The Association Between Prenatal Care and Smoking Cessation Among Pregnant Women: A Cross-Sectional Analysis

The Association Between Prenatal Care and Smoking Cessation Among Pregnant Women: A Cross-Sectional Analysis | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 31 December 2025 V1 Latest version Share on The Association Between Prenatal Care and Smoking Cessation Among Pregnant Women: A Cross-Sectional Analysis Authors : Whitley Cooper , Ingrid Luffman , Rafie Boghozian , Mamudu Hadii M , and Emily Kelley Flores 0000-0002-1338-714X [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176717529.97684685/v1 172 views 84 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To determine associations between number of prenatal care visits and smoking cessation during pregnancy and postpartum. Design: Cross-sectional analysis utilizing national data from Phase 8 of the Pregnancy Risk Assessment Monitoring System (PRAMS). Setting: Phase 8 of the PRAMS dataset (2016-2021); United States of America. Sample: Women who reported smoking in the three months prior to pregnancy (n = 9,450). Survey weights were applied to ensure the results were representative of the target population. Methods: Multivariable logistic regression assessed associations between prenatal visit frequency and smoking cessation, adjusting for maternal age, education, and socioeconomic status. Main Outcome Measures: Smoking cessation status during the last three months of pregnancy and postpartum. Smoking cessation status was evaluated in relation to demographic, behavioral, spatial, and prenatal care factors. Results: Among respondents who reported smoking prior to pregnancy, 49% continued smoking throughout pregnancy (Sustained Smoking), 20% stopped and then restarted (Restarted), 4% quit after birth (Postpartum Cessation), and 27% quit and did not restart (Sustained Cessation). Higher numeric categories of prenatal care visits were significantly associated with increased odds of smoking cessation during and after pregnancy compared to those with 0-3 prenatal care visits. The odds of cessation more than doubled for those with 9-12 visits in the “Sustained Cessation” group (AOR 2.18, CI 1.34-3.53), and with 13-16 visits in the “Postpartum Cessation” group (AOR 2.09, CI 1.40-3.10). Conclusions: Prenatal care has positive and protective effects against smoking during and after pregnancy, with the impact increasing with the number of visits. Funding: No external funding Title The Association Between Prenatal Care and Smoking Cessation Among Pregnant Women: A Cross-Sectional Analysis Authors 1 Cooper, Whitley; 2,3 Luffman, Ingrid; 4 Boghozian, Rafie; 5,6 Mamudu, Hadii M; 1,5 Flores, Emily Kelley 1 East Tennessee State University Bill Gatton College of Pharmacy, Department of Pharmacy Practice, Johnson City, Tennessee, USA 2 East Tennessee State University, College of Arts and Sciences, Department of Geosciences, Johnson City, Tennessee, USA 3 East Tennessee State University Spatial Public Health, Environment, and Resilience Exploration (SPHERE) Lab, Johnson City, Tennessee, USA 4 Nashville State Community College, Nashville, Tennessee, USA 5 East Tennessee State University Center for Cardiovascular Risk Research, Johnson City, Tennessee, USA 6 East Tennessee State University, College of Public Health, Department of Health Services Management and Policy, Johnson City, Tennessee, USA Corresponding Author Emily K. Flores, PharmD, BCPS East Tennessee State University, Department of Pharmacy Practice Box 70657 Johnson City, Tennessee, USA. 37614 +1 423 439 6754 [email protected] Shortened Title Prenatal Care Association with Smoking Cessation Abstract Objective: To determine associations between number of prenatal care visits and smoking cessation during pregnancy and postpartum. Design: Cross-sectional analysis utilizing national data from Phase 8 of the Pregnancy Risk Assessment Monitoring System (PRAMS). Setting: Phase 8 of the PRAMS dataset (2016-2021); United States of America. Sample: Women who reported smoking in the three months prior to pregnancy (n = 9,450). Survey weights were applied to ensure the results were representative of the target population. Methods: Multivariable logistic regression assessed associations between prenatal visit frequency and smoking cessation, adjusting for maternal age, education, and socioeconomic status. Main Outcome Measures: Smoking cessation status during the last three months of pregnancy and postpartum. Smoking cessation status was evaluated in