Postpartum smoking relapse experiences of women who quit during pregnancy: a qualitative descriptive study

Abstract

Background

Understanding postpartum smoking relapse in women is important for protecting both maternal and infant health in the long term. This study aimed to explore the postnatal smoking relapse experiences of women who quit smoking during pregnancy.

Methods

This descriptive qualitative study was conducted with 11 women who quit smoking during pregnancy and relapsed in the postnatal period. The participants were selected via a purposive sampling method. The study included women who quit smoking during the first trimester of pregnancy and resumed smoking after childbirth; those with a psychiatric diagnosis were excluded. Data were collected through the “Introductory Information Form” and “Semistructured Interview Form” and through online in-depth individual interviews. The interviews were performed between January 1 and 17, 2025. The data were analyzed via a six-stage thematic analysis method.

Results

The study revealed three main themes: motivations for smoking cessation during pregnancy, factors influencing postpartum smoking relapse, and behavioral processes involved in postpartum relapse.

Conclusions

Various factors play a role in postpartum smoking relapse, including the intention to resume smoking, low risk perception, breastfeeding, stress, and the attitudes of the social environment. Even if women quit smoking during pregnancy, they should be assessed for the risk of relapse both during pregnancy and in the postpartum period and should be supported when necessary.

Background

Women who smoke experience changes in their smoking patterns during pregnancy [1]. Most women try to quit smoking during pregnancy [2, 3]. Despite this, approximately half of women who quit smoking during pregnancy experience relapse in the postnatal period [4]. This high relapse rate increases the risk for both maternal health and infant health due to exposure to secondhand smoke [5]. The initial two years following smoking cessation are considered the period of highest vulnerability to relapse [6]. This process represents a transitional period encompassing the postpartum and early motherhood phases, during which women undergo significant physical and emotional adjustments. Therefore, it is important to prevent women from smoking relapse during the postnatal period.

A meta-analysis has shown that existing interventions targeting postpartum smoking relapse are largely ineffective in preventing relapse [7]. For this reason, in-depth examination of women’s relapse experiences in the postpartum period can guide the development of effective interventions to prevent relapse [8].

Postpartum smoking relapse has been associated with several factors, including low educational attainment, a partner who smokes, inadequate partner support, smoking as a coping strategy for stress, the absence of breastfeeding, and postpartum depression [9, 10]. Despite the identification of various risk factors contributing to postpartum relapse, there remains a paucity of qualitative research that delves into women’s subjective experiences during pregnancy and the postpartum period [9, 11].

Within this context, examining the lived experiences of women who experience postpartum smoking relapse can offer valuable insights into the underlying dynamics of relapse. This study aims to explore the experiences of women who quit smoking during pregnancy in the process of relapse in the postpartum period. The results of this study may guide the development of effective interventions to prevent smoking relapse in the postpartum period. This will contribute to public health policies to protect women’s health.

Methods

Research design

This study conducted as a descriptive qualitative approach to explore participants’ subjective experiences, capture diverse perspectives, and present findings directly aligned with the research question [12]. Given that smoking cessation and relapse are shaped by complex factors, this approach allows for an in-depth exploration of these behaviors within a meaningful context. In this context, the research question has been defined as the experiences of women who quit smoking during pregnancy regarding the process of resuming smoking in the postpartum period. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines have been used in reporting the study [13].

Sample and setting

The study was conducted with women who had presented to the pediatric or obstetric outpatient clinics of a hospital for any reason and had resumed smoking during the postpartum period.

Inclusion criteria

• Smoking cessation during the first trimester of pregnancy.

• Relapse into smoking during the postpartum period.

Exclusion criteria

• Having a psychiatric diagnosis.

The participants were selected through purposive sampling. Among the 24 eligible individuals, 13 declined to participate. The sample size was guided by data and thematic saturation; thus, data collection and analysis were conducted concurrently via constant comparative analysis [14, 15]. Starting with the ninth interview, it was observed that semantic repetition began to emerge in the data and no new codes appeared. The fact that no new information units were encountered in the following two interviews that would expand or alter the existing themes indicated that the data had reached a point of saturation. The process concluded with 11 participants. Descriptive information about the participants is presented in Table 1.

Table 1.

