The association of depressive, anxiety, and stress symptoms and postpartum relapse to smoking: A longitudinal study
Open accessAbstract
INTRODUCTION: The aim of this prospective repeated measures, mixed-methods observational study was to assess whether depressive, anxiety, and stress symptoms are associated with postpartum relapse to smoking. METHODS: A total of 65 women who smoked prior to pregnancy and had not smoked during the last month of pregnancy were recruited at delivery and followed for 24 weeks. Surveys administered at baseline and at 2, 6, 12, and 24 weeks postpartum assessed smoking status and symptoms of depression (Beck Depression Inventory [BDI]), anxiety (Beck Anxiety Inventory [BAI]), and stress (Perceived Stress Scale [PSS]). In-depth interviews were conducted with women who reported smoking. RESULTS: Although 92% of the participants reported a strong desire to stay quit, 47% resumed smoking by 24 weeks postpartum. Baseline factors associated with smoking at 24 weeks were having had a prior delivery, not being happy about the pregnancy, undergoing counseling for depression or anxiety during pregnancy, and ever having struggled with depression (p < .05). In a repeated measures regression model, the slope of BDI scores from baseline to the 12-week follow-up differed between nonsmokers and smokers (-0.12 vs. +0.11 units/week, p = .03). The slope of PSS scores also differed between nonsmokers and smokers (-0.05 vs. +0.08 units/week, p = .04). In qualitative interviews, most women who relapsed attributed their relapse and continued smoking to negative emotions. DISCUSSION: Among women who quit smoking during pregnancy, a worsening of depressive and stress symptoms over 12 weeks postpartum was associated with an increased risk of smoking by 24 weeks.
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Women who quit smoking during pregnancy might be more likely to relapse if they experience negative emotions or depressive symptoms.
“The two other studies demonstrated that women who quit smoking during pregnancy might be more likely to relapse if they experience negative emotions or depressive symptoms.55,84”
From Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes (2019) · cites this paper as [55]
Depressed mothers seemed to have more risky behaviors, including the risk of starting smoking again after pregnancy and an increased prevalence of suicidal ideations.
“Depressed mothers seemed to have more risky behaviors (including the risk of start smoking again after pregnancy55,84 and an increased prevalence of suicidal ideations).30,33,76,81,85”
From Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes (2019) · cites this paper as [55]
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“Pregnancy factors Unhappy with pregnancy [24] (USA)”
BackgroundInfluentialCorrea, J. B., Simmons, V. N., Sutton, S. K., Meltzer, L. R., & Brandon, T. H. (2014) · Maternal and Child Health Journal · doi:10.1007/s10995-014-1556-2 · Cited by 21 · see citing works
“A secondary aim of the current study was to identify differences in reasons for smoking or abstinence in terms of income [25], age [12], and depression [26], which constitute key demographic and psychosocial risk factors for post-partum relapse to smoking.”
BackgroundBertani, A. L., Garcia, T., Tanni, S. É., & Godoy, I. (2015) · Jornal Brasileiro de Pneumologia · doi:10.1590/s1806-37132015000004482 · Cited by 21 · see citing works
Factors Associated with American Indian Cigarette Smoking in Rural Settings
Hodge, F. S., & Nandy, K. (2011) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph8040944 · Cited by 20 · see citing works
“Additionally, our data indicate American Indians begin smoking at a younger age, a finding documented in other studies [16], and which influences smoking during adulthood and increases risk for morbidity and mortality.”
BackgroundCurrent Tobacco-Smoking and Neural Responses to Infant Cues in Mothers
Rutherford, H. J. V., Maupin, A. N., Landi, N., Potenza, M. N., & Mayes, L. C. (2017) · Parenting · doi:10.1080/15295192.2017.1262176 · Cited by 20 · see citing works
“Even when women abstain during pregnancy, many relapse in the postpartum (Park et al., 2009).”