relation to demographic, behavioral, spatial, and prenatal care factors. Results: Among respondents who reported smoking prior to pregnancy, 49% continued smoking throughout pregnancy (Sustained Smoking), 20% stopped and then restarted (Restarted), 4% quit after birth (Postpartum Cessation), and 27% quit and did not restart (Sustained Cessation). Higher numeric categories of prenatal care visits were significantly associated with increased odds of smoking cessation during and after pregnancy compared to those with 0-3 prenatal care visits. The odds of cessation more than doubled for those with 9-12 visits in the “Sustained Cessation” group (AOR 2.18, CI 1.34-3.53), and with 13-16 visits in the “Postpartum Cessation” group (AOR 2.09, CI 1.40-3.10). Conclusions: Prenatal care has positive and protective effects against smoking during and after pregnancy, with the impact increasing with the number of visits. Funding: No external funding Keywords: smoking, tobacco, cessation, pregnancy, postpartum, Pregnancy Risk Assessment Monitoring System (PRAMS), prenatal care Introduction Smoking during pregnancy is one of the most preventable causes of poor pregnancy outcomes for both the mother and the child. It is associated with complications such as ectopic pregnancy, spontaneous abortion, and preterm delivery, and increases the risk of perinatal mortality, including stillbirth and sudden infant death syndrome (SIDS). 1 Despite increased awareness of these negative health consequences, smoking during pregnancy remains a substantial public health concern, with disparities across population subgroups and geographic areas. 2 This issue is especially evident in areas such as Tobacco Nation, a group of 12 states in the United States of America, where smoking rates are nearly 50% higher than the national average. 3 Sociodemographic factors and social determinants of health (SDOH) play critical roles in smoking behaviors and cessation efforts. Low education, limited income, and unequal access to resources, power, and services contribute to higher tobacco use and disparities in access to tobacco cessation support, 4,5 serving as an impetus to examine the role of prenatal care in smoking cessation. Prenatal care is crucial to promoting the health and well-being of both the mother and unborn child throughout pregnancy. The World Health Organization (WHO) recommends assessment of current and past tobacco use at every prenatal visit, especially for those with a prior history of use. 6 Therefore, inquiring about tobacco use during prenatal care is considered a best practice. Previous studies have examined how prenatal care influences smoking cessation. 2,7 These studies suggest that prenatal care, including counseling, has the potential to improve smoking cessation. 2,7 However, the impact of the number or frequency of prenatal care visits on smoking cessation has not been thoroughly studied. Additionally, no previous studies have used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to examine specific components of prenatal care and their association with smoking cessation. This study addresses these gaps in the extant literature by investigating the connection between prenatal care and smoking cessation rates during and after pregnancy. Specifically, the objective of this study is to determine how the number of prenatal care visits relates to smoking cessation during and after pregnancy. The study will also analyze the prevalence of prenatal care in the PRAMS dataset and examine factors such as visit attendance, visit frequency, and care components that may influence smoking cessation. By identifying the most effective aspects of prenatal care, this research aims to guide targeted strategies and interventions to enhance smoking cessation among pregnant individuals. Methods This study used U.S. national data from PRAMS Phase 8 (2016–2021), a collaborative surveillance project conducted by state health departments along with the Centers for Disease Control and Prevention, Division of Reproductive Health (CDC, DRH). PRAMS gathers self-reported maternal information, health behaviors, healthcare use, and infant health through a questionnaire given 2–6 months postpartum for births occurring from 2016 to 2021. A description of the PRAMS methodology and data collection has been provided elsewhere. 