Descriptive information of the participants

No	Age	Marital Status	Education Level	Cigarettes /day (prepregnancy)	Cigarettes/day (current)	Cessation week (pregnancy)	Relapse week (postpartum)	Partner’s smoking status
P1	32	Married	Bachelor’s degree	30	5	4th week	15th month	Smoker
P2	31	Married	Bachelor’s degree	20	20	12th week	1st month	Nonsmoker
P3	28	Married	High school	10–15	5–10	3th week	16th month	Smoker
P4	33	Married	Bachelor’s degree	15	15	4th week	20th day	Smoker
P5	32	Married	Bachelor’s degree	10–12	10–12	10th week	3rd month	Smoker
P6	30	Married	High school	10	10	6th week	40th day	Smoker
P7	32	Married	Bachelor’s degree	4–5	3–4	4th week	6th month	Smoker
P8	29	Married	Bachelor’s degree	5	5	10th week	20th day	Smoker
P9	36	Married	Bachelor’s degree	5–6	5–6	4th week	1st month	Smoker
P10	36	Married	Postgraduate degree	8–9	2	6th week	4th month	Nonsmoker
P11	38	Married	Bachelor’s degree	20	4–5	2nd week	5th month	Smoker

The participants were aged 28–38 years, and most held a bachelor’s degree. All were married, and the majority had partners who smoked. They quit smoking between the 2nd and 12th weeks of pregnancy, with relapse occurring between 20 days and 16 months postpartum.

Data collection tools

Personal information form

This form was developed by the researchers to assess participants’ sociodemographic and smoking-related characteristics. It includes eight items on age, marital status, education level, prepregnancy and current cigarette use, week of cessation during pregnancy, timing of postpartum relapse, and partner smoking status [16].

Semistructured interview form

The semistructured interview form was developed through a systematic process. Its content validity was evaluated by two experts, and a pilot study with two similar individuals was conducted. Data from the pilot were excluded from the main study. The final version is presented in Table 2.

Table 2.

Semistructured interview questions

Could you explain your reasons for quitting smoking during pregnancy?

Could you describe your experience of quitting smoking during pregnancy?

Could you describe your relapse into smoking during the postpartum period?

Could you explain the factors that led to your smoking relapse in the postpartum period?

Data collection

Women who consented to participate completed a demographic form via Google Forms, and online appointments were arranged for individual interviews. The interviews were conducted between January 1 and 17, 2025, via video call on the WhatsApp app by the lead researcher, guided by a semi-structured interview guide. The researcher conducting the interview took notes during the sessions. To ensure confidentiality and focus during the data collection process, participants were reminded prior to the interview to be in a quiet and private setting. All participants participated in the interviews from their homes and alone. Each online interview lasted approximately 30 min. At the beginning of each interview, participants were asked to provide verbal consent again, and an audio recording was made; no participant refused to be recorded. Each participant was interviewed once. The interviews were transcribed on the same day they were conducted and sent to the participants to verify the accuracy of the data. No participant requested any corrections or changes to the content.

Data analysis and synthesis

The researchers are an all-female group of public health nursing academics with prior experience in qualitative studies. The first author is a doctoral student trained in qualitative research; the second is an associate professor. Neither had a history of smoking. Neither researcher had established any prior relationship with the participants before the study began. When the participants were invited to participate in the study, they were informed both verbally and in writing about the researchers’ academic affiliations, the primary purpose of the study, how the collected data would be used, and the principle of voluntary participation.

Data analysis began after the first interview and was conducted concurrently with data collection. In the data analysis process, Braun and Clarke’s (2021) six-step reflective thematic analysis method was employed [15]. First, all audio-recorded data were listened to again by the first researcher on the same day the interviews were conducted and manually transcribed (Step 1). Subsequently, both researchers read the transcripts multiple times, underlining notable statements to create initial codes (Step 2). To evaluate existing codes and gain a deeper familiarity with the data, the original transcripts were revisited repeatedly, and all data relevant to the research question were coded. Based on the codes obtained, initial potential themes were identified (Step 3). These potential themes, which reveal patterns of meaning in the data, were re-examined and refined in terms of their relationships both with the codes within them and with the entire dataset (Step 4). At the end of the process, the theme names were revised and defined in a concise and meaningful way that best reflected the data (Step 5). At the conclusion of the analysis, a thematic structure and thematic map were developed that most comprehensively addressed the research questions. In the final stage, the relationships between the themes were structured to form a cohesive narrative, and the analysis findings were reported alongside participant quotes that provided evidence grounded in the data (Step 6).

