摘要：Objectives . This study examined the patterns and correlates of maternal smoking before, during, and after pregnancy. Methods . We examined socioeconomic, demographic, and clinical risk factors associated with maternal smoking in a nationally representative cohort of women (n = 8285) who were surveyed 17 ± 5 months and again 35 ± 5 months after delivery. Results . Smoking rates among women with a college degree decreased 30% from before pregnancy to 35 months postpartum but did not change among the least educated women. Risk factors clustered, and a gradient linked the number of risk factors (0, 2, 4) to the percentage smoking (6%, 31%, 58%, P < .0001). Conclusions . The period of pregnancy and early parenthood is associated with worsening education-related disparities in smoking as well as substantial clustering of risk factors. These observations could influence the targeting and design of maternal smoking interventions. Smoking poses a significant threat to women’s health. 1 Women are more likely to stop smoking during pregnancy than at other times, 1 yet the majority who quit are smoking again within 1 year postpartum. 2– 8 The lack of sustained benefit from interventions during pregnancy and postpartum 9– 16 suggests that our understanding of the determinants of smoking before, during, and after pregnancy remains inadequate. In the only national population-based longitudinal study to examine this issue, Fingerhut et al. 2 found that although 39% of smokers quit during pregnancy, 70% of them relapsed within 1 year postpartum. The lowest quitting rates were among those who smoked most before pregnancy and who had the least education. No significant risk factors for smoking relapse were identified. Although this was an important early contribution to smoking cessation research, the study included only White women, had a small sample size for examining relapse rates (n = 191 quitters), and did not assess potentially important risk factors, such as income 17 and the presence of other household smokers. 3, 5– 7, 18 A population-based, cross-sectional study found similar quitting and relapse rates but also identified African American race, parity, stressful events, and pregnancy weight gain as predictors. 8 Other studies have found additional significant factors, including marital status, 19 alcohol use, 12 and breastfeeding. 3, 4 Surprisingly few studies have examined maternal depression despite the link between depression and smoking outside the context of pregnancy 20– 26 and its prevalence among women with young children. 27, 28 This prior research offers a detailed but fragmented picture of the factors associated with maternal smoking. First, the relative importance of any given risk factor is difficult to interpret, because past studies each examined different sets of covariates. Second, important clinical (e.g., depressive symptoms) and social (e.g., income) risk factors remain inadequately studied. Third, no study has examined the clustering of these risk factors or assessed their cumulative effects. 29– 31 Finally, small sample sizes, 3, 5– 7 sample homogeneity, 2 and a lack of longitudinal data 17 have further limited interpretation. The present study used data from the 1988 National Maternal and Infant Health Survey (NMIHS) and 1991 Longitudinal Follow-Up (LF), a national cohort study designed to identify factors related to poor pregnancy outcomes. 32, 33 We investigated factors associated with maternal smoking trends over the course of pregnancy and the first 3 years postpartum. We examined a more comprehensive set of clinical and social factors than has been analyzed to date, for both their individual and their cumulative associations with maternal smoking behaviors.