8 Study sample The dataset was weighted using survey weights to ensure that the sample was representative of the target population of pregnant women in the U.S. The original data consisted of 221,381 participants. All mothers who reported smoking in the past two years and in the three months prior to pregnancy were included for analysis (N=9,450). PRAMS respondents could choose to answer or skip any questions as they completed the survey. All available responses were used for the descriptive analysis of individual questions. However, respondents were excluded from the bivariate analysis if prenatal care data were missing, and from the multivariable logistic regression models if any variable of interest was missing. Dependent variable measures The primary outcome variable was smoking status at various points related to pregnancy, based on questions 21 and 22 of the PRAMS survey. Question 21 asked, “In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day?” Responses were categorized as negative (“I didn’t smoke then”) or positive (any other response). Question 22 asked, “How many cigarettes do you smoke on an average day now?” Responses were categorized as negative (“I don’t smoke now”) or positive (any other response). These questions were used to group respondents into the four smoking status categories based on their smoking behavior at multiple time points. “Sustained Smoking” included respondents who never quit, indicated by positive responses to Questions 21 and 22. “Restarted” included respondents who quit during pregnancy but resumed postpartum, indicated by a negative response to Question 21 and a positive response to Question 22. “Postpartum Cessation” included respondents who smoked throughout pregnancy but quit postpartum, indicated by a positive response to Question 21 and a negative response to Question 22. “Sustained Cessation” included respondents who quit during pregnancy and remained abstinent, indicated by negative responses to Questions 21 and 22. Independent variables/covariates measures The primary independent variable was the number of prenatal care visits, categorized as 0–3, 4–8, 9–12, 13–16, 17–20, and 21+ visits. Several covariates were included to adjust for potential confounding factors. These included demographic and socioeconomic factors such as maternal age, race, ethnicity, geographic region (Appalachian vs. Non-Appalachian), residence in a Tobacco Nation state, place of residence (urban versus rural), marital status, income, and education. Health and behavioral factors such as comorbidities, alcohol consumption prior to pregnancy, and pregnancy intention were also included. Further, prenatal care adequacy based on the Kotelchuck Index, 9 the number of prenatal care visits, and prenatal vitamin intake were included as covariates. The Kotelchuck Index classifies care as inadequate, intermediate, adequate, or adequate-plus based on timing of initiation and the number of prenatal care visits. 9 Statistical Analysis Survey methods accounted for the complex sampling design of PRAMS. Descriptive statistics were calculated to summarize demographic and clinical characteristics. Rao-Scott chi-square tests were used to compare categorical variables across smoking cessation groups, while Wilcoxon rank-sum tests were employed for continuous variables; both tests incorporated survey weighting. Variables with significant associations (p < 0.05) were included in the final regression model to control for potential confounding factors. The Kotelchuck Index was examined at the bivariate level but was excluded from the logistic regression model because of its correlation with the primary independent variable. Multinomial logistic regression assessed the association between prenatal visits and smoking cessation outcomes. Results are reported as adjusted odds ratios (AORs) with 95% confidence intervals (CIs), comparing each smoking category to “Sustained Smoking” as the reference group. The level of significance was set at p-value < 0.05. Description of Study Population Demographic characteristics of the total surveyed population (N=221,381) and the study population (N=9,450) alongside the determined smoking outcome categories are presented in Tables 1 and 2. The majority of the study population in the analytic sample did not reside in a Tobacco Nation state (53.4%) and were predominantly non-Appalachian (63.8%), urban (72.2%), non-Hispanic (94.3%), white (63.0%), and unmarried (68.4%). The median maternal age was 28 years (IQR: 24, 32). Educational attainment varied, with 70.8% of participants completing high school or an associate degree and 7.8% holding an undergraduate degree. Nearly 75% of participants reported low income, including 