], I was quit.” When asked if she waited after having a cigarette to breast-feed, Melissa explained she did not because “nicotine is in your body if you smoke, so it doesn’t matter how long before or after a cigarette you breast-feed.” She noted that smoking had no effect on the quantity of milk she had, although she imagined that “nicotine might create a flavor.”
Although Melissa recognized that she was sending her children the wrong message by smoking around them, she had little motivation to quit because she inhabited a local world where smoking was pervasive. Staying quit also carried a high social risk as it might alienate her from types of social interaction viewed as desirable. Notably, Melissa reduced her smoking significantly from her prepregnancy level from more than a pack a day to a half pack a day. Her motivation for doing so was mostly her children’s desires to see her as a nonsmoker and their concern about her health.
In both case studies presented, we find that the return to smoking postpartum is a gradual process that enables a woman to reenter her social world as either a single or a married woman. Smoking at a reduced level when compared to prepregnancy levels was perceived to be relatively safe, and both women expressed pride that they had not exposed their fetus to nicotine.
Women Who Had Not Quit During Pregnancy: Harm Reducers and Shifters
Harm reducers (n = 19) were women in our study who reduced their smoking significantly (by 50% of their prepregnancy level) during pregnancy. Most of these women were motivated to engage in harm reduction by both issues related to their moral identity as a good mother and concerns about the health of their fetus. Postpartum, we explored whether these women had quit smoking, returned to their prepregnancy levels of smoking (M = 20 cigarettes per day), or experienced new patterns of smoking. Results indicated that by 6 months postpartum, all 19 women (100%) continued to smoke. It is important that, despite the fact that they had not quit, almost 70% (n = 13) of these women still maintained a smoking level that was 50% lower than the amount smoked prepregnancy, at 6 months postpartum. Another 3 women in this category had reduced their smoking by one third of their prepregnancy level, still a substantial reduction. In fact, only 3 women (16%) had returned to the same level they had smoked prepregnancy.
Shifters (n = 11), identified as a distinct category of smoker during pregnancy, were those women who were able to cut back only slightly during pregnancy, typically for a short time, and exhibited erratic smoking patterns, shifting between reductions and increases in their smoking levels (prepregnancy M = 23 cigarettes per day). As a group, these women had the least amount of social support and appeared to be the most vulnerable in the sample, with lives marked by economic, relational, and residential instability. Three of these women were able to quit smoking postpartum (27%), two (18%) reduced their smoking by 50% of their prepregnancy level, and four women (36%) reduced their smoking by one third of their prepregnancy level. Two women (18%) reverted to their prepregnancy smoking level. Reasons for harm-reduction efforts postpartum among the harm reducers and shifters are discussed below.
Reasons for Harm-Reduction Efforts Following Delivery
One reason for reduced smoking in the first month following delivery was the belief that a newborn was particularly vulnerable to smoke. While pregnant, the mother’s body was thought to serve as a filter for the smoke, preventing it from reaching and harming the fetus. After birth and during the first month, cigarette smoke was particularly hazardous to the infant’s small lungs. Once the baby was bigger, however, it was believed that the child would become accustomed to the smoke. This idea might arise in part from providers’ messages that women should limit the exposure of the newborn to residual smoke that might linger on the mother’s shirt by changing their shirt after they have had a cigarette. Once the baby had passed this critical period of vulnerability, many of our informants began to increase their smoking.
Guilt About Smoking and Intentions to Quit
Among the women who engaged in significant harm-reduction efforts, there was a recognition and concern about the harm they might be causing their child. Women expressed considerable guilt about smoking. Many women longed to be a good role model for their child and described their desire to quit before the child was old enough to imitate their smoking or had recognition of their behavior. They believed their smoking would predispose their children to smoke when they got older. One woman vividly related how her friend’s toddler had already used a pacifier as a cigarette, imitating his mom’s frequent smoking. Images of their own children becoming smokers were frequent in their narratives. One woman explained how she already hid her smoking from her 6-month-old baby: “I don’t really want him to see me smoking. I don’t want him to think that’s a cool thing to do…. I know what happened to me and that’s why I wanted to smoke, and I ended up getting addicted.”
Some women hoped that their harm-reduction efforts would enable them to achieve a goal of quitting by the baby’s 1st birthday. They viewed cutting back during pregnancy as a step toward quitting postpartum. Some informants noted that because they were no longer pregnant, they might be able to use the patch or nicotine gum to help them quit—neither of which were allowed during pregnancy. A few women noted that it was important to quit within the 1st year because by the time the baby became a toddler, the baby would require increased energy and ample breath to keep up with.
In interviews, very few women made direct statements about secondhand smoke being unhealthy for their children. Rather, women had only a vague understanding about how tobacco would actually harm their child. As one woman noted,
I still get that guilty feeling…. Everybody’s quick to tell me “don’t smoke,” but nobody’s told me actually what it does. You know, it’s just like, I think it’s better off that I don’t. But they just tell me, “Oh it’s bad, and it’s bad for your health and it’s bad for his health,” but they don’t tell me why.
Significantly, in health care encounters, very few of our informants were asked about their smoking after pregnancy or, if asked, were simply told not to smoke. Typically when the woman said she did not smoke inside the home, the conversation ended there. One informant, when asked if her provider had asked about her smoking, responded, “It’s not like the doctor has given up on me, but I guess they are just used to seeing a lot of women who smoke, because the doctor I go to is for low-income people. He just said, ‘I’m only gonna tell you once.’ After that, he hasn’t asked me nothing.”
Despite intentions to quit smoking, few of these women were able to do so. One factor that reduced their ability to quit was the need to return to work as soon as possible. Most women returned to work environments where coworkers smoked. Many also lived in social worlds where smoking was normative. Spending time with partners, friends, and family often involved smoking as a form of interaction and shared consumption. Some women commented that if their husband or boyfriend were to quit, it would limit their access to cigarettes and there would be less temptation to light up. Other factors that led women to continue smoking were the use of cigarettes as stress management, as self-medication during times of anger, as something to do when bored, and as a way to enjoy oneself in social contexts where drinking and smoking went together.