Rigor and trustworthiness

To ensure the study’s trustworthiness, four criteria-transferability, credibility, confirmability, and dependability-were addressed. Transferability was enhanced by providing detailed descriptions of the method, sample, setting, and procedures. Credibility was supported through audio-recorded and transcribed interviews, with follow-up clarification from participants when needed. Confirmability was ensured through bracketing, whereby researchers consciously set aside personal biases [17], supported by reflective notes and direct quotations. Dependability was established through independent coding by both researchers (researcher triangulation), comparison of codes, and validation through expert feedback.

Ethical considerations

The study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Scientific Research Ethics Committee of Lokman Hekim University on December 30, 2024 (Approval Code: 2024283). Written permission was obtained from the hospital, and informed consent was obtained from all participants.

Results

Three main themes and nine subthemes were identified in the study. The themes and subthemes that emerged from the study are presented in Table 3.

Table 3.

The themes and subthemes

Themes	Subthemes
Theme 1. Motivations for Smoking Cessation During Pregnancy	Subtheme 1.1. External motivators
	Subtheme 1.2. Internal motivators
Theme 2. Factors Influencing Postpartum Smoking Relapse	Subtheme 2.1. Postpartum intention to resume smoking
	Subtheme 2.2. Perceived low risk
	Subtheme 2.3. Breastfeeding
	Subtheme 2.4. Stress management
	Subtheme 2.5. Social environment
Theme 3. Behavioral Processes in Postpartum Smoking Relapse	Subtheme 3.1. Integration into daily routines
	Subtheme 3.2. Developing protective strategies for the baby

Theme 1. Motivations for smoking cessation during pregnancy

Subtheme 1.1. External motivators

Women reported a strong aversion to the smell of cigarettes due to pregnancy-related nausea and heightened sensitivity to odors. This aversion often led them to quit smoking spontaneously. In addition, external pressures, particularly from their social environment, were identified as influential. Women with nonsmoking partners especially described feeling compelled to quit due to their partner’s expectations and concerns about fetal harm.

“You become sensitive to smells during the first few months. I was truly disgusted by both the smell and the taste. I couldn’t even stay near it… Therefore, it happened quite naturally.” P7

“My husband doesn’t smoke. He absolutely didn’t want me to smoke either. Therefore, he might have been a kind of external force that pushed me to quit. Because he thought it would harm our baby.” P10

Subtheme 1.2. Internal motivators

The participants emphasized that their primary motivation for quitting smoking during pregnancy was the health and safety of their babies. Many expressed a strong maternal instinct that compelled them to quit, often driven by the fear of miscarriage or harm to the fetus. This internal drive was described as a natural and powerful force that helped them maintain abstinence.

“While I was pregnant, I quit to avoid causing a miscarriage. Since the risk of losing the baby is greater during that time, it’s easier to convince yourself to quit.” P9

“The space inside my womb was already tight. I used to think, if I smoke, it’s like putting a plastic bag over the baby’s head and suffocating them. That image kept coming to mind. That’s how I adapted myself to quitting.” P5

Theme 2. Factors influencing postpartum smoking relapse

Subtheme 2.1. Postpartum intention to resume smoking

The participants indicated that they perceived their smoking cessation during pregnancy as temporary. Rather than viewing it as a complete and permanent decision, they had no real intention of quitting for good. This mindset contributed to their relapse after childbirth.

“As I said, after the baby was six months old, I started to crave it again. I had the urge to smoke. Maybe if I hadn’t wanted it, I wouldn’t have started again. However, I never, at any point, truly ended it in my mind.” P7

“In fact, during my entire pregnancy, I keep saying, ‘Once I give birth, I’m going to smoke.’ I was like, ‘As soon as I’m discharged, I’ll light a cigarette.’ I keep thinking I would start again after a certain period. I had never actually quit for good.” P11

Subtheme 2.2. Perceived low risk

The participants expressed a belief that smoking after childbirth posed minimal or no harm to their babies. The perception that the baby was no longer physically connected to them or that limited cigarette use would not significantly affect breast milk contributed to their justification for resuming smoking.

“I thought, ‘The baby is out of my body now. Nothing will transfer from me to them anymore, so I can smoke.’ I believed that since the baby was no longer in my body, smoking wouldn’t harm them.” P4

“I’m breastfeeding my baby, but I thought maybe it wouldn’t affect my milk that much if I just smoked one or two times a day. I smoked thinking that two cigarettes wouldn’t cause much harm.” P10

Subtheme 2.3. Breastfeeding

The participants described breastfeeding as both a delaying factor and a potential trigger for relapse. While some women postpone smoking because of a sense of responsibility or guilt associated with breastfeeding, difficulties or changes in the breastfeeding process also appear to increase the likelihood of relapse.