BackgroundSocio-demographic and psychological features associated with smoking in pregnancy
Fujita, Â. T. L., Rodrigues, A. L., Gomes, N. C., Martinis, B. S. D., & Martínez, J. A. B. (2021) · Jornal Brasileiro de Pneumologia · doi:10.36416/1806-3756/e20210050 · Cited by 19 · see citing works
“(5-7) It has also been associated with some psychological characteristics, including high levels of anxiety, depression, and perceived stress.(8-10) On the other hand, quitting has been associated mainly with higher educational levels, planned gestation, first pregnancy, non-smoking partners, and lower levels of anxie…”
BackgroundCumulative Poor Psychosocial and Behavioral Health Among Low-Income Women at 6 Weeks Postpartum
Walker, L. O., Sterling, B. S., Guy, S., & Mahometa, M. J. (2013) · Nursing Research · doi:10.1097/nnr.0b013e31829499ac · Cited by 19 · see citing works
“…vulnerability in the psychosocial domains (depressive symptoms and body image dissatisfaction) and behavioral domains of health (diet and exercise, use of various psychoactive substances, and general self-care; Beeghly et al., 2003; Park et al., 2009; Walker, 1989), we focus on these in this study.”
BackgroundInfluentialPerceived support to stay quit: What happens after delivery?
Park, E. R., Chang, Y., Quinn, V. P., Ross, K. M., & Rigotti, N. A. (2009) · Addictive Behaviors · doi:10.1016/j.addbeh.2009.06.005 · Cited by 18 · see citing works
Self-citationFigueiró, L. R., Bortolon, C. B., Benchaya, M. C., Bisch, N. K., Ferigolo, M., Barros, H. M. T., & Dantas, D. C. M. (2013) · Trends in Psychiatry and Psychotherapy · doi:10.1590/s2237-60892013000300008 · Cited by 17 · see citing works
van der Merwe, C., Haylett, W. L., Harvey, J., Lombard, D., Bardien, S., & Carr, J. A. (2012) · South African Medical Journal · doi:10.7196/samj.5879 · Cited by 17 · see citing works
Perinatal smoking and depression in women with concurrent substance use
Forray, A., Gotman, N., Kershaw, T., & Yonkers, K. A. (2013) · Addictive Behaviors · doi:10.1016/j.addbeh.2013.12.008 · Cited by 15 · see citing works
“This is in contrast to most studies that have shown an association between symptoms of depression and an increased risk of relapse in postpartum women (Allen, Prince, & Dietz, 2009; Munafo et al., 2008; Park et al., 2009; Solomon et al., 2007; Whitaker, Orzol, & Kahn, 2007).”
BackgroundResultNorthrup, T. F., Wootton, S. H., Evans, P. W., & Stotts, A. L. (2013) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2013.805195 · Cited by 13 · see citing works
“Smoking and depression have been linked in several studies [37,38].”
ResultFigueiró, L. R., Barros, H. M. T., Ferigolo, M., & Dantas, D. C. M. (2017) · Trends in Psychiatry and Psychotherapy · doi:10.1590/2237-6089-2016-0041 · Cited by 13 · see citing works
Smoking status: A tacit screen for postpartum depression in primary care settings
Barber, G. A., & Shenassa, E. D. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.09.033 · Cited by 12 · see citing works
Zhang, K., Siziba, L. P., Suo, N. J., Rothenbacher, D., & Genuneit, J. (2022) · Midwifery · doi:10.1016/j.midw.2022.103289 · Cited by 13 · see citing works
Liu, Z. F., Sylivris, A., Gordon, M., & Sundram, S. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-04178-6 · Cited by 13 · see citing works
“For the mother, PPD is associated with poorer overall physical and psychological health [10], leading to decreased quality of life [11] and increased risk of addictive behaviour and suicidal ideation [12, 13].”
BackgroundCoping Strategies and Perceived Stress in Pregnant Smokers Seeking Help for Cessation
Varescon, I., Leignel, S., Poulain, X., & Gerard, C. (2011) · The Journal of Smoking Cessation · doi:10.1375/jsc.6.2.126 · Cited by 11 · see citing works
Míguez, M. C., & Pereira, B. (2020) · Maternal and Child Health Journal · doi:10.1007/s10995-020-03019-w · Cited by 11 · see citing works
Antenatal physical activity: Investigating the effects on postpartum depression
Guida, J., Sundaram, S., & Leiferman, J. A. (2012) · Health · doi:10.4236/health.2012.412188 · Cited by 11 · see citing works
“Smoking during pregnancy has been previously established as associated with being multiparous, pregnancy unwantedness and current or previous diagnoses of depression [57].”
