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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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“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]
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“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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Neighborhood safety as a correlate of tobacco use in a sample of urban, pregnant women
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Grande, L. A., Olsavsky, A. K., Erhart, A., Dufford, A. J., Tribble, R. C., Phan, K. L., & Kim, P. (2021) · Cognitive Affective & Behavioral Neuroscience · doi:10.3758/s13415-021-00914-9 · Cited by 37
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Simmons, V. N., Sutton, S. K., Quinn, G. P., Meade, C. D., & Brandon, T. H. (2013) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntt177 · Cited by 36
“Previous research has identified psychosocial and socioeconomic factors related to postpartum smoking relapse such as depression and anxiety (Park et al., 2009); friends, partners, and family members who smoke (Solomon et al.”
BackgroundKendzor, D. E., Businelle, M. S., Costello, T. J., Castro, Y., Reitzel, L. R., Vidrine, J. I., Li, Y., Mullen, P. D., Velasquez, M. M., Cinciripini, P. M., et al. (2010) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntq132 · Cited by 35
Correa-Fernández, V., Ji, L., Castro, Y., Heppner, W. L., Vidrine, J. I., Costello, T. J., Mullen, P. D., Cofta-Woerpel, L., Velasquez, M. M., Greisinger, A., et al. (2012) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0027532 · Cited by 31
“In both prospective and retrospective studies, negative affect and stress are among the most frequently identified factors for postpartum smoking relapse (Park et al., 2009; Polanska, Hanke, Sobala, Lowe, & Jaakkola, 2011; Solomon et al., 2007).”
InfluentialDevelopment of a Postpartum Stressor Measure
Park, E. R., Psaros, C., Traeger, L. N., Stagg, A. R., Jacquart, J., Willett, J. B., Alert, M. D., LaRoche, K. L., & Ecker, J. L. (2015) · Maternal and Child Health Journal · doi:10.1007/s10995-015-1731-0 · Cited by 31
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“Studies indicate the difficulty of maintaining cessation in the postpartum period [24–26], which may be influenced by stress and/or depression.”
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“However, our study was not designed to assess concurrent changes in smoking behavior and depression, which can be more informative about parallel processes and cessation [21, 63].”
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Toler, S., Stapleton, S. R., Kertsburg, K., Callahan, T. J., & Hastings‐Tolsma, M. (2018) · Midwifery · doi:10.1016/j.midw.2018.03.016 · Cited by 29
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Do Risk Factors for Post-partum Smoking Relapse Vary According to Marital Status?
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“Pregnancy factors Unhappy with pregnancy [24] (USA)”
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“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.”
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Factors Associated with American Indian Cigarette Smoking in Rural Settings
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“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.”
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“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
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“(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…”
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“…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.”
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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
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“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).”
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“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
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 22
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“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].”
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Varescon, I., Leignel, S., Poulain, X., & Gerard, C. (2011) · The Journal of Smoking Cessation · doi:10.1375/jsc.6.2.126 · Cited by 11
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Antenatal physical activity: Investigating the effects on postpartum depression
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“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
“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
“[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
“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
“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
“…(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
Kocataş, S., Güler, N., & Sezer, R. E. (2020) · Florence Nightingale Journal of Nursing · doi:10.5152/fnjn.2020.18031 · Cited by 7
Pereira, B., Figueiredo, B., Pinto, T. M., & Míguez, M. C. (2021) · Addictive Behaviors · doi:10.1016/j.addbeh.2021.107090 · Cited by 7
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
“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
“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
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
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
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
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
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
“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
“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
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
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
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
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
“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
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
Bertani, A. L., Garcia, T., Tanni, S. É., & Godoy, I. (2015) · Cited by 2
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
“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
“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
Collins, B. N., & Nair, U. S. (2013) · Wiley eBooks · doi:10.1002/9781394260454.ch6 · Cited by 2
A relação entre fatores maternos e a resposta à dor e ao estresse do prematuro em posição canguru
Castral, T. C. (2011) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.22.2011.tde-18072011-112116
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].”
BackgroundFatores sociodemográficos e psicológicos associados ao tabagismo na gravidez
Fujita, Â. T. L. (2020) · Digital Library of Theses and Dissertations (Universidade de São Paulo) · doi:10.11606/t.17.2020.tde-13042020-142302
Yan, 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,”…”
Metadata
- 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 › Public Health, Environmental and Occupational Health › 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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