Factors That Modify the Association of Maternal Postpartum Smoking and Exclusive Breastfeeding Rates

Abstract

Background and Objective:

Maternal postpartum smoking increases the risk for poor infant health outcomes, while exclusive breastfeeding has been shown to support infant health. Limited population-based research has been published on the interaction between maternal smoking and exclusive breastfeeding. The objective of this study was to examine factors modifying the association between maternal postpartum smoking and exclusive breastfeeding among women in the United States.

Methods:

Secondary data analysis was conducted using the 2009–2011 Pregnancy Risk Assessment Monitoring System. Stratified analyses were used to examine the associations between maternal postpartum smoking and exclusive breastfeeding by sociodemographic factors.

Results:

The postpartum smoking rate was 17.1%. The relationship between postpartum smoking and exclusive breastfeeding at 12 weeks varied by maternal education level, race/ethnicity, Medicaid use, and pregestational or gestational diabetes. The magnitude of reduction in the odds of exclusive breastfeeding at 12 weeks postpartum among the women who smoked in the postpartum period ranges from odds ratio (95% confidence interval) 0.52 (0.37–0.74) for non-Hispanic blacks to 0.31 (0.22–0.43) for women who had <12 years of education.

Conclusions:

Women who smoked in the postpartum period, who also suffered from socioeconomic disadvantages, had a higher likelihood of not continuing exclusive breastfeeding. Identification of women at high risk for not exclusively breastfeeding is important for targeting populations in need of appropriate and timely support for prenatal and postpartum smoking cessation and breastfeeding promotion.

Introduction

Maternal health behavior during the prenatal and postpartum periods is important for shaping children's health development.¹ Research has shown that both direct and indirect exposures to smoking are linked to increased risk of acute diseases, including otitis media and respiratory problems,² and chronic diseases such as childhood asthma.³ Increased knowledge about the effects of prenatal and postpartum smoking on the health of fetus and children has led to significant, but moderate declines in the prenatal smoking rate.⁴ Yet, approximately 1 in 14 women in the United States smoked during pregnancy in 2016.⁵

Pregnancy is an optimal time for smoking cessation because pregnant women are motivated to engage in healthy behaviors and stop smoking.⁶ Accordingly, ∼50% of pregnant women who smoked before pregnancy successfully abstained from smoking.⁴ Unfortunately, the relapse rate has been noted to be high among women who stopped smoking during pregnancy.⁷ Population-based research and a systematic review have shown that smoking relapse is common after birth, with varied success in preventing relapse with prenatal intervention,^7,8 thereby pointing to a concerning postpartum issue.

The overall breastfeeding initiation rate in the United States in 2015 was estimated as 83.2% and the exclusive breastfeeding rate at 12 weeks postpartum was 46.9%, with differences between states and based on maternal characteristics.⁹ Based on previous research, prenatal smoking and postpartum smoking relapse are associated with reduced breastfeeding initiation and shortened duration of any breastfeeding and exclusive breastfeeding.^10–12 It has been shown that the number of cigarettes smoked before pregnancy is negatively associated with breastfeeding initiation.¹³ In addition, at high doses, maternal smoking adversely affects the lactation process, including compositional changes and reduced volume of milk produced,¹⁴ which may suggest an increased risk of early breastfeeding termination. As exclusive breastfeeding has been found to be health promotional and protects against acute and chronic diseases for both mothers and infants, it is important to examine factors that affect maintaining exclusive breastfeeding practices among mothers who smoke during the postpartum period. Yet, there is a dearth of published information regarding the association on a population-based level. The purpose of this study was to describe the factors that modify the association between postpartum smoking and exclusive breastfeeding among women in the United States using national data.

Materials and Methods

A cross-sectional design was carried out using a secondary analysis of Pregnancy Risk Assessment Monitoring System (PRAMS) data that had been collected by the Centers for Disease Control and Prevention (CDC) during the phase 6 of the data collection process from 2009 to 2011. The main goal of PRAMS is to identify prenatal factors associated with maternal and infant health outcomes. Annually, women are randomly selected from states' birth certificate registries according to the CDC's data collection protocol using a stratified systematic approach to sampling (CDC).^a The CDC PRAMS office prepared the de-identified dataset before sharing the data with the researchers.

