Smoking during pregnancy: A population-based study

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1 676034SJP / G. N. Oskrsdottir et l.smoking during pregnncy reserch-rticle2016 Scndinvin Journl of Public Helth, 2017; 45: Originl Article Smoking during pregnncy: A popultion-bsed study GUDRUN NINA OSKARSDOTTIR 1, HEDINN SIGURDSSON 1 & KRISTJAN G. GUDMUNDSSON 2 1 Glesiber Helth Cre Centre, Reykjvik, Icelnd, nd 2 Reykjlundur Rehbilittion Centre, Mosfellsber, Icelnd Abstrct Aims: Tobcco is mjor cuse of disese nd mortlity in modern times. The risk of smoking in pregnncy is serious thret to the development nd future helth of n unborn child. The im of this study ws to explore the epidemiologicl fctors ssocited with smoking during pregnncy in primry helthcre setting. Methods: All 856 mternity records t the Glesiber Helth Cre Centre in Reykjvik during were reviewed nd informtion on smoking hbits investigted. Results: The records showed tht in 108 (12.2%) pregnncies, women smoked t first visit nd 63 stopped smoking in erly pregnncy, leving 45 (5.3%) mothers smoking throughout the whole gesttionl period. The men ge of the smoking women ws 27.8 yers nd for the non-smokers 29.7 yers. Low socil sttus (odds rtio (OR) = 2.66; 95% confidence intervl (CI): ), previous mentl helth dignosis (OR = 2.7; 95% CI: ), nd unstble reltionship with prtner (OR = 3.78; 95% CI: ) were ssocited with smoking. Smoking fewer cigrettes ws ssocited with 0.04-unit lower risk of smoking during pregnncy (OR = 0.04: 95% CI: ). Conclusions: Our results indicted tht the women who smoked during pregnncy were often hevy smokers nd living without prtner. They were younger, hd worse mentl helth, nd lower socil sttus thn those pregnnt women who did not smoke. Bering in mind the consequence of smoking in pregnncy, this subgroup should get incresed ssistnce to quit smoking before nd during erly pregnncy, s well s pproprite medicl nd socil support. Key Words: Smoking, pregnncy, socil sttus, eduction, ge, tobcco use, mentl helth, medicines in pregnncy Introduction Tobcco is still mjor cuse of disese nd mortlity in modern times. Smoking nd its relted nicotine dependency often begins during dolescence nd hlf of its users will die becuse of the devstting effects smoking hs on humn helth [1]. The prevlence of smoking by women of childbering ge is the sme s for the society in generl, nd bout hlf of the pregnnt women were ble to quit smoking [2]. Smoking is serious thret to the development of the unborn child. Its mlicious effects re cused by the tertotoxins in the tobcco nd nicotine, which is highly ddictive substnce [1,2]. This risk lso pplies to the use of smokeless tobcco [3]. Tobcco use in pregnncy increses the risk of miscrriges, plcentl bruption nd stillbirths, s well s sudden infnt deth [4,5]. The newborn children of smoking mothers hve been shown to be smller, nd preterm deliveries re more common thn for non-smoking mothers [6,7]. Smoking hs lso been ssocited with birth defects, including congenitl hert defects, musculoskeletl defects, spin bifid, orofcil clefts, nd gstrointestinl mlformtions [8]. Mternl smoking nd nicotine replcement therpy re relted to ttention deficit hyperctivity disorder (ADHD) in children [9,10]. Additionlly, mternl smoking my hve consequences lter in life, such s mentl illness including psychotic symptoms in young people [11]. While children born of smoking mothers hve lower preterm weight, they prdoxiclly hve incresed weight nd lower height in childhood [5,12,13]. Thus, Correspondence: Kristjn G. Gudmundsson, Reykjlundur Rehbilittion Centre, Deildrs 19, Reykjvik 110, Icelnd. E-mil: Kristjng@reykjlundur.is (Accepted 29 September 2016) Author(s) 2016 Reprints nd permissions: sgepub.co.uk/journlspermissions.nv DOI: / sjp.sgepub.com