24.2% classified as low income and 50.0% living below the poverty line. Respondents reported varying levels of pregnancy intentionality, with 30.6% indicating their pregnancy was intended at that time. The majority of respondents reported some level of alcohol use in the three months before pregnancy (65.5%), and about half (49.2%) acknowledged having comorbidities. The number of prenatal visits varied, with 40.4% reporting 9–12 visits. During pregnancy, 68.0% of respondents did not take prenatal vitamins, and others varied in their consistency of use. Description of Smoking Status Categories Tables 1 and 2 also provide insights into differences in demographic, socioeconomic, and health-related characteristics by smoking status, as determined by the Chi-Square and Wilcoxon Rank-Sum tests. “Sustained Smoking” was the largest category (49.3%), followed by “Sustained Cessation” (27%). The median age was 28 years across all groups except for the “Restarted” group, which had a median age of 27 years. Significant differences in Tobacco Nation residency were also observed across all outcome groups (p = 0.001). In the “Sustained Smoking” group, 49% resided in a Tobacco Nation state, compared to 42% of the “Sustained Cessation” group. Smoking cessation outcomes did not differ significantly between Appalachian and non-Appalachian regions (p = 0.5). Rural and urban locations differed significantly across smoking status groups (p < 0.001), with rural respondents highest in ”Sustained Smoking” (32%) and urban respondents highest in ”Sustained Cessation” (78%). Non-Hispanic respondents predominated across all smoking status groups (92–97%), suggesting potential ethnic disparities in smoking behaviors and cessation outcomes. Marital status varied significantly across smoking status groups (p < 0.001), with unmarried women comprising 75% of the “Sustained Smoking” group and 56% of the “Sustained Cessation” group. Both educational attainment and income levels differed significantly across all smoking status groups (p < 0.001). A high school diploma or an associate degree was the most common level of educational attainment across all categories, ranging from 66% to 72%. Among “Sustained Cessation” respondents, 23% had an undergraduate or graduate degree, compared to just 4.3% of women who continued “Sustained Smoking.” The “Sustained Cessation” group also had the highest proportion of high-income individuals (31%), while the “Sustained Smoking” group had the highest proportion of individuals living below the poverty level (63%). Pregnancy intention differed between the outcome groups (p < 0.001). Respondents who wanted the pregnancy at that time were most common in the “Sustained Cessation” category (36%), whereas unintended pregnancy was highest in the “Sustained Smoking” category (14%). Significant differences in alcohol consumption during the three months prior to pregnancy were also observed across the outcome groups (p < 0.001). A higher proportion of women in the “Sustained Cessation” group reported consuming alcohol (80%) compared to those in the “Sustained Smoking” group (56%). Likewise, significant differences in comorbidities were observed across the outcome groups (p < 0.001), with the “Postpartum Cessation” group reporting the highest proportion of individuals with at least one comorbidity (54%). Levels of prenatal care, as described by the Kotelchuck index and the number of prenatal visits, differed significantly across the outcome groups (p < 0.001). The “Sustained Cessation” group had the highest proportions receiving adequate care (39%) or adequate plus care (42%), while the “Sustained Smoking” group had 22% receiving inadequate care and 10% with intermediate care. Fewer visits (0-3 prenatal visits) were more common among the “Sustained Smoking” group (10%), while a higher number of visits was more common among the “Sustained Cessation” group: 13-16 visits (28%), 17-20 visits (5.7%), and 21+ visits (3.1%). The highest proportion of daily vitamin use was in the “Sustained Cessation” group (26%), whereas 73% of women in the “Sustained Smoking” group reported no regular prenatal‑vitamin use. Association Between Prenatal Care and Smoking Cessation Table 3 shows the results of the multinomial regression analyses examining associations between prenatal care and smoking cessation outcomes as compared to the “Sustained Smoking” reference category. Across all categories, rural respondents were less likely to ever quit smoking during the prenatal or postpartum