A total of 105,013 women in the United States participated in the PRAMS survey during the time period of 2009–2011. Of those, 84,769 women gave birth to a singleton infant ≤42 weeks of gestation, who was alive at the time of PRAMS survey participation of at least 12 weeks postpartum. Analyses were then limited to the women who had no missing data for the questions regarding the primary variables of interest, with the final sample size of 72,861 (86.0% of the eligible sample). Approval for the study was obtained from the CDC and the researchers' academic Institutional Review Board determined the study to be exempt from human subjects' research requirements.

Variables

For this study, the primary outcome variable was maternal exclusive breastfeeding at 12 weeks postpartum or later. The variable was constructed using the women's responses to the questions regarding their breastfeeding initiation, whether or not they were still breastfeeding at the time of the survey, the infant age in weeks when liquid other than mother's milk was fed for the first time, the infant age in weeks when solid food was introduced for the first time, and the age of the infant on the day of the survey. Termination of exclusive breastfeeding was determined based on maternal report of the timing that the infant was fed liquid (water, juice, formula, etc.) or food other than mother's milk.

Postpartum smoking status was the primary independent variable and was assessed using the variable that inquired into women's current smoking status. Covariates were selected based on previously published research from the literature review. The sociodemographic factors included maternal education, maternal race/ethnicity, maternal age at birth, marital status (married or not), insurance status (on Medicaid or not) at the time of delivery, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during the prenatal period. Maternal education was categorized into less than high school (<12 years), high school diploma (12 years), some college or higher (13–15 years), and college degree (≥16 years). Maternal race/ethnicity was categorized into non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and others. Maternal age at birth was categorized into <20 years of age, 20–24 years of age, 25–29 years of age, 30–34 years of age, and 35 years of age and older.

Other health-related behaviors and characteristics or conditions included provision of breastfeeding information by healthcare provider, prepregnancy weight status, presence of pregestational diabetes or gestational diabetes, infant's birth order, infant's gender (male or female), gestational week, and the number of maternal stressors during the 12 months before birth. Maternal prepregnancy weight status was calculated from reported height and weight at the time of the survey, and categorized according to the CDC body mass index categories (underweight = less than 18.5 kg/m², healthy weight = 18.5–24.99 kg/m², overweight = 25.0–29.99 kg/m², and obese = 30 kg/m² or greater). If maternal prepregnancy height and weight were not available at the time of the survey, information was used from birth certificate data. Computed gestational age was provided by PRAMS and categorized as either preterm (under 37 weeks) or term (37–42 weeks). Maternal stressors included in the dataset were hospitalization or death of family members, separation or divorce, relocation, loss of home, loss of employment, financial difficulty, physical or verbal fight with partner, incarceration of partner, addiction problem in family or close friends, and unwelcomed pregnancy by partner. PRAMS categorized the total number of stresses (0 = none, 1 = 1–2, 2 = 3–5, and 3 = 6–18). In addition, the year of survey administration (2009, 2010, and 2011) was controlled for in the model.

Data analysis

Statistical analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC). PROC SURVEY procedures were used to account for the complex survey design. Chi-square tests were used to compare characteristics of women who were cigarette smokers at the time of the PRAMS survey with those who were nonsmokers. Both bivariate and multivariate logistic regression models were used to explore the relationship between maternal postpartum smoking and exclusive breastfeeding at 12 weeks by other sociodemographic variables. All interactions significant at α = 0.20 were examined in stratified models.

Results

The overall characteristics of the study sample are displayed in Table 1. Among the study sample (n = 72,861), 81.3% (n = 59,812) initiated breastfeeding (any amount), 42.7% (n = 31,373) were breastfeeding (any amount) at 12 weeks postpartum, and 24.4% (n = 17,927) were exclusively breastfeeding at 12 weeks. The women who exclusively breastfed for at least 12 weeks were more likely to be nonsmokers, educated, older in age, and married, and had a vaginal delivery (versus cesarean). These women were less likely to have received Medicaid at delivery, utilized WIC services during pregnancy, reported experiencing stressors, or been diagnosed with diabetes. More white women compared to women of other racial/ethnic backgrounds reported having continued breastfeeding at 12 weeks. In addition, 17.1% (n = 14,113) of women reported smoking during the postpartum period. Of those who reported smoking during the postpartum period, 38.3% (n = 4,728) quit smoking before or during pregnancy, but relapsed during the postpartum period, and the rest smoked throughout pregnancy and postpartum.