BackgroundThe role of negative affect management in postpartum relapse to smoking
Psaros, C., Pajolek, H., & Park, E. R. (2011) · Archives of Women s Mental Health · doi:10.1007/s00737-011-0250-2 · Cited by 10 · see citing works
“Findings from the quantitative portion of this study suggest that women who relapsed to smoking experienced a worsening of depressive symptoms and perceived stress, while women who did not relapse experienced a decrease in these symptoms over time; there was a similar trend (though not a statistically significant rela…”
BackgroundSelf-citationLee, S. H., Yi, Y. H., Lee, Y. I., Lee, H. Y., & Lim, K.-M. (2022) · Medicine · doi:10.1097/md.0000000000029595 · Cited by 10 · see citing works
“[48] In addition, in a study conducted on mothers who quit smoking during pregnancy, the risk of smoking relapse was greater if depression and stress symptoms worsened after quitting smoking.[49] Similarly, in a study conducted on people who succeeded in quitting smoking for 6 months through a smoking cessation clinic…”
BackgroundEffects of 7.5% carbon dioxide inhalation on anxiety and mood in cigarette smokers
Attwood, A. S., Ataya, A. F., Bailey, J., Lightman, S. L., & Munafo, M. R. (2014) · Journal of Psychopharmacology · doi:10.1177/0269881114529378 · Cited by 8 · see citing works
“Epidemiological studies that prospectively examine this relationship have identified anxiety as a risk factor for smoking initiation, nicotine dependence and relapse (Mckenzie et al., 2010; Park et al., 2009; Patton et al., 1998).”
BackgroundCollins, B. N., Nair, U. S., Shwarz, M., Jaffe, K., & Winickoff, J. P. (2012) · Journal of Child and Family Studies · doi:10.1007/s10826-012-9663-4 · Cited by 8 · see citing works
“Pediatric providers should be aware that depressive symptoms have been implicated in lower abstinence and increased risk of smoking relapse (Allen et al. 2009; Park et al. 2009).”
Walker, L. O., Murphey, C. L., & Xie, B. (2016) · Journal of Obstetric, Gynecologic & Neonatal Nursing · doi:10.1016/j.jogn.2016.05.004 · Cited by 8 · see citing works
“…(Ainsworth et al., 2013; Berge et al.; Hull et al., 2010), increased weight (Berge et al., 2011; Walker, Fowles, & Sterling, 2011), smoking relapse (Park et al., 2009), high-risk alcohol use (Jagodzinski & Fleming, 2007; W. Liu, Mumford, & Petras, 2015), and depression (Gavin et al., 2005).”
Body focused repetitive behavior disorders and perceived stress: Clinical and cognitive associations
Grant, J., Leppink, E. W., & Chamberlain, S. (2015) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2015.02.001 · Cited by 10 · see citing works
Kocataş, S., Güler, N., & Sezer, R. E. (2020) · Florence Nightingale Journal of Nursing · doi:10.5152/fnjn.2020.18031 · Cited by 7 · see citing works
Pereira, B., Figueiredo, B., Pinto, T. M., & Míguez, M. C. (2021) · Addictive Behaviors · doi:10.1016/j.addbeh.2021.107090 · Cited by 7 · see citing works
Receiving Versus Being Denied an Abortion and Subsequent Tobacco Use
Roberts, S. C. M., & Foster, D. G. (2014) · Maternal and Child Health Journal · doi:10.1007/s10995-014-1515-y · Cited by 7 · see citing works
“Consistent with previous literature, we found that, among all participants, having had a previous live birth was associated with higher levels of tobacco use and, for women carrying to term, changes in tobacco use over time [9, 12].”
