Web-Based Smoking Cessation Program in Pregnancy Cuts Postpartum Relapse in Trial

Pregnancy is one of the most powerful motivators for women to stop smoking, yet staying smoke-free after the baby arrives is a different battle altogether. A new randomized controlled trial from Türkiye suggests that a carefully timed digital intervention may tip the odds. Researchers report that pregnant women who worked through a web-based smoking cessation program built on the Transtheoretical Model were far less likely to resume smoking in the early postpartum period than women who received only standard prenatal care. Nearly all women in the control group had relapsed by the postpartum follow-up, while 38 percent of women in the intervention group had done so, a difference the authors report as statistically significant.

The study, published in BMC Digital Health, enrolled pregnant women registered at Family Health Centers in a provincial center in eastern Türkiye. The researchers started with a population of 288 pregnant women who had smoked before pregnancy and were either current smokers or ex-smokers. After excluding 190 women who did not meet the eligibility criteria, 98 women were randomly allocated at a 1:1 ratio using computer-assisted simple randomization, with group assignment determined by a lottery procedure. The trial was ultimately completed with 70 women, 34 in the experimental group and 36 in the control group. A post hoc power analysis indicated the achieved sample provided 95 percent statistical power.

To join, women had to be able to read and write, own a smartphone or computer with internet access, be at or below 32 weeks of gestation, and report smoking at least two cigarettes per day during the three months before conception. The only exclusion criterion was failure to watch the videos included in the web-based intervention. Data were collected through a dedicated study website between March 24, 2021, and May 1, 2022, with participants contacted by telephone and given unique usernames and passwords to complete the study forms online.

The intervention itself consisted of five animated videos, each lasting five to ten minutes, corresponding to the five stages of the Transtheoretical Model: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Each video was narrated by the researcher and accompanied by written theoretical content displayed beneath it. Women in the experimental group watched the videos matched to their current stage of change, and all modules were delivered during pregnancy, up to delivery. The researchers monitored viewing activity through an administrative panel and sent reminders and motivational messages to participants who had not yet watched their assigned videos. The control group received standard prenatal care in line with national guidelines, with no structured smoking cessation counseling, educational brochures, or access to the digital platform.

The researchers measured outcomes using several validated instruments: the Fagerstrom Test for Nicotine Dependence, which assesses the level of nicotine dependence; the Stages of Change scale, which classifies a person’s readiness to quit; the Processes of Change scale, which captures the cognitive and behavioral activities people use while changing behavior; the Self-Efficacy scale, which measures confidence in maintaining abstinence in challenging situations; and the Decisional Balance scale, which weighs the perceived pros and cons of smoking. Post-test data were collected at four weeks postpartum. To determine relapse accurately, each participant’s smoking abstinence status was assessed and confirmed via self-report at the end of pregnancy, and only women who had achieved abstinence by delivery were evaluated for postpartum relapse.

The results pointed in a consistent direction. Women in the experimental group showed significant progression through the stages of change compared with the control group: at post-test, most women in the control group were classified in the Contemplation stage, whereas most women in the intervention group had progressed to the Action stage. Mean scores on the Processes of Change and Self-Efficacy scales increased in the experimental group, and the mean score on the Cons subscale of the Decisional Balance scale was significantly higher in the intervention group than in the control group. Mean Fagerstrom scores, by contrast, decreased in the experimental group relative to the control group, which the authors interpret as reduced nicotine dependence following the intervention.

The relapse findings were the trial’s headline result. Nearly all women in the control group resumed smoking in the postpartum period, compared with 38 percent of the intervention group. The experimental group also reported lower daily cigarette consumption after delivery. Timing mattered as well: the third postpartum week was the most common point of smoking resumption in both groups, but 24.2 percent of women in the control group had already resumed smoking by the second postpartum week, compared with none in the experimental group. More than half of the intervention group resumed smoking during or after the third postpartum week, whereas more than half of the control group resumed during or before that point.

The study sits within a broader body of evidence showing that pregnancy creates a window of opportunity for cessation efforts. A comprehensive study across 54 low- and middle-income countries reported an overall prevalence of tobacco smoking during pregnancy of 2.6 percent, with Türkiye showing the highest prevalence at 15 percent. A meta-analysis by Jones and colleagues found that 43 percent of women who stopped smoking during pregnancy resumed within six months after delivery. Previous research has linked postpartum relapse to fatigue, the stress of caring for a newborn, and the belief that smoking no longer directly affects the child once it is born, as well as to risk factors including young age, exposure to smokers in the immediate environment, low income, and early cessation of breastfeeding. The authors note that the relapse rate observed in their study exceeds some figures reported in the existing literature, which they attribute in part to high tobacco production in the region where the study was conducted, increasing women’s access to cigarettes.

The trial has limitations the authors acknowledge. Simple randomization rather than block randomization can occasionally produce unequal group sizes or baseline imbalances, particularly in smaller samples, although the study found no significant baseline differences between the groups in sociodemographic and obstetric characteristics. More importantly, smoking cessation and abstinence were assessed through participants’ self-reports rather than biochemical verification, meaning the relapse figures rest on what women reported about their own behavior. The trial was also registered at ClinicalTrials.gov (NCT05711225) retrospectively, on December 12, 2022, after participant enrollment had begun, although the authors state that the protocol and all outcome measures had been finalized and approved by the ethics committee before recruitment. Follow-up extended only to four weeks postpartum, leaving longer-term sustainability untested.

Even with those caveats, the trial adds to growing evidence that digital platforms can deliver behaviorally grounded support to pregnant smokers, a population that is often difficult to reach through conventional services. The Transtheoretical Model’s appeal lies in its stage-matched, non-judgmental approach: rather than treating quitting as a single event, it tailors support to each smoker’s motivational readiness, which the authors argue helps reduce resistance. The team recommends integrating web-based interventions of this kind into routine health care practices aimed at preventing postpartum relapse, and calls for future multicenter studies with larger samples, biochemical validation of smoking status, and postpartum follow-up extended to six or twelve months to determine whether the early benefits seen here endure.

Subject of Research: A randomized controlled trial of a web-based Transtheoretical Model smoking cessation intervention delivered during pregnancy to prevent postpartum smoking relapse.

Article Title: The effect of smoking cessation intervention according to a web-based transtheoretical model in pregnancy on postpartum smoking relapse

Article References: YILMAZ, S., & TAŞHAN, S. T. (2026). The effect of smoking cessation intervention according to a web-based transtheoretical model in pregnancy on postpartum smoking relapse. BMC Digital Health, 4(1), Article 69. https://doi.org/10.1186/s44247-026-00296-3

Image Credits: AI Generated

DOI: 10.1186/s44247-026-00296-3

Keywords: smoking cessation, pregnancy, postpartum relapse, Transtheoretical Model, digital health, randomized controlled trial, nicotine dependence, web-based intervention, Türkiye, maternal health, stages of change, self-efficacy