Table 1.

Sample Characteristics of Women Who Participated in Pregnancy Risk Assessment Monitoring System Survey Between 2009 and 2011

	TotalN = 72,861n^a (%)^b	Women who exclusively breastfed for at least 12 weeksn = 17,927n^a (%)^b	Women who did not exclusively breastfeed for 12 weeksn = 54,934n^a (%)^b	p ^*
Maternal characteristics
Current smokers
Yes	14,113 (17.1)	1,255 (6.1)	12,858 (20.7)	<0.001
No	58,748 (82.9)	16,672 (93.9)	42,076 (79.3)
Years of education completed (years)
<12	10,841 (15.3)	1,262 (7.0)	9,579 (18.1)	<0.001
12	19,587 (25.9)	2,993 (15.6)	16,594 (29.2)
13–15	20,305 (27.2)	4,944 (26.5)	15,361 (27.4)
16+	22,128 (31.6)	8,728 (50.9)	13,400 (25.4)
Race/Ethnicity
Non-Hispanic White	40,199 (60.5)	11,526 (71.9)	28,673 (56.8)	<0.001
Non-Hispanic Black	11,430 (14.0)	1,562 (7.7)	9,868 (16.0)
Hispanic	10,134 (17.8)	1,954 (12.3)	8,180 (19.5)
Others	11,098 (7.8)	2,885 (8.0)	8,213 (7.7)
Age at Childbirth (years)
<20	6,920 (9.3)	695 (3.3)	6,225 (11.2)	<0.001
20–24	16,929 (22.4)	2,819 (14.6)	14,110 (24.9)
25–29	20,874 (29.3)	5,723 (31.9)	15,151 (28.4)
30–34	17,169 (25.0)	5,515 (33.4)	11,654 (22.3)
35+	10,969 (14.1)	3,175 (16.8)	7,794 (13.2)
Medicaid at child delivery
Yes	14,372 (17.9)	1,964 (9.3)	12,408 (20.6)	<0.001
No	58,489 (82.1)	15,963 (90.7)	42,526 (79.3)
Marital status
Married	44,133 (61.5)	14,156 (81.0)	29,977 (55.2)	<0.001
Other	28,728 (38.5)	3,771 (19.0)	24,957 (44.8)
Prenatal WIC use
Yes	34,936 (46.1)	5,284 (26.8)	29,652 (52.3)	<0.001
No	37,925 (53.9)	12,643 (73.1)	25,282 (47.7)
Pregestational or gestational diabetes
Yes	8,446 (10.4)	1,560 (7.7)	6,886 (11.3)	<0.001
No	64,415 (89.6)	16,367 (92.3)	48,048 (88.7)
Health care provider discussed breastfeeding
Yes	61,127 (82.9)	14,480 (79.5)	46,647 (84.0)	<0.001
No	11,734 (17.1)	3,447 (20.5)	8,287 (16.0)
Vaginal delivery
Yes	47,711 (67.4)	12,708 (71.9)	35,003 (66.0)	<0.001
No	25,150 (32.6)	5,219 (28.1)	19,931 (34.1)
Prepregnancy BMI (kg/m²)
<18.5	3,513 (4.2)	736 (3.9)	2,777 (4.2)	<0.001
18.5–24.99	36,403 (50.5)	10,622 (60.0)	25,781 (47.4)
25–29.99	17,386 (24.1)	3,969 (22.2)	13,417 (24.7)
30+	15,559 (21.3)	2,600 (14.0)	12,959 (23.6)
Number of stressors
None	20,368 (29.2)	6,317 (36.9)	1,4051 (26.6)	<0.001
1–2	30,528 (42.3)	8,045 (44.9)	22,483 (41.5)
3–5	17,504 (23.0)	3,037 (15.7)	14,467 (25.3)
6–18	4,461 (5.6)	528 (2.5)	3,933 (6.6)
Parity
Primipara	31,727 (41.9)	7,171 (38.0)	24,556 (43.2)	<0.001
Multipara	41,134 (58.1)	10,756 (62.0)	30,378 (56.8)
Child characteristics
Gestational age (weeks)
<37	12,986 (7.7)	2,208 (5.4)	10,778 (8.4)	<0.001
37–42	59,875 (92.3)	15,719 (94.6)	44,156 (91.6)
Sex
Male	36,934 (51.3)	8,906 (49.5)	28,028 (51.9)	0.0010
Female	35,927 (48.7)	9,021 (50.4)	26,906 (48.1)
Survey year
2009	18,477 (26.5)	4,308 (24.3)	14,169 (27.2)	<0.001
2010	27,604 (39.1)	6,699 (38.1)	20,905 (39.4)
2011	26,780 (34.4)	6,920 (37.7)	19,860 (33.3)

