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标题：Self-Help Booklets for Preventing Postpartum Smoking Relapse: A Randomized Trial
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作者：Thomas H. Brandon ; Vani Nath Simmons ; Cathy D. Meade 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：102
期号：11
页码：2109-2115
DOI：10.2105/AJPH.2012.300653
语种：English
出版社：American Public Health Association
摘要：Objectives. We tested a series of self-help booklets designed to prevent postpartum smoking relapse. Methods. We recruited 700 women in months 4 through 8 of pregnancy, who quit smoking for their pregnancy. We randomized the women to receive either (1) 10 Forever Free for Baby and Me (FFB) relapse prevention booklets, mailed until 8 months postpartum, or (2) 2 existing smoking cessation materials, as a usual care control (UCC). Assessments were completed at baseline and at 1, 8, and 12 months postpartum. Results. We received baseline questionnaires from 504 women meeting inclusion criteria. We found a main effect for treatment at 8 months, with FFB yielding higher abstinence rates (69.6%) than UCC (58.5%). Treatment effect was moderated by annual household income and age. Among lower income women (< $30 000), treatment effects were found at 8 and 12 months postpartum, with respective abstinence rates of 72.2% and 72.1% for FFB and 53.6% and 50.5% for UCC. No effects were found for higher income women. Conclusions. Self-help booklets appeared to be efficacious and offered a low-cost modality for providing relapse-prevention assistance to low-income pregnant and postpartum women. Tobacco smoking is the leading preventable cause of premature morbidity and mortality, and smoking cessation is associated with immediate and long-term improvement in quality of life and a wide range of health outcomes. 1 Pregnant women represent a unique subgroup for whom continued smoking is associated with multiple immediate adverse outcomes, including increased risk of ectopic pregnancy, spontaneous abortion, preterm delivery, low birth weight, and perinatal mortality. 2 Pregnant women who smoke exhibit a relatively high rate of spontaneous smoking cessation. Today, nearly 50% of female smokers report quitting during pregnancy, 3 and the prevalence of smoking during pregnancy dropped from 18.4% in 1990 to 10.4% by 2007. 4,5 Moreover, interventions designed to promote smoking cessation during pregnancy have demonstrated efficacy. 6 Unfortunately, smoking relapse rates following childbirth remain very high. Estimates range from 50% to 80% over the first year, 7–9 and have shown little decline in recent years. 3 Postpartum relapse is detrimental not only to the mother, but to the infant (and any other member of the household) who is exposed to secondhand smoke. Secondhand smoke is associated with a variety of health problems in children, including decreased lung growth, increased rates of respiratory tract infections, otitis media, childhood asthma, sudden infant death syndrome, behavioral problems, neurocognitive decrements, and increased rates of adolescent smoking. 10 It has been estimated that secondhand smoke is responsible for nearly 6000 deaths annually among children younger than 5 years. 11 Numerous interventions have attempted to reduce postpartum smoking relapse, ranging from brief interventions during maternity hospitalization to intensive face-to-face counseling. However, recent meta-analyses concluded that postpartum relapse prevention has been ineffective. 12,13 Thus, development and validation of effective interventions for preventing smoking relapse among pregnant and postpartum women remains a public health priority. The general problem of smoking relapse led to the development of relapse-prevention interventions designed to facilitate long-term tobacco abstinence and circumvent the progression from an initial slip or lapse to a complete return to regular smoking. These interventions have largely taken the form of cognitive-behavioral therapies delivered in conjunction with initial smoking cessation counseling. 14 However, less than 10% of smokers attempting to quit enroll in counseling programs, with the majority attempting cessation with minimal assistance. 15 This observation led to the development of a minimal “self-help” relapse-prevention intervention designed to communicate key elements of cognitive-behavioral counseling in a format and engaging modality that is more amenable to dissemination and implementation—a series of 8 booklets delivered by mail. These relapse-prevention booklets, currently titled Forever Free, include didactic information about the nature of tobacco dependence, instruction in the use of cognitive and behavioral coping skills to deal with urges to smoke, awareness of and preparation for high-risk “triggers” to smoke, strategies for managing an initial slip or lapse, and specific information and advice about weight control, stress, and health benefits associated with quitting smoking. The booklets were tested in 2 randomized controlled trials, with findings that they significantly reduced smoking relapse among recent quitters through at least 2 years after booklet delivery. 