“When my baby was 15 months old, I was still breastfeeding, and I didn’t smoke because of the responsibility I felt… I constantly felt guilty because I was still breastfeeding.” P3

“It [the relapse] was something I deliberately postponed. I didn’t think about it at first because my baby was nursing very frequently. I waited until the baby grew a bit and nursed less before starting again. That’s why I delayed it.” P10

Subtheme 2.4. Stress management

Women reported returning to smoking as a coping mechanism for stress during the postpartum adjustment period. They face various stressors related to infant care and maternal responsibilities. The key contributing factors to relapse included caring for the baby without support, anxiety about returning to work and finding a suitable caregiver, and the overwhelming stress experienced by first-time mothers.

“Being a first-time mother feels like hitting a wall. Your life turns upside down. Inevitably, you turn to something. Smoking is considered an escape route. It feels like smoking brings relief.” P11

“I take care of my baby alone. I get no support other than my husband, and he can only help after work in the evenings. Therefore, I calm myself down with smoking. That’s how it is.” P4

“For working mothers, returning to work is stressful. The worry of who will care for the baby while you’re at work—it’s stressful. Smoking has always been my way of coping with stress, even before.” P3

Subtheme 2.5. Social environment

The social environment was found to play a significant role in postpartum smoking relapse. Women whose partners smoked reported that their partner’s smoking behavior facilitated their own relapse. Additionally, being in social settings where others smoked—particularly among friends—was described as a strong trigger.

“Because my husband smokes, the smell is always there. Maybe if he didn’t smoke and there wasn’t anything like that at home, I might have actually given up completely. However, since he does, I’d wait until he gets home in the evening and takes one from him to smoke.” P7

“For example, in a social setting—like having a Turkish coffee—I’d say, ‘Let me have just one cigarette, it won’t hurt.’ After six months, I started smoking occasionally like that.” P11

Theme 3. Behavioral processes in postpartum smoking relapse

Subtheme 3.1. Integration into daily routines

The participants described smoking in the postpartum period as a way to carve out time for themselves or to take a break during the day. Smoking became integrated into their daily routines as a socially acceptable excuse for rest and solitude.

“That five or ten minutes—it was my break time. It was like an escape… a few minutes to just listen to myself. Yes, it was time for myself.” P8

Subtheme 3.2. Development of protective strategies for the baby

The participants reported taking specific precautions to protect their babies from the harmful effects of cigarette smoke in the postpartum period. These included efforts to minimize passive smoke exposure and practice hygiene measures. Some mothers also described adjusting their smoking times on the basis of breastfeeding schedules to avoid passing nicotine to their infants through breast milk.

“I smoke on the balcony while the baby stays inside, but still… the windows are open, and he’s sometimes walking around nearby. At those times, I think, I wish he didn’t have to be exposed to even the smell.” P1

“After smoking, I change my clothes, change my top, wash my hands—I try to take these kinds of precautions before touching the baby.” P9

“I asked the doctor, ‘How would it affect my baby?’ They said it takes three hours for the nicotine to leave your body. So you should breastfeed after three hours. After I learned that, I started paying attention. If I was going to breastfeed, I would time it—like smoke three hours before feeding to avoid passing anything through the milk.” P4

Discussion

This study identified three main themes: motivations for smoking cessation during pregnancy, factors influencing postpartum relapse, and behavioral processes in postpartum smoking relapse.

Motivations for smoking cessation during pregnancy

Smoking cessation during pregnancy is influenced by both internal factors, such as the desire to protect the baby’s health and self-efficacy, and external factors, including partner support, social pressure, and healthcare professionals’ advice [1]. Similar factors were identified in this study.

Pregnancy may also exert a biological suppressive effect on tobacco use [18], with increased sensitivity to odors, nausea, and hormonal changes contributing to this effect [19]. Similarly, the participants in this study described heightened sensitivity to smells, nausea, and feelings of disgust as key external motivators for quitting smoking during pregnancy.

Perceived social support from partners, family, and friends plays a key role in smoking cessation during pregnancy. While some women view social pressure as helpful, others may find it discouraging [1]. In this study, participants identified social pressure as an external motivator for quitting. Women with nonsmoking partners reported stronger support for cessation, which is consistent with previous findings [20]. Thus, both partner support and social pressure can act as external motivators. However, internal motivation is known to be more effective in sustaining long-term abstinence [21]. Therefore, strengthening internal motivation is critical for preventing postpartum relapse.