Numbers of women were from unweighted sample distribution.

Percentages were weighted to survey oversampling, nonresponse and noncoverage.

Significance assessed using Wald Chi-Square test.

WIC, women, infants, and children; BMI, body mass index.

Table 2 shows the association between postpartum smoking and exclusive breastfeeding at 12 weeks. The interactions between maternal smoking and maternal education of <12 years (p = 0.128), between maternal smoking and maternal race/ethnicity (p = 0.005), between maternal smoking and Medicaid at delivery (p = 0.080), and between maternal smoking and pregestational or gestational diabetes (p = 0.118) were further examined in stratified models. Women with <12 years of educational attainment were ∼70% less likely to continue exclusive breastfeeding for at least 12 weeks if they smoked during the postpartum period after adjusting for other confounding factors (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.22–0.43) compared to nonsmoking women with similar educational attainment. Similarly, having received Medicaid during pregnancy further reduced the odds of exclusive breastfeeding at 12 weeks postpartum for women who smoked during the postpartum period (OR 0.32, 95% CI 0.25–0.41). Magnitude of the association between postpartum smoking and exclusive breastfeeding at 12 weeks differed by racial/ethnic groups.

Table 2.

Odds of Continuing Exclusive Breastfeeding to at Least 12 Weeks (N = 72,861)

Variables	Unadjusted model	Multivariate model
Variables	OR [95% CI]	OR [95% CI]
Postpartum smoking
No	Ref.	Ref.
Yes
Maternal education
<12 years	0.29 [0.22–0.39]	0.31 [0.22–0.43]
12 years	0.37 [0.31–0.45]	0.39 [0.32–0.47]
13–15 years	0.36 [0.30–0.43]	0.42 [0.35–0.50]
16+ years	0.37 [0.29–0.48]	0.41 [0.32–0.54]
Race/Ethnicity
Non-Hispanic White	0.21 [0.18–0.23]	0.38 [0.34–0.44]
Non-Hispanic Black	0.34 [0.24–0.47]	0.52 [0.37–0.74]
Hispanic	0.23 [0.15–0.35]	0.31 [0.20–0.49]
Others	0.31 [0.22–0.43]	0.51 [0.35–0.72]
Medicaid at child delivery
No	0.27 [0.24–0.30]	0.41 [0.36–0.46]
Yes	0.31 [0.25–0.39]	0.32 [0.25–0.41]
Pregestational or gestational diabetes
No	0.24 [0.22–0.27]	0.38 [0.34–0.43]
Yes	0.37 [0.26–0.52]	0.50 [0.35–0.72]
Maternal age in years
<20	0.50 [0.43–0.59]	0.74 [0.62–0.88]
20–24	Ref.	Ref.
25–29	1.92 [1.76–2.10]	1.15 [1.05–1.27]
30–34	2.57 [2.35–2.80]	1.20 [1.08–1.33]
35+	2.17 [1.97–2.40]	1.01 [0.90–1.14]
Marital status
No	Ref.	Ref.
Yes	0.29 [0.27–0.31]	0.65 [0.59–0.71]
Prenatal WIC participation
No	Ref.	Ref.
Yes	0.33 [0.31–0.36]	0.80 [0.73–0.87]
Health care provider discussed breastfeeding
No	1.36 [1.27–1.46]	0.91 [0.84–0.98]
Yes	Ref.	Ref.
Vaginal delivery
No	0.76 [0.71–0.81]	0.76 [0.71–0.81]
Yes	Ref.	Ref.
Prepregnancy BMI (kg/m²)
<18.5	0.72 [0.62–0.83]	0.93 [0.79–1.09]
18.5–24.99	Ref.	Ref.
25–29.99	0.71 [0.66–0.76]	0.79 [0.73–0.85]
30+	0.47 [0.43–0.51]	0.59 [0.54–0.64]
Number of stressors
0	Ref.	Ref.
1–2	0.78 [0.73–0.83]	0.96 [0.90–1.03]
3–5	0.45 [0.41–0.49]	0.83 [0.76–0.91]
6–18	0.28 [0.23–0.33]	0.78 [0.65–0.94]
Parity
Primipara	Ref.	Ref.
Multipara	1.24 [1.17–1.31]	1.26 [1.18–1.34]
Gestational age (weeks)
37–42	Ref.	Ref.
<37	0.62 [0.56–0.69]	0.74 [0.66–0.83]
Child sex
Male	Ref.	Ref.
Female	1.10 [1.04–1.16]	1.12 [1.05–1.19]
Year of survey
2009	Ref.	Ref.
2010	1.08 [1.01–1.17]	1.09 [1.01–1.18]
2011	1.25 [1.18–1.36]	1.23 [1.14–1.33]