periods (Restarted: AOR 0.66, CI 0.46-0.95; Postpartum Cessation: AOR 0.66, CI 0.53-0.81; Sustained Cessation: AOR 0.65, CI 0.53-0.80). Respondents with Hispanic ethnicity were more likely to stop smoking (Postpartum Cessation: AOR 3.62, CI 2.40-5.45; Sustained Cessation: AOR 4.07, CI 2.76-6.00), as were Black/African American (Postpartum Cessation: AOR 2.47, CI 1.96-3.11; Sustained Cessation: AOR 1.37, CI 1.08-1.73), and Asian (Postpartum Cessation: AOR 3.55, CI 1.60-7.87; Sustained Cessation: AOR 3.44, CI 1.56-7.57). Older respondents had lower odds of cessation (Postpartum Cessation: AOR 0.92, CI 0.91-0.94; Sustained Cessation: AOR 0.93, CI 0.91-0.94). Married respondents had higher odds of cessation (Postpartum Cessation: AOR 1.37, CI 1.12-1.69; Sustained Cessation: AOR 1.23, CI 1.01-1.49). The odds of cessation increased with educational attainment, from High School/Associates (Postpartum Cessation: AOR 1.53, CI 1.18-1.98; Sustained Cessation: AOR 1.80, CI 1.40-2.31), to Undergraduate (Postpartum Cessation: AOR 2.7, CI 1.71-4.27; Sustained Cessation: AOR 3.88, CI 2.55-5.90) to respondents holding a Masters or PhD (Postpartum Cessation: AOR 3.89, CI 2.10-7.20; Sustained Cessation: AOR 6.18, CI 3.61-10.60). Similarly, the odds of cessation increased with income, with those in the highest income bracket most likely to quit smoking (Postpartum Cessation: AOR 2.63, CI 1.90-3.66; Sustained Cessation: AOR 5.78, CI 4.32-7.73). The likelihood of cessation was lower among respondents who were unsure of the pregnancy (Postpartum Cessation: AOR 0.69, CI 0.55-0.88; Sustained Cessation: AOR 0.73, CI 0.58-0.92) and those who did not want the pregnancy (Postpartum Cessation: AOR 0.72, CI 0.52-0.996). Consumption of alcohol in the three months prior to pregnancy was related to higher odds of cessation (Postpartum Cessation: AOR 1.58, CI 1.29-1.93; Sustained Cessation: AOR 2.17, CI 1.80-2.62). The frequency of taking prenatal vitamins was associated with higher odds of “Restarting” (1-3/Week: AOR 2.25, CI 1.27-4.00; Daily: AOR 1.62, CI 1.08-2.43) as well as “Sustained Cessation” (4-6/Week: AOR 2.06, CI 1.39-3.05; Daily: AOR 1.29, CI 1.05-1.59). The frequency of prenatal care visits was associated with higher odds of cessation in the “Sustained Cessation” group (4-8 visits: AOR 1.41, CI 0.85-2.33; 9-12 visits: AOR 2.18, CI 1.34-3.53; 13-16 visits: AOR 2.82, CI 1.71-4.62; 17-20 visits: AOR 2.51, CI 1.40-4.50; 21+ visits: AOR 2.93, CI 1.48-5.79). Similarly, higher frequency of prenatal care visits was associated with higher odds of cessation in the “Postpartum Cessation” group (4-8 visits: AOR 1.00, CI 0.66-1.50; 9-12 visits: AOR 1.68, CI 1.15-2.47; 13-16 visits: AOR 2.09, CI 1.40-3.10; 17-20 visits: AOR 2.01, CI 1.21-3.34; 21+ visits: AOR 2.95, CI 1.61-5.41). Results of sensitivity analysis When completing the PRAMS survey, mothers could skip any desired questions, resulting in varying amounts of missing data. A sensitivity analysis was conducted on the total population of 37,143 smoking mothers with missing outcomes and exposure records. The impact of including imputed data for missing observations was analyzed for changes in the direction, magnitude, or statistical significance of associations. The analysis confirmed that the effect of the primary variable, number of prenatal visits, remained consistent with the main results. The sensitivity analysis demonstrated increased cessation as the number of prenatal visits increased across the first three categories, with sustained higher cessation rates in the highest visit category (0-3 visits: OR 1.15; 9-12 visits: OR 1.67, p < 0.01; 13-16 visits: OR 1.84, p < 0.001; 17-20 visits: OR 1.66). The inclusion of imputed data for missing observations did not significantly alter the direction, magnitude, or statistical significance of the associations. Overall, the sensitivity analysis supports the robustness of the main findings, highlighting that higher prenatal care engagement, reflected in the number of visits, remains a critical factor influencing smoking cessation among pregnant women. Discussion Main Findings Smoking during pregnancy has been established to lead to poor health outcomes for both the mother and baby, yet how prenatal care and its components affect smoking cessation remains underexplored. This study provides evidence that engagement in prenatal care is associated with smoking cessation during pregnancy and postpartum. Nearly half of respondents who smoked prior to pregnancy continued throughout pregnancy (49%, Sustained Smoking), while one in five stopped and restarted (20%, Restarted). In contrast, one in four stopped smoking during pregnancy (27%, Sustained Cessation), and only 4% stopped postpartum (Postpartum Cessation). Overall, more than two-thirds of participants either continued or restarted smoking (69%), highlighting the need to identify the underlying causes and develop targeted interventions. These findings align with existing literature showing the challenges of smoking cessation due to the addictive properties of tobacco that create dependence and make quitting difficult. 