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Maternal and Child Health Journal ISSN 1092-7875 Matern Child Health JDOI 10.1007/s10995-012-1108-6
Smoking Status and Factors Associatedwith Smoking of First-Time MothersDuring Pregnancy and Postpartum:Findings from the Healthy Beginnings Trial
Huilan Xu, Li Ming Wen, Chris Rissel &Louise A. Baur
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Smoking Status and Factors Associated with Smokingof First-Time Mothers During Pregnancy and Postpartum:Findings from the Healthy Beginnings Trial
Huilan Xu • Li Ming Wen • Chris Rissel •
Louise A. Baur
� Springer Science+Business Media, LLC 2012
Abstract This study aimed to investigate smoking status
and factors associated with smoking among first-time
mothers and their partners during pregnancy and post-
partum. A prospective cohort study with 201 first-time
mothers was conducted using data from the Healthy
Beginnings Trial, undertaken in one of the most socially
and economically disadvantaged areas of south-western
Sydney, Australia in 2007–2010. Smoking status of the
mothers and their partner and smoke-free home status were
assessed at 30–36 weeks of pregnancy, and also at 6, 12
and 24 months postpartum. Multivariable two-level logis-
tic random-intercept models were conducted. Smoking
rates of the first-time mothers were 17.6 % during preg-
nancy and 22.5 % postpartum. The likelihood of being a
current smoker among the mothers significantly increased
after giving birth, with an adjusted odds ratio of 3.96 (95 %
CI 1.3–12.1) at 6 months, 6.19 (95 % CI 1.84–30.9) at
12 months, and 6.58 (95 % CI 1.86–23.23) at 24 months
postpartum. Mothers’ smoking status was significantly
inversely associated with educational level and positively
associated with their partner’s smoking status. In addition,
mothers who breastfed their child were significantly less
likely to be a smoker, with an adjusted odds ratio of 0.10
(95 % CI 0.02–0.68). Although pregnancy may act as a
motivator to quit smoking, it is of concern that maternal
smoking rate increased after giving birth. Smoking cessa-
tion programs should not only focus on smoking in preg-
nancy, but also address other risk factors, particularly in
postpartum women and their partners.
Keywords Smoking status � First-time mothers �Pregnancy and postpartum
Introduction
Pregnancy and childbirth are recognized as good opportu-
nities for parents to quit smoking and institute a smoke-free
home [1]. Unfortunately, pregnancy related smoking
abstinence does not typically lead to lifelong abstinence,
even with a smoking cessation intervention [2, 3]. Previous
studies have found that many mothers who quit during
pregnancy relapse within 6 months postpartum [4–8]. For
example, one study found that 41 % of those mothers who
quit smoking during pregnancy resumed smoking at
2 weeks postpartum [8]. Another study found that 72 % of
those mothers returned to smoking at 12–22 months [9].
Some factors such as mother’s educational level, having a
partner who was a smoker, and self-reported stress were
identified as contributing factors to smoking relapse [4–10].
Converting smoking abstinence during pregnancy to
lifelong abstinence is beneficial not only to the health of
mothers but also to the health of children and other family
members. Many studies have found that smoking abstinence
after giving birth is associated with longer breastfeeding time
[11–17]. Hence, young children benefit from their mother’s
smoking abstinence by both being not exposed to environ-
mental tobacco smoke and longer breastfeeding. Mothers’
H. Xu � L. M. Wen (&)
Health Promotion Service, South Western Sydney and Sydney
Local Health Districts, Level 9, King George V Building,
Missenden Road, Camperdown, NSW 2050, Australia
e-mail: lmwen@email.cs.nsw.gov.au
L. M. Wen � C. Rissel � L. A. Baur
School of Public Health, Sydney Medical School,
University of Sydney, Sydney, NSW 2050, Australia
L. A. Baur
Discipline of Paediatrics and Child Health, Sydney Medical
School, University of Sydney, Sydney, NSW 2050, Australia
123
Matern Child Health J
DOI 10.1007/s10995-012-1108-6
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smoking abstinence is also beneficial to their next pregnancy
[18]. Their partner may also be persuaded to quit smoking or
at least declare their home smoke-free [19]. Therefore,
understanding the factors associated with the smoking status
of mothers and their partners during pregnancy and the
postpartum period may help to develop effective interven-
tion strategies regarding parent smoking cessation.
Most previous studies on maternal smoking have
\1 year follow-up, or only have examined smoking rates
and risk factors using cross-sectional data [5, 6, 8–11, 13–
16, 20]. However, some factors of interest might change
over time for each individual, such as smoking status,
marital status, household income, and stress level.