Numbers of women were from unweighted sample distribution; 95% CIs were weighted to survey oversampling, nonresponse, and noncoverage.

OR, odds ratio; CI, confidence interval; Ref., reference.

We also assessed the representativeness of the analytic sample by comparing the women who were included in the study (n = 72,861) with those who were excluded (n = 11,908). We found statistically significant differences in the characteristics of women who were included in the study compared to women who were excluded. Compared to those who were excluded, women in the analytic sample were more likely to be smokers at the time of the survey (17.1% versus 14.1%, p < 0.01) and were less likely to have exclusively breastfed for 12 weeks (75.6% versus 79.0%, p < 0.01). Women who were included in the study were more likely to be educated compared to those excluded (less than high school 15.3% versus 35.2%; some college 27.2% versus 19.9%; and college graduates 31.6% versus 18.5%; p < 0.01), slightly older at childbirth (<20 years 9.3% versus 11.3%; 20–24 years 22.4% versus 24.0%; 25–30 years 29.3% versus 27.4%; and 30–34 years 25.0% versus 23.4%; p < 0.01), married (61.5% versus 50.6%; p < 0.01), primipara (41.9% versus 36.3%; p < 0.01), and have had a term birth (92.3% versus 90.9%; p < 0.01). They were less likely to have used WIC prenatally (46.1% versus 60.0%; p < 0.01), have received Medicaid (17.9% versus 22.1%, p < 0.01), have pregestational or gestational diabetes (10.4% versus 14.3%; p < 0.01), and have a healthcare provider talk about breastfeeding (82.9% versus 85.7%; p < 0.01). In addition, a greater proportion of non-Hispanic white women and less of Hispanic women were included (60.5% NHW, 14.0% NHB, 17.8% Hispanic, and 7.8% others versus 34.5% NHW, 13.2% NHB, 43.2% Hispanic, and 9.0% others; p < 0.01).

