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QUESTION: How do women describe their experiences of smoking relapse after the birth of a child?
Design
Narrative analysis.
Setting
Vancouver, British Columbia, Canada.
Participants
27 women (age range 18–39 y) who had stopped smoking during pregnancy and relapsed during the postpartum period were recruited after participation in a clinical trial of smoking relapse prevention and by a newspaper advertisement.
Methods
During one hour telephone or face to face interviews, women told their stories of smoking relapse. Interviews were tape recorded and transcribed verbatim. Analysis of data included close readings of the narratives; preparation of brief summaries and line drawing representations; and identification, coding, re-reading, and probing of central storylines.
Main findings
In telling their stories, women used various combinations of 5 general storylines. The first, controlling one's smoking, was about beginning with an unplanned “puff” of a cigarette at a social gathering or during a stressful time, which developed into a pattern of infrequent puffs and borrowed cigarettes. Women believed, however, that smoking could be controlled, and strategies were developed to limit the amount smoked (eg, not buying cigarettes). Smoking was cast in a positive light, with the benefits of occasional smoking emphasised (eg, to facilitate stopping at a later date). The second storyline was about being vulnerable to smoking. Women described themselves as passive players, who, in a moment of weakness, could not resist the urge to smoke. Moments of vulnerability occurred in the presence of other smokers and in situations involving alcohol consumption. Women were unhappy about smoking, but felt they had no choice because they were addicted. The third storyline of nostalgia for one's former self was about relapsing to recapture feelings of happier times. Women remembered smoking as an accompaniment to certain social and personal activities and associated it with feelings of freedom, fun, and camaraderie. With motherhood, these activities were curtailed, and so women longed for smoking and for their “old selves.” The fourth storyline of smoking for relief described relapsing as the only way women knew how to manage the fatigue, isolation, and stress experienced after the birth of a baby. Smoking, with its “hidden” adverse effects, was portrayed as an acceptable coping mechanism compared with, for example, overeating. Women talked about the soothing and relaxing effects of smoking and the opportunity for “time out” from their children. The fifth storyline of never really having quit was about relapsing because they had not stopped smoking for themselves. Women who said they had stopped smoking for their baby, rather than for themselves, portrayed themselves as self sacrificing and honourable. A subnarrative of good mothers don't smoke underpinned all of these storylines, and reflected the internal conflict and guilt as women recognised that as smokers, “they could not live up to idealised portrayals of mothers as self sacrificing protectors and perfect role models for their children” (p132). Women hid smoking from their children, worried about putting their children at risk from secondhand smoke, and feared ridicule and embarrassment from society.
Conclusion
Women's stories of smoking relapse after the birth of a child were underpinned by combinations of 5 storylines: controlling one's smoking, being vulnerable to smoking, nostalgia for one's former self, smoking for relief, and never having really quit.
Commentary
Research has shown that smoking cessation during pregnancy reduces the risk of having a low birthweight baby.1 Studies indicate that up to 40% of women stop smoking during their pregnancy; unfortunately, up to 75% relapse within the first 6 months after the child's birth.2 Smoking cessation during pregnancy is often motivated by a concern for the health of the fetus rather than a true desire to stop smoking. Therefore, the “real work” of quitting begins after delivery.
Limited qualitative research exists on postpartum smoking relapse. It is unclear how women think about and make sense of the experience of smoking relapse. The study by Bottorff et al contributes to our understanding of women's experiences through a diversity of stories about smoking relapse after the birth of a child. They identified 5 storylines that were common in the women's narratives. The third storyline of “nostalgia for one's former self” suggests conflict, in which women long to be free from the demanding responsibilities of motherhood, yet feel tied to their infant. Smoking was associated with their former selves and therefore provided a link with the past.
The authors refer to the value of the interaction between the narrator and the listener. For health professionals, listening attentively is an important skill that can help women to become more aware of the underlying reasons for their relapse.
None the less, caution should be exercised in the interpretation and application of the study findings. In other contexts, women's narratives may differ from those in this study. As the authors point out, the study was done in a city that had many restrictions about smoking in public settings. Research is needed to identify and evaluate interventions to help women to avoid smoking relapse during the postpartum period. These interventions are likely to be effective only if they address the context of women's lives as suggested by these 5 storylines.
Footnotes
Source of funding: no external funding.
For correspondence: Dr J L Bottorff, University of British Columbia, School of Nursing, T201-2211 Westbrook Mall, Vancouver, BC V6T 2B5, Canada. Fax +1 604 822 7466.