2 it is impertive tht women of childbering ge re educted bout the risk of smoking during pregnncy for the future helth of their bbies nd tht by quitting smoking, the risk ppers to return to norml [14,15]. Icelnd, like mny other countries, hs comprehensive tobcco control policy with mss coverge of tobcco bnned, nd tobcco products must not be visible t the point of sle. Brs nd resturnts re smoke-free [16]. The im of this study ws to ssess the mternl socil chrcteristics nd helth determinnts of smoking in pregnnt women, including the prevlence nd quitting rte of smoking, ge, socil sttus, mentl helth, nd smoking hbits. Methods The study ws conducted t the Glesiber Helth Cre Centre in Reykjvik, the cpitl nd lrgest city in Icelnd. The centre provides primry helthcre service to pproximtely 9000 individuls nd is stffed by five fmily physicins nd two midwives. The centre opened in Jnury 2006 nd is run by the stte. The residents in this re of the cpitl re of verge socioeconomic sttus, but the men ge of its inhbitnts is high. The study included ll women who hd ttended mternity cre over n eight-yer period, from the beginning of 2006 to the end of Informtion bout smoking hbits, including number of cigrettes smoked per dy, prior to nd during pregnncy, s well s mritl sttus, ethnicity, ge, socil sttus, nd eductionl bckground, were collected retrospectively from the prticipnts mternity records. Socil clss ws estimted from both eduction nd occuption, s is often done [17]. Women in the lowest socil clss were receiving socil benefits, n invlidity pension, were officilly unemployed, or were simply neither working nor in school. The records lso contined informtion bout the subjects physicl nd mentl helth, nd their use of medicines. The cohort The totl number of women included in the study ws 724, but the number of pregnncies ws 856, s in 132 cses the women hd more thn one pregnncy during the time of the study. There ws no difference in smoking between women with multiple pregnncies nd those with single pregnncy. There were nine pirs of twins born during the study nd they re registered s single pregnncy for ech birth. In the cohort, there were two spontneous bortions, one medicl bortion, three preterm births, one foetus died in week 26 cused by Smoking during pregnncy 11 plcentl bltion, nd one stillbirth occurred in week 39. The study ws ccepted by The Dt Protection Authority (number 2012/845) nd by the Ntionl Ethics Committee of Icelnd (number S1). Sttistics: Person s chi-squre ws used to compre the vribles for smokers nd non-smokers. A multiple logistic regression ws conducted nd odds rtios (ORs) were used to evlute risk fctors ssocited with smoking during pregnncy. The clcultions were crried out with the SAS Enterprise Guide, version 7.1 (SAS Institute Inc., Cry, NC) nd sttisticl significnce set s p < Results The men ge of the prticipnts ws 29.6 yers, with the youngest being 16 yers nd the oldest 49 yers. The records showed tht in 108 (12.2%) pregnncies, women smoked prior to the pregnncy nd 63 stopped smoking, leving 45 (5.3%) mothers smoking throughout the entire gesttionl period. The smoking mothers were significntly younger the men ge ws 27.8 yers compred