Discussion

This study examined the modifying factors of the association between maternal postpartum smoking and exclusive breastfeeding at 12 weeks. Our results indicate that certain sociodemographic characteristics influenced the strength of the relationship between maternal postpartum smoking and exclusive breastfeeding. We found that women with less than a high school education, those who received Medicaid at the time of delivery, and women of non-Hispanic white or Hispanic race/ethnicity were likely to discontinue exclusive breastfeeding before 12 weeks postpartum if they smoked during the postpartum period. However, having gestational or pregestational diabetes decreased the likelihood of early discontinuation of breastfeeding among women who reported smoking during the postpartum period compared to those without diabetes. As maternal smoking is not currently considered an absolute contraindication for breastfeeding, breastfeeding is still encouraged for women who experience difficulty in quitting smoking, while emphasizing the importance of smoking cessation and maintaining abstinence throughout the postpartum period.¹⁵

Our results indicate that educational attainment of <12 years as well as having received Medicaid further reduced the odds of exclusive breastfeeding at 12 weeks postpartum for women who smoked during the postpartum period. This is not surprising as the prevalence of prenatal smoking at any time of pregnancy was found to be highest among women with <12 years of education or those who received Medicaid during pregnancy.¹⁶ These women were also less likely to quit smoking during pregnancy.¹⁶ The PRAMS data used for this study were collected before the Affordable Care Act (ACA) of 2010. Women on Medicaid before the ACA received limited prenatal and postnatal breastfeeding support services, whereas ACA may have increased access to those services for low-income women.¹⁷ Improving access to lactation support for women with health disparities has shown to increase rates of breastfeeding intention, initiation, and continuation.^18,19 As such, findings from our study further inform advocacy for women who face disparities and who should receive assistance to promote exclusive breastfeeding.

The observed interaction between postpartum smoking and race/ethnicity on exclusive breastfeeding is noteworthy. The likelihood of exclusive breastfeeding at 12 weeks postpartum among non-Hispanic black women with postpartum smoking was higher compared to non-Hispanic white and Hispanic women who smoked during the postpartum. A previous study using a group of primarily non-Hispanic black women from a low-income background reported a similar finding²⁰ that breastfeeding rates and duration did not differ by smoking status among their study sample. While the lack of significant findings may be attributed to the small subsample size, the findings may indicate that non-Hispanic black women face more barriers to exclusive breastfeeding than their smoking status.²¹ Overall, strategies to encourage exclusive breastfeeding may need to be carefully selected by taking women's racial/ethnic and cultural backgrounds into consideration.

Our results indicate that women with pregestational or gestational diabetes were less likely to exclusively breastfeed their infants for 12 weeks compared to women without any diabetes during pregnancy, after adjusting for other factors. A significant interaction between postpartum smoking and exclusive breastfeeding was unexpected. The likelihood of exclusive breastfeeding at 12 weeks among women who smoked was even lower among women with pregestational or gestational diabetes compared to women without diabetes who smoked. A previous study also indicated that women with a history of gestational diabetes were less likely to exclusively breastfeed at hospital discharge.²² The same study also noted a similar interaction using breastfeeding initiation as the outcome.²³ The reason for the attenuated negative relationship between exclusive breastfeeding and diabetes among smokers compared to nonsmokers is unclear, although women with diabetes may have benefited from receiving an increased level of healthcare attention than those who do not. More research is needed to explain this behavioral phenomenon.

A secondary finding of the study is that, among the study sample, 14,113 women reported smoking at the time of the PRAMS survey, with a majority (61.7%) smoking throughout pregnancy and postpartum and a large proportion (38.3%) resuming smoking during the postpartum period. In addition, among the 19,682 women who reported having smoked 3 months before pregnancy, only 29.5% quit during pregnancy and remained smoke-free. This finding highlights the need to more effectively reduce prepregnancy smoking among women of childbearing age as well as the need to promote prenatal and postpartum smoking cessation, especially among women with a history of smoking.

Limitations and strengths

Limitations of the study are related to the self-reported nature of the cross-sectional methods that are dependent upon maternal recall of the previous year, although maternal recall of breastfeeding practices has previously been found to be valid for six years postpartum.²⁴ Factors identified in other studies such as family members' opinions of breastfeeding and cultural perspectives on breastfeeding were not available in the dataset. In addition, after excluding participants who did not meet criteria for analysis, there were significant differences between those included and excluded from the sample on specific characteristics. Therefore, caution must be taken when interpreting results of this study. This may have resulted in underestimation of the relationship between exclusive breastfeeding and socioeconomic factors, and overestimation of the relationship between exclusive breastfeeding and smoking status. Nonetheless, use of a large diverse population from across the United States is a strength of the study and allowed for the examination of interaction effects of maternal postpartum smoking and other maternal characteristics on exclusive breastfeeding. As noted in previous literature, Spanish-speaking Hispanic women who participate in PRAMS survey tend to have more missing data than women from other racial/ethnic groups.²⁵ In addition, the smoking rate among young adults is lower among Hispanic women than non-Hispanic white women.²⁶ These may have resulted in an unequal distribution between included and excluded samples during the sample selection process. Therefore, sensitivity analyses were conducted by excluding Hispanic women. The results of multivariate analyses show an approximately similar magnitude of association between postpartum smoking and exclusive breastfeeding (OR 0.41, 95% CI 0.33–0.51).