To investigate smoking status and the factors associated
with smoking among first-time mothers and their partners,
as well as smoke-free home status during pregnancy and
postpartum, we conducted a longitudinal data analysis
using prospective cohort data derived from the Healthy
Beginnings Trial which followed mothers from 30 to
36 weeks of pregnancy to 24 months postpartum [21].
Methods
Study Design
A prospective cohort study was conducted using data from
the Healthy Beginnings Trial, which was undertaken in one
of the most socially and economically disadvantaged areas
of south-western Sydney in 2007–2010. The study was
approved by the Ethics Review Committee of Sydney
South West Area Health Service (RPAH Zone). The details
of the Healthy Beginnings Trial research protocol have
been reported elsewhere [21].
Sample Selection
The Healthy Beginnings Trial is a home-based randomised
controlled trial aiming to determine whether a home-based
early intervention could be effective in improving infant
feeding practice and reducing overweight and obesity for
children at age 2 years. A total of 667 first-time mothers at
24–34 weeks of pregnancy were recruited to the trial from
antenatal clinics at Liverpool or Campbelltown Hospitals,
located in south-western Sydney, Australia. First-time
mothers who were aged 16 years and over, and able to
communicate in English were eligible for the trial. Once
eligibility was established and consent obtained, mothers
were asked to fill in a registration form with their contact
information to allow the research assistants to make further
arrangements for the baseline data collection.
For this particular study, we only selected mothers who
were allocated to the control group (n = 330) to avoid any
potential effects of the intervention (i.e. breastfeeding). In
the control group, 201 mothers were interviewed at their
home before giving birth. Another 129 mothers who were
interviewed within 1 month after giving birth were exclu-
ded, as we were not able to obtain late pregnancy smoking
information for these mothers.
Data Collection
Face-to-face interviews with each participating mother
were conducted by one of two research assistants at
30–36 weeks of pregnancy, and also at 12 and 24 months
postpartum, respectively. A telephone interview survey
with participating mothers was also conducted by a
research assistant at 6 months postpartum. The interviews
asked a range of questions including the mother’s demo-
graphic characteristics, general health status, smoking sta-
tus, smoke-free home status, breastfeeding, and their
partners’ smoking status. The majority of these questions
have been validated in an adult population and are widely
used in NSW population health surveys [22].
To assess the smoking status of mothers and their
partners, mothers were asked, ‘currently, are you a daily
smoker, or occasionally smoker, did you quit smoking
during pregnancy, did you quit smoking sometime ago, or
have you never smoked?’ The mothers were also asked to
report on their partner’s smoking status. For this analysis,
daily or occasional smokers were categorised as current
smokers and the rest were non-smokers.
To assess smoke-free home status, mothers were asked,
‘Which of the following best describes your home situation?’
It was categorised as a smoke-free home if mothers reported
no one smoked inside the home. To assess breastfeeding
status, mothers, at 6, 12, and 24 months postpartum, were
asked ‘Is your child currently being breastfed?’
Statistical Methods
Statistical analyses were carried out using Stata 10 [23].
The relationship of mothers’ smoking status at baseline
(late pregnancy) with demographic variables was examined
using Pearson Chi-square tests. In this study, we had lon-
gitudinal data with 4 measurement points (at late preg-
nancy, 6, 12, and 24 months postpartum), which can be
conceptualised as two-levels with the time points (level 1)
nested in subjects (level 2). Because the measures of a
particular outcome (i.e. smoking status) at 4 time points
from an individual are highly correlated, in the sense that
the measures from the same individual are likely to be
more similar than that from different individuals,
these correlations have to be taken into account when
building statistical models. To address these issues we
used univariable and multivariable two-level logistic
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random-intercept models to analyse how smoking status of
mothers and their partner, and smoke-free home status
changed over time (late pregnancy, 6, 12, and 24 months
postpartum) and what the contributing factors were. Odds
ratios (ORs), adjusted ORs (AOR) and 95 % confidence
intervals (CIs) were estimated.
Four multivariable two-level logistic random-intercept
models were fitted. A stepwise selection process was used
to build the final models. Subjects with missing data at all 4
time points for any variables in the two-level random-
intercept models were excluded from analysis [24, 25].
In the first model (the outcome was mothers’ smoking
status at late pregnancy, 6, 12, and 24 months postpartum),
the effect of time was adjusted for partner’s smoking status
that varied over this period of time, and mothers’ educa-
tional level at late pregnancy. In this model breastfeeding
was not included since there was no breastfeeding infor-
mation at late pregnancy.