BackgroundResultCollins, B. N., DiSantis, K. I., & Nair, U. S. (2011) · Breastfeeding Medicine · doi:10.1089/bfm.2010.0076 · Cited by 7 · see citing works
“Nonetheless, the psychosocial and interpersonal characteristics of our sample represent the broader population of maternal smokers, and the sample represents a group of medically underserved mothers exposed to increased socioeconomic deprivation and stress, which are risk factors for maternal smoking in general.(48,49…”
BackgroundWarren, J. R., Thomas, J., Okuyemi, K. S., Lindgren, B. R., & Ahluwalia, J. S. (2010) · Journal of the National Medical Association · doi:10.1016/s0027-9684(15)30707-0 · Cited by 7 · see citing works
Murphy, C. M., Micalizzi, L., Sokolovsky, A. W., Borrelli, B., Jennings, E., Lee, C. S., Parker, D. R., & Risica, P. M. (2021) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2021.108419 · Cited by 7 · see citing works
Genna, N. M. D., Qu, Y., Cheng, Y., Emery, R. L., Kolko, R. P., & Levine, M. D. (2022) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntac263 · Cited by 7 · see citing works
Siracusano, M., Riccioni, A., Gialloreti, L. E., Carloni, E., Baratta, A., Ferrara, M., Arturi, L., Lisi, G., Adulti, I., Rossi, R., et al. (2021) · Children · doi:10.3390/children8121150 · Cited by 6 · see citing works
Taha, M. N., Al-Ghumgham, Z., Ali, N., Al‐Rifai, R. H., Elbarazi, I., Al‐Maskari, F., Shahawy, O. E., Ahmed, L. A., & Loney, T. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19127498 · Cited by 6 · see citing works
The Changing Process of Women’s Smoking Status Triggered by Pregnancy
Itai, M., Sasaki, A., Mori, M., Tsuda, S., & Matsumoto-Murakoso, A. (2019) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph16224424 · Cited by 5 · see citing works
“A worsening of depressive and stress symptoms over postpartum was associated with an increased risk of smoking [29].”
BackgroundSmoking cessation intervention in puerperium: A systematic review and meta-analysis
Vlachou, M., Kirkou, G., Vivilaki, V. G., Katsaounou, P. A., GEORGAKOPOULOU, V. E., & Diamanti, A. (2024) · Pneumon · doi:10.18332/pne/189842 · Cited by 4 · see citing works
“These findings are consistent with the findings from another study 43 , who identified mental health issues and the partner’s smoking status as significant predictors of postpartum smoking relapse.”
ResultWalker, L. O., Sterling, B. S., Becker, H., Hendrickson, S. G., & Xie, B. (2018) · Journal of Behavioral Medicine · doi:10.1007/s10865-018-9928-5 · Cited by 5 · see citing works
Walker, L. O., Becker, H., Andrews, E. E., & Phillips, C. S. (2020) · Disability and health journal · doi:10.1016/j.dhjo.2020.100977 · Cited by 4 · see citing works
Thomas, D., Davey, M. E., Sterren, A. E., Panaretto, K. S., & Lyons, L. (2020) · Australian and New Zealand Journal of Public Health · doi:10.1111/1753-6405.12993 · Cited by 4 · see citing works
Peprah, P., Agyemang‐Duah, W., Gyamfi, N., Asiamah-Asare, B. K. Y., Boateng, D., Appiah, J. O., & Adu, C. (2022) · PLoS ONE · doi:10.1371/journal.pone.0278373 · Cited by 3 · see citing works
Maternal personality disorder and babies’ exposure to tobacco smoke
Conroy, S., Marks, M. N., Schacht, R., Davies, H. A., & Moran, P. (2010) · Archives of Women s Mental Health · doi:10.1007/s00737-010-0145-7 · Cited by 3 · see citing works
“Allen et al. (2009) recently reported that women who quit smoking during pregnancy may be more likely to relapse if they experience depressive symptoms, while Park et al. (2009) reported that an increase in depressive and stress symptoms was associated with an increased risk of smoking at 24 weeks postpartum.”
BackgroundDetrimental Effects of Prenatal Exposure to Tobacco Smoke and Nicotine
Schneider, T. (2016) · Elsevier eBooks · doi:10.1016/b978-0-12-802574-1.00006-5 · Cited by 2 · see citing works
The Influence of Partner Smoking, Relationship Satisfaction and Parental Stress on Tobacco Use
Foulstone, A. R., Kifle, T., & Kelly, A. B. (2018) · The Journal of Smoking Cessation · doi:10.1017/jsc.2018.37 · Cited by 2 · see citing works
Bertani, A. L., Garcia, T., Tanni, S. É., & Godoy, I. (2015) · Cited by 2 · see citing works
Smoking and Smoking Cessation During Pregnancy and Postpartum
Gadomski, A. (2010) · Current Cardiovascular Risk Reports · doi:10.1007/s12170-010-0123-7 · Cited by 2 · see citing works
“Poor psychological status, negative effect, and depression predict postpartum relapse [21, 22].”