Conclusion

Postpartum smoking is an independent factor associated with reduced exclusive breastfeeding for 12 weeks. Furthermore, smoking during the postpartum period was associated with socioeconomic disadvantages. It is imperative for healthcare providers to educate and support women during prepregnancy, prenatal, and postpartum periods regarding smoking cessation and about breastfeeding promotion. Identification of at-risk women and targeted provision of education and support for smoking cessation and breastfeeding promotion are important in sustaining a longer duration of exclusive breastfeeding. Endorsing healthcare policies that provide prenatal and postpartum healthy lifestyle education and breastfeeding support to women from disadvantaged backgrounds can positively impact exclusive breastfeeding rates.

Footnotes

Acknowledgments

The authors would like to acknowledge the PRAMS Working Group (Alabama: Izza Afgan, MPH; Alaska: Kathy Perham Hester, MS, MPH; Arkansas: Mary McGehee, PhD; Colorado: Rickey Tolliver, MPHC; Connecticut: Jennifer Morin, MPH; Delaware: George Yocher, MS; Florida: Elizabeth C. Stewart, MSPH; Georgia: Florence A. Kanu, MPH; Hawaii: Matt Shim, PhD, MPH; Illinois: Patricia Kloppenburg, MT [ASCP], MPH; Iowa: Jessica Egan; Kentucky: Tracey D. Jewell, MPH; Louisiana: Rosaria Trichilo, MPH; Maine: Tom Patenaude, MPH; Maryland: Laurie Kettinger, MS; Massachusetts: Emily Lu, MPH; Michigan: Peterson Haak; Minnesota: Mira Grice Sheff, PhD, MS; Mississippi: Brenda Hughes, MPPA; Missouri: David McBride, PhD; Montana: Emily Healy, MS; Nebraska: Jessica Seberger; New Hampshire: David J. Laflamme, PhD, MPH; New Jersey: Sharon Smith Cooley, MPH; New Mexico: Oralia Flores; New York State: Anne Radigan; New York City: Pricila Mullachery, MPH; North Carolina: Kathleen Jones Vessey, MS; North Dakota; Grace Njau, MPH; Ohio: Connie Geidenberger, PhD; Oklahoma: Ayesha Lampkins, MPH, CHES; Oregon: Claudia W. Bingham, MPH; Pennsylvania: Tony Norwood; Rhode Island: Karine Tolentino Monteiro, MPH; South Carolina: Kristin Simpson, MSW, MPA; Texas: Tanya Guthrie, PhD; Tennessee: Ramona Lainhart, PhD; Utah: Nicole Stone; Vermont: Peggy Brozicevic; Virginia: Sara Varner, MPH; Washington: Linda Lohdefinck; West Virginia: Melissa Baker, MA; Wisconsin: Christopher Huard; and Wyoming: Lorie Chesnut, PhD); and Centers for Disease Control and Prevention PRAMS Team, Applied Sciences Branch, Division of Reproductive Health.

Disclosure Statement

No competing financial interests exist.

a

References

Halfon

, Hochstein

Life course health development: An integrated framework for developing health, policy, and research. Milbank Q, 2002; 80:433–479, iii.

Amani

, Yarmohammadi

. Study of effect of household parental smoking on development of acute otitis media in children under 12 Years. Glob J Health Sci, 2015; 8:81–88.

Kanoh

, Kaneita

, Hara

, et al. Longitudinal study of parental smoking habits and development of asthma in early childhood. Prev Med, 2012; 54:94–96.