The second multivariable two-level logistic random-
intercept model was fitted to investigate the effect of cur-
rent breastfeeding status (yes, no) on mothers’ postpartum
smoking status over time (6, 12, and 24 months post-
partum). The effect of breastfeeding was adjusted for
partner’s smoking status that varied over time and mother’s
education level.
In the third model (the outcome was the partner’s smoking
status at late pregnancy, 6, 12, and 24 months postpartum),
the effect of time was adjusted for mother’s smoking status
that varied over time, and partner’s educational level.
The fourth model was fitted to investigate how the
smoke-free home status changed during the period of late
pregnancy and 24 months postpartum. The effect of time
was adjusted for mothers’ employment status that varied
over this period of time and partner’s educational level.
Results
Of 201 mothers selected from the baseline (late pregnancy),
172, 162 and 146 remained in the study at 6, 12, and
24 months postpartum, respectively. The smoking rate of
mothers was 17.6 % at late pregnancy, and increased to 22, 25
and 21 % at 6, 12 and 24 months postpartum, respectively.
At late pregnancy, 12 % of the mothers were a ‘‘current
smoker’’, 26 % were former smokers and 62 % had never
smoked. Of those who never smoked, 1 % became a smoker
at 1 year and kept smoking at 2 years postpartum. Another
2 % mothers became a smoker for the first time at 2 years.
Of those who were former smokers in late pregnancy, 24 %
returned to smoking at 6 months postpartum and kept
smoking at 1 year postpartum. Another 9 % returned to
smoking at 1 year postpartum (33 % in total). At 2 years
postpartum 27 % kept smoking.
As shown in Table 1, mothers’ demographic character-
istics such as age, employment status, educational level and
country of birth were significantly associated with mother’s
smoking status at late pregnancy. The proportion of current
smokers was much higher in younger mothers (28 % for
16–24 years of age) than older mothers (10 % for over
25 years of age, P = 0.001). Mothers who were employed,
non-Australia born, or had a higher education level were
significantly less likely to be current smokers. Comparisons
of socio-demographics were made between those included
and excluded and no significant differences were found
between the groups.
Model 1
Compared with smoking status at late pregnancy, mothers’
likelihood of being a current smoker significantly increased
after giving birth, with an adjusted odds ratio of 3.96 (95 % CI
1.30–12.06) at 6 months, 6.19 (95 % CI 1.84–30.90) at
12 months and 6.58 (95 % CI 1.86–23.23) at 24 months
postpartum, after adjustment for partner’s smoking status, and
mothers’ education level (Table 2). However, these odds
ratios did not differ significantly (P = 0.62). Hence, mothers’
likelihood of being a current smoker significantly increased
after giving birth but did not change significantly over the 6, 12
and 24 months postpartum period. Mothers’ smoking status
was associated with their partner’s smoking status and
mothers’ educational level. Mothers with a partner being a
current smoker were more likely to be current smokers (AOR
13.01, 95 % CI 3.23–52.46) (Table 2). Compared with those
who only had school certificate or lower, mothers who com-
pleted secondary school or higher (AOR 0.007, 95 % CI
0.0006–0.08) were significantly less likely to be current
smokers. Mothers’ age, marital status and country of birth
were not significantly associated with mother’s smoking sta-
tus after adjustment for mother’s educational level.
Model 2
Table 3 shows factors associated with first-time mothers
being current smokers after giving birth using a multivariable
two-level logistic random-intercept model. Compared with
smoking status at 6 months postpartum, mothers’ likelihood
of being a current smoker increased at 12 and 24 months
postpartum with an odds ratio of 2.20 or 1.98, respectively, but
they were not statistically significant (trend test P = 0.35).
This result is consistent with the finding from model 1
(Table 2), which showed that mothers’ likelihood of being a
current smoker did not change significantly over 6–24 months
postpartum period. Mothers who breastfed their child were
significantly less likely to be a smoker, with an adjusted odds
ratio of 0.10 (95 % CI 0.02–0.68) after adjustment for part-
ner’s smoking status, and mother’s educational level.