BackgroundCan, S. S., & Selek, S. (2014) · Journal of Substance Use · doi:10.3109/14659891.2014.916355 · Cited by 2 · see citing works
“The relationship between smoking and psychiatric disorders and the negative impacts of smoking on treatment outcomes have been shown in many studies (Goodwin et al., 2008; Hermes et al., 2011; Jamal et al., 2012; John et al., 2004; Linares et al., 2009; Park et al., 2009; Vatss et al., 2012; Ziedonis et al., 2008).”
BackgroundResultNicotine Dependence Measures for Perinatal Women
Yang, I. H., & Hall, L. A. (2016) · Clinical Nursing Research · doi:10.1177/1054773816635522 · Cited by 2 · see citing works
Collins, B. N., & Nair, U. S. (2013) · Wiley eBooks · doi:10.1002/9781394260454.ch6 · Cited by 2 · see citing works
Kohl, C. A. (2011) · Psychiatrie und Psychotherapie · doi:10.1007/s11326-011-0180-7
A relação entre fatores maternos e a resposta à dor e ao estresse do prematuro em posição canguru
Preto, E. D. E. D. R. (2010)
Dewi, V. K., Barkinah, T., & Kirana, R. (2015) · Journals & Books Hosting (International Knowledge Sharing Platform)
Development of a Postpartum Stressor Measure
Otes, M. N. (2015)
Resumption of Smoking by Women after Childbirth: Influence of Spousal Smoking
Satoh, A., Kishi, C., Tomita, M., Saitoh, M., Hirakawa, M., Kumasaka, M., Sasaki, J., Lee, S., & Sasaki, H. (2016) · Health · doi:10.4236/health.2016.89086
“Smoking habits may be influenced by mental disorders, including anxiety and depression [2], increased actual or perceived stress [3], and abuse-related post-traumatic stress disorders [4].”
BackgroundYan, K., Yang, M., & Feng, Y. (2025) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-025-01452-y
Liu, Z. F., Sylivris, A., Gordon, M., & Sundram, S. (2022) · Figshare · doi:10.6084/m9.figshare.20454535
Prenatal exposure to nicotine and postpartum depression: a systematic review and meta-analysis
Alddin, R. S., Salama, M., McKinney, D., Saade, G. R., & Zhang, Q. (2026) · Archives of Women s Mental Health · doi:10.1007/s00737-026-01739-6
“PPD has both short-and long-term consequences for maternal health, (Darcy et al. 2011; Gagliardi et al. 2012; Kim et al. 2015; Lilja et al. 2012; Park et al. 2009; Pope et al. 2013) as well as significant impacts on child development, (Hay et al. 2003; “Maternal depression and child development,”…”
- Authors
- Park, E. R., Chang, Y., Quinn, V., Regan, S., Cohen, L., Viguera, A., Psaros, C., Ross, K., & Rigotti, N.
- Affiliations
- Massachusetts General Hospital (US)
- ORCID
- Venue
- Nicotine & Tobacco Research
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-05-12
- Volume
- 11
- Issue
- 6
- Pages
- 707-714
- ISSN
- 1462-2203 (ISSN-L)
- 1469-994X
- PMC
- PMC2722237
- OpenAlex
- W2035479189
- Cited by
- 102
- References
- 36
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 1 · 2022: 9 · 2021: 7 · 2020: 5 · 2019: 3 · 2018: 3 · 2017: 3 · 2016: 4 · 2015: 14 · 2014: 7 · 2013: 10 · 2012: 10
- FWCI
- 7.31
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Nicotine & Tobacco Research (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- HighWire Press Open Archive (submittedVersion)
- Funders
- Van Ameringen Foundation
- National Heart, Lung, and Blood Institute (K24-HL-04440, K24HL004440)
- Topics
- Health Sciences › Medicine › Physiology › Smoking Behavior and Cessation
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Substance Exposure Effects
- Keywords
- postpartum smoking relapse, smoking cessation during pregnancy, depressive symptoms, anxiety symptoms, perceived stress, postpartum women, maternal mental health, negative emotions
- MeSH terms
- Adult, Female, Humans, Longitudinal Studies, Mothers, Pregnancy, Surveys and Questionnaires, Recurrence, Smoking, Stress, Psychological, Substance Withdrawal Syndrome, Comorbidity, Smoking Cessation, Risk Assessment, Depression, Postpartum, Young Adult
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