to 29.7 yers for the non-smokers group (OR = 1.07; 95% confidence intervl (CI): ). Smokers were more likely to be single mothers or 46.7% compred to 19% of the non-smoking group (OR = 3.78; 95% CI: ). No difference ws observed between women of different ethnicities. A similr proportion of immigrnt women smoked compred to ntive Icelnders (OR = 0.76; 95% CI: ) (Tble I). Of the 45 women tht smoked through pregnncy, some 16 (35%) smoked 1 10 cigrettes dy, nd seven (19%) of them smoked more thn 10 cigrettes dy; of the 63 women who quit smoking, there were 12 (15%) who hd smoked 1 10 cigrettes nd two (3%) who hd smoked more thn 10 cigrettes. A low eductionl level nd receiving n invlidity pension or socil benefits were relted to smoking in pregnncy (OR = 2.66; 95% CI: ) (Tble II). Women who smoked during pregnncy more often hd dignosis of depression nd nxiety (OR = 2.7; 95% CI: ), nd were more likely to be receiving tretment for mentl disorders (OR = 2.7; 95% CI: ) (Tble III). The vribles of mentl helth, using psychophrmceuticls, ge, socil sttus, living lone, nd the mount of smoking, were ssocited with smoking during pregnncy when nlysed seprtely (see Tble IV). However, by djusting pired vribles with multiple logistic regression nlysis, only two vribles were ssocited with smoking during pregnncy. Living with prtner hd 0.24-unit lower risk of smoking during

3 12 G. N. Oskrsdottir et l. Tble I. Smoking during pregnncy with some demogrphic fctors. Smokers Non-smokers OR (95% CI) N % N % Number in study 108 (12.6) 748 During pregnncy 45 (5.3) 811 Quit 63/108 (58) Number of children None 20 (44.4) 351 (41) One 16 (35.6) 295 (34) Two 7 (15.6) 134 (15.6) Three or more 2 (4.5) 31 (6.6) 0.95 ( ) Men ge 27.8 SD SD ( ) 20< 3 (14.2) 18 (85.8) (6.7) 125 (93.3) (5.5) 255 (94.4) (4.9) 249 (95.1) (2.7) 141 (97.3) (4.5) 20 (95.5) Older thn 45 0 (0) 3 (100) Living with prtner b 24 (53.3) 657 (81.2) Single b,* 21 (46.7) 152 (19) 3.78 ( ) Country of origin b Icelnd 39 (86.7) 674 (83.1) 1 Scndinvi 0 2 (0.2) Polnd 3 (6.7) 29 (3.6) 1.79 ( ) Thilnd 1 (2.2) 9 (1.1) 1.0 ( ) Other EU countries 2 (4.4) 24 (3.0) 1.24 ( ) Southest Asi (2.8) Other countries outside Europe (6.7) Totl 6/45 (13.3) 137/811 (16.8) 0.76 ( ) Continuous vrible. b *Informtion on the exct mritl sttus of two women re missing; thus, 854 in this ctegory. OR: odds rtio; CI: confidence intervl; SD: stndrd devition; EU: Europen Union. Tble II. Smoking during pregnncy nd socil bckground of the mothers. Compring the OR of ech clss to ll cohorts. Socil group Smoking Not smoking OR (95% CI) N % N % University degree/specilist 1 (2.2) 237 (28.9) 0.06 ( ) Student 4 (8.9) 127 (15.7) 0.53 ( ) Lerned trde/medium eduction 11 (24.4) 135 (16.7) 1.62 ( ) Workers/low eduction 21 (46.7) 251 (30.9) 1.96 ( ) Socil benefits/not working 8 (17.7) 61 (7.5) 2.66 ( ) Totl OR: odds rtio; CI: confidence intervl. pregnncy (OR = 0.24; 95% CI: ) nd smoking fewer cigrettes hd 0.04-unit lower risk of smoking during pregnncy (OR = 0.04; 95% CI: ) (Tble IV). Discussion It is estimted tht some 5% 10% of pregnnt women in Icelnd smoke [18]. However, it hs to be tken into considertion tht pregnnt women my tend to underestimte or deny their smoking hbits. Smoking by pregnnt women is thought to be 25% more prevlent thn they dmit to the helth provider. This ws found by comprison between cotinine mesurement in the blood nd the nswers to questions, nd the difference ws even greter mong pregnnt women which re better off socilly, where the pressure to quit smoking is greter [19]. In

