The impact of postpartum smoking on breastfeeding initiation and duration: racial and ethnic analysis using PRAMS...

To examine the associations between postpartum smoking and breastfeeding initiation and duration by race/ethnicity among U.S. women.

Cross-sectional survey weighted data from the 2016-2022 Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed. Breastfeeding initiation and duration were defined by self-report of ever breastfeeding and breastfeeding duration (weeks), postpartum smoking was any cigarette use in the prior three months. Multivariable logistic regression estimated the adjusted odds of breastfeeding initiation by smoking status. Cox proportional hazards regression quantified the median time to and adjusted hazard of breastfeeding cessation by smoking status. Significant interaction between smoking and race/ethnicity led to stratified analyses.

Among 203,802 women, 87.9% initiated breastfeeding; 11.0% reported postpartum smoking with highest among American Indian/Alaska Native (AI/AN) women (28.8%) and lowest among Asian women (1.3%). Smoking was associated lower odds of initiation across all groups except Native Hawaiian/Pacific Islanders (NH/PI), with the strongest association among Hispanic women (aOR 0.39; 95% CI, 0.33-0.45) and Asian women (aOR 0.40; 0.25-0.63). In Cox models, smoking was associated with higher hazards of breastfeeding cessation for all groups except NH/PI; the greatest hazards were seen in non-Hispanic White women (aHR 1.90; 95% CI, 1.81-2.00), and AI/AN women (HR 1.82; 1.55-2.13). Median time to cessation was shorter for smokers.

Postpartum smoking was associated with lower breastfeeding initiation and duration, with persistent racial/ethnic disparities. Culturally tailored interventions integrating smoking cessation support and breastfeeding promotion-including harm reduction strategies for continuing smokers-are essential to advance maternal and infant health equity.