16,17 Moreover, the intervention was highly cost-effective, with estimates as low as $83 per quality-adjusted life-year saved. 17,18 A recent meta-analysis concluded that written self-help materials were the only type of relapse-prevention intervention for unaided quitters with established efficacy. 12 Another meta-analysis concluded that self-help was more effective than standard care at producing initial smoking cessation among pregnant women, 19 but self-help had not yet been tested for preventing postpartum relapse. Smoking has increasingly become a behavior of lower socioeconomic groups, with the highest prevalence found among those with the least education and income. For example, in 2009, the smoking prevalence among those below the poverty line was 31.1% compared with 19.4% for those above the poverty line. 20 Additionally, lower income and financial strain are associated with poorer success rates among those attempting to quit smoking. 21,22 Aside from the emotional burdens of financial stress, low-income smokers may be hampered in their quitting attempts because of the practical limitations (e.g., cost and transportation) of finding and attending smoking cessation programs or obtaining cessation medications, as well as by the multiple barriers that impede clinicians from providing smoking cessation services to disadvantaged populations. 23 In short, having less money and fewer resources places a significant burden on the smoker who wants to quit. The association between income and smoking behavior extends to pregnant and postpartum women. For example, women with annual incomes less than $15 000 were found to be half as likely to quit smoking during their pregnancy (33% vs 67%), and among those who did quit, low-income women were nearly twice as likely to relapse within 4 months of delivery (63% vs 38%) compared with those with incomes of more than $15 000. 3 Therefore, a low-cost, easily disseminated intervention, such as self-help booklets, might be particularly feasible for overcoming income-related barriers in this population. The primary aim of the present study was to test, via a randomized controlled trial, a self-help intervention for preventing smoking relapse among a vulnerable population of smokers at uniquely high risk of relapse—pregnant and postpartum women. We modified the Forever Free series of self-help relapse-prevention booklets for use with pregnant women based on previous research and a systematic formative evaluation. 24 We tested the hypothesis that women who received the series of Forever Free for Baby and Me booklets (FFB) would demonstrate less relapse through the course of the intervention (8 months postpartum) and beyond (12 months postpartum), compared with women who received high-quality existing materials that were less comprehensive. In addition, we examined whether intervention efficacy was moderated by the key demographic, smoking, and pregnancy variables listed in Table 1 to identify highly responsive subgroups for future targeting. We did not specify a priori hypotheses with respect to these potential moderating variables. TABLE 1— Demographic, Pregnancy, and Smoking Variables as Reported at Baseline, by Intervention Group: Self-Help Booklets for Preventing Postpartum Smoking Relapse, United States, 2004–2008 Demographic Variables^a Forever Free Booklets (n = 245), %, Median, or Mean (SD) Usual Care (n = 259), %, Median, or Mean (SD) Race/ethnicity, White 93.9 90.7 Black 3.7 5.0 Other 2.4 4.2 Hispanic 5.8 5.7 Education < HS diploma 9.4 8.9 HS diploma or GED 36.3 34.0 College or technical school 54.3 57.1 Living with husband or boyfriend 82.9 78.5 Employed 41.2 41.7 Household income, $ 30 000–40 000 30 000–40 000 Age, y 26.2 (5.7) 25.4 (5.4) Pregnancy No. of pregnancies 2.2 (1.3) 2.2 (1.6) Had previous miscarriage(s) 27.3 25.1 Quit smoking before end of 1st trimester 85.2 88.8 Smoking Years of smoking 8.7 (4.8) 8.5 (4.8) Cigarettes/d 15.0 (6.3) 15.4 (6.9) Precessation FTND score 3.6 (2.3) 3.8 (2.2) Plan to quit for good 64.5 68.7 Other smoker(s) in house 53.1 54.1 Open in a separate window Note. FTND = Fagerström Test for Nicotine Dependence; GED = general equivalency diploma; HS = high school. ^aThere were no significant group differences.