4 Smoking during pregnncy 13 Tble III. Mentl helth nd use of medicines, including SSRI inhibitors nd smoking during pregnncy. Smoking during pregnncy compred to non-smokers. Smoker Non-smoker OR (95% CI) N % N % Mentlly helthy 35 (78) 733 (90) Depression 7 (16) 33 (4) 4.4 ( ) Anxiety 2 (4) 26 (3) 1.6 ( ) Depression nd nxiety 1 (1) 19 (2) 1.1 ( ) All mentl disorders 10/45 (22) 78/811 (9.6) 2.7 ( ) Using medicine* 5 (11.9) 37 (4.5) 2.7 ( ) Not using medicine 40 (88.1) 774 (95.5) *Mediction for nxiety or depression, such s SSRI, sleep medicine, medicines for ADHD. SSRI: selective serotonin reuptke inhibitors; OR: odds rtio; CI: confidence intervl. Tble IV. Multivrite logistic regressions evluting the fctors involved, showing tht living with prtner nd smoking fewer cigrettes before pregnncy diminished the risk of smoking during pregnncy. Vrible Undjusted Adjusted without number of cigrettes Adjusted with number of cigrettes OR (95% CI) OR (95% CI) OR (95% CI) Age 1.1 ( ) ( ) 0.99 ( ) Mentl helth b 2.7 ( ) 2.0 ( ) 2.51 ( ) Cohbiting/living lone b 0.3 ( ) 0.3 ( ) 0.24 ( ) Psychophrmceuticls b 2.6 ( ) 0.9 ( ) 0.23 ( ) Low socil sttus b,c 0.4 ( ) 1.6 ( ) 1.29 ( ) Number of cigrettes,d 28.0 ( ) 27.7 ( ) Continuous vrible. b c In the regression clssified s 1, ll other s 0. d Number of cigrettes: 1 10/dy registered s 1, 11+ registered s 2. OR: odds rtion; CI: confidence intervl. Austrli, some 7% 17% of pregnnt women smoke [20 22]. Similr results were found in study in the US where bout 11% smoked prentlly [23], nd nother from the UK where 5% of women smoked during pregnncy [24]. In Scotlnd, bout 25% of the pregnnt women smoked nd only 2 4% of them mnged to quit smoking while pregnnt [25]. These findings cn be compred to studies from Austrli where 4 5% were ble to quit [20,22]. In some other studies, up to hlf of the pregnnt women were ble to quit smoking [2]. The results presented here indicte tht women without prtner, with high nicotine dependency, who re younger, with low socil sttus, nd with history of mentl disorders re t incresed risk of smoking during pregnncy. In our study, 63 women out of 108 (58%) stopped smoking before or during pregnncy, which ws higher proportion thn in study from Michign, USA, with quitting rtes of 39% [26]. Our results were similr to n Austrlin study where some 7% smoked during pregnncy, nd these women hd moderte to hevy nicotine dependency, were younger, hd lower eduction level, unemployed, nd more often living without prtner [22]. In the present study, women with nxiety nd depression were more likely to smoke during pregnncy finding which is consistent with other findings [26,27]. This vulnerble group of women should certinly be prime trget of support in the first trimester of their pregnncy while ttending mternity helthcre service. There re strong indictions tht consulting service nd pid nicotine replcement therpy cn diminish smoking mongst grvid women [28]. There is much to gin, s quitting erly in the pregnncy hs been shown to diminish the risk of mlformtion to lmost norml risk level [29]. Controlling smoking s prt of preventive helthcre progrms in the society t lrge is n importnt wy to reduce smoking mong the generl popultion, nd the benefits re well documented for mternl smoking s well. Rising the price of tobcco through higher txes nd legisltion mndting smoke-free working environment re well-known wys to diminish smoking mongst pregnnt women [30,31].