1, 11 The number of prenatal care visits was significantly associated with both “Sustained Cessation” and “Postpartum Cessation”, with a clear dose-response relationship observed between the number of prenatal visits and smoking cessation outcomes. Individuals with a higher number of visits (13–16 and 17–20) consistently showed higher odds of quitting smoking. This progressive increase in odds indicates that greater engagement in prenatal care positively influences smoking cessation rates. These results are consistent with prior studies showing that interventions by healthcare providers increase quit attempts and smoking cessation. 12,13 Therefore, regular visits to healthcare providers during pregnancy and postpartum should be encouraged and integrated into prenatal care delivery. 13 The results for the sociodemographic characteristics indicate that Hispanic ethnicity, Black/African-American and Asian race, being married, higher education, and higher income were protective factors for smoking cessation outcomes (Postpartum Cessation and Sustained Cessation groups), while maternal age was a risk factor. These findings suggest that cultural and community influences may support cessation and align with the 2024 Surgeon General’s Report on Tobacco-Related Health Disparities, which recommends that prenatal care be culturally aware and personalized to address SDOH. 14 A clear income gradient was observed, with higher income and education associated with increased odds of quitting smoking during pregnancy and postpartum, which may reflect differences in access to resources or knowledge about the harms of tobacco use. 15,16 Regarding age, it has been reported by the U.S. Surgeon General that over 90% of regular smokers start smoking before the age of 18 years. 17 This population becomes dependent on smoking, with difficulty quitting, providing a rationale for the inverse association observed between maternal age and smoking cessation during pregnancy and postpartum. With a median age of 28 years, participants in the study remain within a population highly targeted by tobacco advertising and marketing, 17 highlighting the need for enhanced health education and promotion for this population. Three health behaviors were examined in this study: pregnancy intention, alcohol use, and prenatal vitamin uptake. Unintended pregnancy categories demonstrated decreased odds of smoking cessation during pregnancy and postpartum compared to those with intended pregnancies. Drinking alcohol three months before pregnancy increased the odds of smoking cessation during pregnancy and postpartum. Prenatal vitamin use significantly increased the odds of smoking cessation during pregnancy (Sustained Cessation). The two spatial factors examined in the study were residing in a Tobacco Nation State and living in a rural area. Women in urban areas had higher smoking cessation odds compared to those in rural regions, while women residing in Tobacco Nation states were more likely to continue smoking. Higher tobacco use in Tobacco Nation states has been documented, 3 and this study shows that the environment is a risk factor for smoking cessation as well. These findings suggest location or place may influence smoking cessation, and such factors should be incorporated into smoking cessation efforts in the country. Strengths and Limitations This study utilized a multifactorial approach to provide a comprehensive view of factors influencing smoking cessation during pregnancy and postpartum. The PRAMS Phase 8 dataset encompasses data from multiple U.S. states, providing a diverse sample that strengthens the external validity of the findings. Not all states participated in Phase 8, or some may have had insufficient response rates. However, a sensitivity analysis confirmed that the association between prenatal visit frequency and smoking cessation remained consistent. PRAMS data are also subject to recall bias, selection bias, and non-response bias, as is typical with self-reported survey data. Interpretation (in light of other evidence) The results of this study align with existing evidence that greater prenatal care is associated with improved smoking cessation rates among pregnant women. Moore et al. (2016) found similar results, showing that more prenatal visits enhanced the likelihood of smoking cessation during pregnancy and postpartum. 