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Model 3
Similar to mothers, the partner’s smoking status was
associated with their educational level, and the mother’s
smoking status (Table 4). But, interestingly, the partner’s
likelihood of being a current smoker significantly
decreased at 6 (AOR 0.34, 95 % CI 0.13–0.94) and
24 months postpartum (AOR 0.22, 95 % CI 0.07–0.69),
Table 2 Factors associated
with first-time mothers being
smokers using multivariable
two-level logistic random-
intercept model
� P value for trend testa Crude odds ratiob Odds ratio adjusted by
variables in the tablec HSC/TAFE refer to high
school certificate/technical and
further education
Variables ORa 95 % CI P AORb 95 % CI P
Time 0.002� 0.004�
Late pregnancy _ _
6 months postpartum 5.36 1.62–17.75 3.96 1.30–12.06
1 year postpartum 11.35 3.18–40.54 6.19 1.84–30.90
2 years postpartum 9.18 2.49–33.86 6.58 1.86–23.23
Partners’ smoking status \0.0001 \0.0001
No _ _
Yes 17.21 4.59–64.61 13.01 3.23–52.46
Education at being pregnant \0.0001 \0.0001
School certificate/lower _ _
HSC/TAFEc/University 0.003 3e-4–0.04 0.007 6e-4–0.08
Age at being pregnant 0.002
16–24 _
25–29 0.02 0.002–0.18
C30 0.06 0.005–0.69
Marital status 0.096
Other _
Married/de-factor partner 0.19 0.03–1.34
Country of birth 0.018
Other _
Australia 14.81 1.59–137.98
Table 1 Mothers’ smoking
status at late pregnancy by
demographics
a Does not add to 201 due to
missing valueb HSC/TAFE refer to high
school certificate/technical and
further education
* Chi squared test
Variables Total na (%) Current smokers
n (raw %)
P*
Age 0.001
16–24 85 (43) 24 (28)
C25 114 (57) 11 (10)
Marital status 0.096
Married/de-factor partner 174 (88) 27 (16)
Other 24 (12) 7 (29)
Employment status 0.021
Employed 109 (55) 13 (12)
Other 90 (45) 22 (24)
Household yearly income 0.43
\40,000 47 (25) 11 (23)
40,000–\80,000 65 (35) 9 (14)
C80,000 73 (40) 13 (18)
Country of birth 0.051
Australia 135 (68) 28 (21)
Other 63 (32) 6 (10)
Education \0.0001
Primary school/school certificate 44 (22) 18 (41)
HSC/TAFEb/University 154 (78) 17 (11)
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Table 3 Factors associated
with first-time mothers being
smokers after giving birth using
multivariable two-level logistic
random-intercept model
� P value for trend testa Crude odds ratiob Odds ratio adjusted by
variables in the tablec HSC/TAFE refer to high
school certificate/technical and
further education
Variables ORa 95 % CI P AORb 95 % CI P
Time 0.35�
6 months postpartum _
1 year postpartum 2.20 0.68–7.17
2 years postpartum 1.98 0.58–6.74
Current breastfeeding 0.017 0.018
No _ _
Yes 0.08 0.01–0.64 0.10 0.02–0.68
Partners’ smoking status \0.0001 0.002
No _ _
Yes 22.03 4.41–109.92 11.35 2.49–51.7
Education at late pregnancy \0.0001 0.001
School certificate/lower _ _
HSC/TAFEc/University 0.001 3e-5–0.02 0.01 0.0008–0.14
Age at late pregnancy 0.003
16–24 _
25–29 0.01 0.0007–0.15
C30 0.05 0.003–0.90
Marital status 0.014
Other _
Married/de-factor partner 0.01 0.0005–0.42
Country of birth 0.007
Other _
Australia 30.21 2.49–366
Table 4 Factors associated
with partners’ smoking using
multivariable two-level logistic
random-intercept model
� P value for trend testa Crude odds ratiob Odds ratio adjusted by
variables in the tablec HSC/TAFE refer to high
school certificate/technical and
further education
Variables ORa 95 % CI P AORb 95 % CI P
Time 0.03� 0.02�
Late pregnancy _ _
6 months postpartum 0.44 0.15–1.30 0.34 0.13–0.94
1 year postpartum 0.82 0.27–2.48 0.56 0.20–1.56
2 years postpartum 0.22 0.06–0.73 0.22 0.07–0.69
Mothers’ smoking status 0.002 \0.0001
No _ _
Yes 8.19 2.22–30.24 17.99 3.54–91.51
Partner’ education \0.0001 \0.0001
School certificate/lower _ _
HSC/TAFEc/University 0.0005 5e-5–0.006 0.009 0.0006–0.11
Partner age \0.0001
16–24 _
25–29 0.0008 6e-5–0.01
C30 0.001 9e-5–0.01
Partner country of birth 0.008
Other _ _
Australia 0.07 0.01–0.50
Marital status 0.14
Other _
Married/de-factor partner 0.23 0.03–1.60
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compared with the smoking status at late pregnancy, except
for at 12 months postpartum. The smoking rates of partners
before and after the birth of a new baby were 40 and 33 %,
respectively.