Tong

, Dietz

, Morrow

, et al. Trends in smoking before, during, and after pregnancy—pregnancy risk assessment monitoring system, United States, 40 sites, 2000–2010. MMWR Morb Mortal Wkly Rep, 2013; 62:1–19.

Drake

, Driscoll

, Mathews

. Cigarette smoking during pregnancy: United States, 2016. NCHS Data Brief, 2018:1–8.

Orleans

, Johnson

, Barker

, et al. Helping pregnant smokers quit: Meeting the challenge in the next decade. West J Med, 2001; 174:276–281.

Tran

, Reeder

, Funke

, et al. Association between smoking cessation interventions during prenatal care and postpartum relapse: Results from 2004 to 2008 multi-state PRAMS data. Matern Child Health J, 2013; 17:1269–1276.

Hoedjes

, Berks

, Vogel

, et al. Effect of postpartum lifestyle interventions on weight loss, smoking cessation, and prevention of smoking relapse: A systematic review. Obstet Gynecol Surv, 2010; 65:631–652.

Breastfeeding Report Card. Centers for Disease Control and Prevention Website. Updated August 20, 2018. Available at https://cdc.gov/breastfeeding/data/reportcard.htm (accessed August 29, 2018).

10.

Jones

, Kogan

, Singh

, et al. Factors associated with exclusive breastfeeding in the United States. Pediatrics, 2011; 128:1117–1125.

11.

Liu

, Rosenberg

, Sandoval

. Breastfeeding duration and perinatal cigarette smoking in a population-based cohort. Am J Public Health, 2006; 96:309–314.

12.

Weiser

, Lin

, Garikapaty

, et al. Association of maternal smoking status with breastfeeding practices: Missouri, 2005. Pediatrics, 2009; 124:1603–1610.

13.

Bailey

, Wright

. Breastfeeding initiation in a rural sample: Predictive factors and the role of smoking. J Hum Lact, 2011; 27:33–40.

14.

Napierala

, Mazela

, Merritt

, et al. Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review. Environ Res, 2016; 151:321–338.

15.

Reece-Stremtan

, Marinelli

. ABM clinical protocol #21: Guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med, 2015; 10:135–141.

16.

Curtin

, Matthews

. Smoking prevalence and cessation before and during pregnancy: Data from the birth certificate, 2014. Natl Vital Stat Rep, 2016; 65:1–14.

17.

Hawkins

, Dow-Fleisner

, Noble

. Breastfeeding and the Affordable Care act. Pediatr Clin North Am, 2015; 62:1071–1091.

18.

Kapinos

, Bullinger

, Gurley-Calvez

. Lactation support services and breastfeeding initiation: Evidence from the Affordable Care act. Health Serv Res, 2017; 52:2175–2196.

19.

Wouk

, Chetwynd

, Vitaglione

, et al. Improving access to medical lactation support and counseling: Building the case for Medicaid reimbursement. Matern Child Health J, 2017; 21:836–844.

20.

Bogen

, Davies

, Barnhart

, et al. What do mothers think about concurrent breast-feeding and smoking?. Ambul Pediatr, 2008; 8:200–204.

21.

Ogbuanu

, Probst

, Laditka

, et al. Reasons why women do not initiate breastfeeding: A southeastern state study. Womens Health Issues, 2009; 19:268–278.

22.

Haile

, Oza-Frank

, Azulay Chertok

, et al. Association between history of gestational diabetes and exclusive breastfeeding at hospital discharge. J Hum Lact, 2016; 32:NP36–NP43.

23.

Oza-Frank

, Chertok

, Bartley

. Differences in breast-feeding initiation and continuation by maternal diabetes status. Public Health Nutr, 2015; 18:727–735.

24.

Amissah

, Kancherla

, Ko

, et al. Validation study of maternal recall on breastfeeding duration 6 years after childbirth. J Hum Lact, 2017; 33:390–400.

25.

Ahluwalia

, Helms

, Morrow

. Assessing the validity and reliability of three indicators self-reported on the pregnancy risk assessment monitoring system survey. Public Health Rep, 2013; 128:527–536.

26.

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.