5 14 G. N. Oskrsdottir et l. Smoking during pregnncy hs both ethicl nd politicl spects. It is the prime duty of governments of ll societies to protect the public from hrm. This hs been the core of the socil contrct from ncient times. The Romn politicin nd philosopher Cicero declred: Slus populi suprem lex esto The sfety of the people is the supreme lw. The fmous British politicin Disreli proclimed: It is the first duty of sttesmen to protect public helth [32]. The unborn person hs no mens to protect itself. Ethiclly, this is strong rgument tht the lw nd policymkers, nd society s whole, should protect its children by leglly restricting the distribution nd trding of tobcco [32]. The strength of this study is tht it covered clerly defined sector of the cpitl city of Reykjvik, Icelnd, s the primry helth mternity cre service is provided in this re or district of the city. The smple is thought to be representtive of the popultion of Reykjvik s whole. As the study ws retrospective in nture, ll women who ttended during the eight-yer period were included, so neither fmilies who were well off, nor those in difficult socil sitution, could exclude themselves. This type of study hs its obvious nd known weknesses. We were not directly intercting with the mothers who would possibly hve nswered the questions in nother wy. We built our observtions on documents from the mternity cre ppers tht re usully well written nd punctilious, but on occsion hd to be interpreted by us; for exmple, how to clssify the recorded job ccording to its sttus in the socil hierrchicl order. Conclusion Our results indicte tht the women who smoked during pregnncy hd history of smoking more cigrettes. They were often living without prtner, were younger, hd worse mentl helth, nd lower socil sttus thn those pregnnt women who did not smoke. Bering in mind the potentil consequences of smoking in pregnncy, this subgroup should get incresed ssistnce to quit smoking before nd during erly pregnncy, s well s pproprite medicl nd socil support. Acknowledgements We thnk Sunn Gestsdóttir for ssistnce with the sttistics, Professor Reynir Arngrímsson nd Dr Terry G Lcy for ssistnce with the text, nd Jónín Jónsdóttir nd Helg Bjrndóttir, midwives t the helthcre centre, for their ssistnce. Declrtion of conflicting interests The uthor(s) declred no potentil conflicts of interest with respect to the reserch, uthorship, nd/or publiction of this rticle. Funding The uthor(s) disclosed receipt of the following finncil support for the reserch, uthorship, nd/ or publiction of this rticle: The work ws prtly funded by the Icelndic Fmily Physicins Reserch Fund. References [1] Centers for Disese Control nd Prevention. The biology nd behviorl bsis for smoking-ttributble disese: report of the Surgeon Generl, nih.gov/pubmed/ (2010, ccessed 25 November 2015). [2] Anderk M, Romitti PA, Sun L, et l. Ptterns of tobcco exposure before nd during pregnncy. Act Obstet Gynecol Scnd 2010;89(4): [3] Bb S, Wikstrom A, Stephnsson O, et l. Influence of snuff nd smoking hbits in erly pregnncy on risks for stillbirth nd erly neontl mortlity. Nicotine Tob Res 2014;16(1): [4] Cnttingius S. The epidemiology of smoking during pregnncy: smoking prevlence, mternl chrcteristics, nd pregnncy outcomes. Nicotine Tob Res 2004;6(Suppl 2):S [5] Andres RL nd Dy M-C. Perintl complictions ssocited with mternl tobcco use. Semin Neontol 2000;5(3): [6] Annth CV nd Pltt RW. Reexmining the effects of gesttionl ge, fetl growth, nd mternl smoking on neontl mortlity. BMC Pregnncy Childbirth 2004;4(1):22. [7] Grdosi J nd Frncis A. Erly pregnncy predictors of preterm birth: the role of prolonged menstrution-conception intervl. Int J Obstet Gynecol 2000;107(2): [8] Hckshw A, Rodeck C nd Bonifce S. Mternl smoking in pregnncy nd birth defects: systemtic review bsed on 173,687 mlformed cses nd 11.7 million controls. Hum Reprod Updte 2011;17(5): [9] Obel C, Linnet KM, Henriksen TB, et l. Smoking during pregnncy nd hyperctivity-inttention in the offspring compring results from three Nordic cohorts. Int J Epidemiol 2009;38(3): [10] Zhu J, Olsen J, Liew Z, et l. Prentl smoking during pregnncy nd ADHD in children: the Dnish ntionl birth cohort. Peditrics 2014;134(2): [11] Zmmit S, Thoms K, Thompson A, et l. Mternl tobcco, cnnbis nd lcohol use during pregnncy nd risk of dolescent psychotic symptoms in offspring. Br J Psychitry 2009;195(4): [12] Gorog K, Pttenden S, Antov T, et l. Mternl smoking during pregnncy nd childhood obesity: results from the CESAR study. Mtern Child Helth J 2011;15(7): [13] Ino T, Shibuy T, Sito K, et l. Effects of mternl smoking during pregnncy on body composition in offspring. Peditr Int 2011;53(6): [14] Biley BA, McCook JG, Hodge A, et l. Infnt birth outcomes mong substnce using women: why quitting smoking during pregnncy is just s importnt s quitting illicit drug use. Mtern Child Helth J 2012;16(2):

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