Women who quit smoking during pregnancy are known to hold strong beliefs about the benefits of cessation for their baby’s health [20]. In this study, the maternal instinct to protect the baby emerged as a central reason for quitting, with some women explicitly stating that their decision was based solely on concern for the baby, not themselves. While this internal motivation is effective in initiating cessation, sustaining abstinence requires the interplay of both internal and external factors [22]. Rockliffe et al. (2021) noted that maternal instinct, combined with social pressure, contributes to shaping the ‘good mothe’ identity. To help women maintain internal motivation postpartum, interventions should adopt a holistic approach that also integrates supportive external influences.

Factors influencing postpartum smoking relapse

In our study, women who relapsed postpartum often viewed pregnancy as a temporary pause in smoking and intended to resume it afterward. This perception is a known predictor of relapse [23]. Therefore, women who quit during pregnancy should receive continued support beyond childbirth to maintain cessation.

One reason for continued smoking was a low perception of risk. This diminished sense of harm may lead women to downplay or deny the consequences of smoking [20]. Similarly, our findings showed that women who relapsed postpartum often held such perceptions.

Breastfeeding for at least six months post-partum has been associated with a reduced risk of smoking relapse [24]. Similarly, participants in our study reported delaying relapse while breastfeeding, although some noted that breastfeeding challenges contributed to resuming smoking. Thus, supporting breastfeeding may serve as a protective factor in relapse prevention.

Stress is a major trigger for smoking [25]. In our study, postpartum stressors-such as concerns about the baby’s health, solo childcare, first-time motherhood, return-to-work anxiety, and difficulty finding a caregiver- were linked to relapse. Women with high anxiety levels are up to six times more likely to relapse postpartum [26]. Many participants described smoking as a way to cope with stress after childbirth. Providing alternative stress management strategies may help prevent relapse in this population.

Our study revealed that being in a smoking social environment facilitated relapse. Exposure to secondhand smoke at home and having a partner who smokes are known risk factors [10, 27]. Similarly, participants who smoked reported higher relapse rates. Therefore, future interventions should involve both partners and the broader social environment.

Behavioral processes in postpartum smoking relapse

The participants often described smoking in the postpartum period as a means of reclaiming personal time. In line with previous findings [16], the women in our study framed smoking as a form of self-time that integrates it into their daily routines to take a break and temporarily escape responsibilities.

Women who resumed smoking reported engaging in harm-reduction practices, such as smoking outdoors, handwashing, changing clothes, and brushing their teeth, to protect their babies. Similar behaviors were reported by smoking parents in other studies [28]. Some participants also timed breastfeeding sessions to reduce nicotine exposure, waiting 2–3 h after smoking. As nicotine levels in breast milk vary with time and quantity smoked, this delay may help reduce exposure [29]. Nonetheless, only a completely smoke-free environment can fully protect infants from tobacco-related harm.

Limitations

Since the research was conducted in Turkish, some meaning may have shifted during translation, and certain cultural nuances may not have been fully conveyed. Additionally, owing to negative societal views on women’s smoking in the study setting, the responses may reflect social desirability bias despite efforts to minimize it.

Conclusions

While extrinsic factors influence smoking cessation during pregnancy, preventing postpartum relapse requires strengthening women’s intrinsic motivation to remain smoke-free. Factors such as intentional relapse, low-risk perception, breastfeeding, stress, and social influences contribute to postpartum smoking resumption. Postpartum follow-up should include relapse risk assessment and tailored support. Raising awareness of the health risks of smoking for both mothers and babies during and after pregnancy is crucial. Since the social environment can either hinder or support cessation, involving smoking partners in interventions may enhance their effectiveness.

Authors' contributions

NO collected the data. NO and BK contributed to the study design, data analysis, interpretation of the findings, and writing of the manuscript. Both authors read and approved the final manuscript.

Funding

The authors reported that there is no funding associated with the work featured in this article.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethical approval and consent to participate

Ethical approval was obtained from the Scientific Research Ethics Committee of Lokman Hekim University on December 30, 2024 (Approval Code: 2024283). Written permission was obtained from the hospital, and informed consent was obtained from all participants. The study was performed in accordance with the most recent version of the Declaration of Helsinki, ensuring full compliance with the ethical principles governing research involving human participants, including respect for autonomy, beneficence, and confidentiality.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.