2 Additionally, a meta-analysis by Dolan-Mullen et al. (1994) demonstrated that smoking cessation interventions delivered during routine prenatal visits resulted in greater odds of smoking cessation. 7 Conclusion This study provides robust evidence that multiple factors influence smoking cessation among pregnant women. This demonstrates that there is not a single factor that determines smoking cessation during pregnancy and postpartum, but rather a combination of factors that affect the ability to quit smoking. Certain SDOH, including higher education, income, geographic location, and marital status, all influence the ability to quit smoking. In addition to these factors, lifestyle behaviors such as prenatal vitamin use and alcohol consumption play critical roles in determining the success of cessation efforts. These findings highlight the importance of targeted, multifactorial interventions such as counseling, education, community-based programs, and supportive policies to enhance smoking cessation efforts, particularly among low-socioeconomic populations with limited healthcare access. Further, adequate prenatal care and increased prenatal visits significantly increase the likelihood of quitting. 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Acknowledgements: We thank the PRAMS Working Group, which includes the PRAMS Team, Division of Reproductive Health, Centers for Disease Control and Prevention (CDC) and all PRAMS sites for their role in conducting PRAMS surveillance and allowing the use of their data in the Automated Research File dataset. We thank Disha Shahani, MS (George Washington University, Washington, District of Columbia, USA) for her assistance with initial data analysis. Disclosure of Interests : The authors have no conflicts of interest to declare. Contribution of Authorship : WC, EF, and HM conceived the study, with input from the entire research team HM acquired the data IL and RB conducted the data management with input from all the researchers WC and IL conducted the data analysis with the support of RB WC and EF produced the first draft of the manuscript All authors contributed to the revision of several iterations of the manuscript Details of Ethics Approval : Human Research Protection Program February 14, 2025 Re: Determination of Not Human Subjects Research It was determined that this proposed activity does not meet the definition of research involving human subjects. Funding: There was no external funding for this study. Table Caption List: Table 1: Results of descriptive statistics and bivariate analysis of sociodemographic variables Table 2: Results of descriptive statistics and bivariate analysis of behavioral variables Table 3: Results of logistic regression analysis as compared to the Sustained Smoking group (n=9,450) Figures: None Supplementary Material File (table 1 rev5 12.9.25 final.docx) Download 32.69 KB File (table 2 rev5 12.9.25 final.docx) Download 30.71 KB File (table 3 rev4 12.5.25 final.docx) Download 49.46 KB Information & Authors Information Version history V1 Version 1 31 December 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords maternal medicine substance misuse in pregnancy Authors Affiliations Whitley Cooper East Tennessee State University Bill Gatton College of Pharmacy View all articles by this author Ingrid Luffman East Tennessee State University College of Arts and Sciences View all articles by this author Rafie Boghozian Nashville State Community College View all articles by this author Mamudu Hadii M East Tennessee State University View all articles by this author Emily Kelley Flores 0000-0002-1338-714X [email protected] East Tennessee State University Bill Gatton College of Pharmacy View all articles by this author Metrics & Citations Metrics Article Usage 172 views 84 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Whitley Cooper, Ingrid Luffman, Rafie Boghozian, et al. The Association Between Prenatal Care and Smoking Cessation Among Pregnant Women: A Cross-Sectional Analysis. Authorea . 31 December 2025. 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