Model 4
The analysis also showed that the rate of a having smoke-
free home was higher postpartum (98 %) than in late
pregnancy (87 %). The likelihood of instituting a smoke-
free home was significantly increased after the birth of a
new baby. Families with mothers who were employed
(AOR 3.34, 95 % CI 1.24–9.05), or partners who had
higher education (HSC/TAFE or higher) (AOR 2.74, 95 %
CI 1.01–7.47) were much more likely to institute a smoke-
free home.
Discussion
In this study we found significant proportions of first-time
mothers and their partners still smoked during pregnancy
and alarmingly, the rate of smoking among the mothers
significantly increased after giving birth. Mothers’ smoking
status was associated with breastfeeding, educational level
and their partner’s smoking status. These findings are
generally consistent with existing evidence [4, 5, 9, 10, 15,
20]. A possible explanation of the high postpartum smok-
ing rate may be that having a new born baby could lead to a
self-perceived stressful situation for first-time mothers that
then triggers them to smoke [6, 8].
It has been suggested that smoking cessation programs
for pregnant women should include partners [5, 10, 15,
26]. Surprisingly, few existing studies reported part-
ners’smoking status during mothers’ pregnancy and the
postpartum period. Two studies found that the partners’
smoking status did not change significantly during the
mothers’ pregnancy and in the postpartum period [27, 28],
but they used cross-sectional data and did not investigate
the contributing factors of partners’ smoking during
pregnancy and postpartum. Yet, our study found that
encouragingly, the partners’ likelihood of being a smoker
decreased significantly after the birth of their child and
remained lower postpartum. Possible explanations may be
that the birth of a new baby increases both caring and
economic burdens for partners and that the fatherhood
role triggered modification of risk-taking behaviours [29].
A qualitative study [19] stated that many men recognized
that their smoking could no longer be viewed as an
individual activity in which they were free to engage
before being a father. Social and maternal pressure to
protect infants from smoking requires the fathers to sep-
arate their smoking from fathering.
As shown in previous studies, mothers’ smoking status
was influenced by partners’ smoking status [5, 8–10, 15,
20]. A study concluded that partners’ smoking was a major
determinant for changes in mothers’ smoking behaviour
during and after pregnancy [30]. Our study also found that
mothers’ and partners’ smoking are associated. Hence, to
be effective, smoking cessation interventions need to target
both mothers and their partners.
Our study also found an inverse relationship between
postpartum smoking and breastfeeding, which was sup-
ported by previous cross-sectional or short-term follow-up
studies [11–17]. Surprisingly, there have been few studies
looking into the effect of combined smoking cessation and
breastfeeding promotion programs. Few breastfeeding
programs have taken account of the particular needs of
women who smoke. Midwives often consider breastfeeding
promotion as part of their role, irrespective of the woman’s
smoking status. There is a need for the development of
health promotion programs including both components of
smoking cessation and breastfeeding promotion for women
during pregnancy and early postpartum.
One of main strengths of this study was that we used a
longitudinal cohort design with 2 year follow-up and four
data collection points and therefore we were able to
investigate the changes in relation to smoking status over
the 2 year period from late pregnancy to 24 months post-
partum. The use of two-level logistic random-intercept
models in order to investigate the contributing factors for
both mothers’ and partners’ smoking allowed us to deal
with the imbalance caused by missing data and increase the
precision of estimates [31]. However, this study is subject
to several limitations. It did not assess mothers’ stress level
after giving birth, which could interfere with the ability to
maintain smoking abstinence [6, 8]. Data on mothers’ and
partners’ knowledge about infant exposure to tobacco
smoke were not collected. The generalisability may also be
limited due to the locality of the study area. Another lim-
itation is loss to follow-up, although this was minimised by
using two-level logistic random-intercept models [31]. The
absence of data on other adults living in the household and
other substance use was another limitation to the study. In
addition, the study did not take full advantage of the lon-
gitudinal data by time-lagging their predictor variables.
Despite the limitations of this study, the findings are
useful in informing the development of family-based
interventions regarding smoking cessation and promoting
the health of children and their families. Since the smoking
rates of mothers are likely to increase after giving birth,
smoking cessation programs should not just focus on the
pregnancy but also include the early postpartum period, in
particular, the first 6 months postpartum. In addition,
smoking cessation program should have a greater focus on
those with lower levels of education.
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Acknowledgments This is part of the Healthy Beginnings Trial
funded by the Australian National Health and Medical Research
Council (ID number: 393112). We wish to thank all the families for
their participation in this study. We also thank members of the project
team based at Health Promotion Service, South Western Sydney &
Sydney Local Health Districts.
Conflict of interest The authors declare that they have no com-
peting interests in this study.
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