Findings from the Growing Up in New Zealand Cohort

Transcription

1 PARENTAL SMOKING DURING PREGNANCY Fidigs from the Growig Up i New Zealad Cohort Prepared for Kathrie Clarke Whakawhetū Natioal Maager Maori Health Service Programme By Gayl Humphrey Chris Bulle Fioa Rosse Natalie Walker

2 Preface This documet is the fial output of the Smokig i Pregacy project completed by the Natioal Istitute for Health Iovatio (NIHI). It provides a aalysis of the Growig Up i New Zealad ateatal (Wave ) data. NIHI idetifies key fidigs ad coclusios. For more iformatio about NIHI or this documet please cotact: Gayl Humphrey Co-Leader ad Seior Research Fellow Health Iformatics & Techology g.humphrey@aucklad.ac.z Mobile: Natioal Istitute for Health Iovatio (NIHI) School of Populatio Health Tamaki Campus The Uiversity of Aucklad Private Bag 9209 Aucklad 42 2 P age

3 Table of Cotets Preface... 2 Executive Summary... 4 Recommedatios Itroductio Materal Smokig durig Pregacy Exposure to Secod Had Smoke Growig Up i New Zealad Data Methods Measuremets... 9 Smokig... 9 Ethicity... 9 Social-ecoomic positio Statistical Aalyses Results Plaed versus Uplaed Pregacy o cotiued smokig Parity ad Smokig Exposure Secod had Smoke Discussio Secod Had Smoke Equity Itervetios Coclusio REFERENCES... 2 List of Tables Table. Mothers smokig pre- ad durig pregacy by demographic characteristics... 2 Table 2: Average umber of cigarettes smoked per day by demographic characteristics... 3 Table 3: Number of cigarettes per day by plaed / uplaed pregacy... 4 Table 4: Number of cigarettes per day by parity... 4 Table 5: Mothers Smokig durig pregacy by plaed/uplaed pregacy... 5 Table 6: Mothers smokig durig pregacy by parity... 6 Table 7: Exposure to secod had smoke by demographic characteristics P age

4 Executive Summary The aim of this research was to ivestigate patters of exposure to tobacco smoke i pregacy amog a represetative sample of New Zealad wome. We aalysed data from the ateatal period (first wave) of the Growig Up i New Zealad (GUiNZ). We foud that 20 of mothers reportig smokig before pregacy ad 9.9 of mothers cotiued durig pregacy. This was more proouced i youger wome (p<.000), with lower educatio achievemet (p<.00) ad of Māori ethic group (p<.00). Similarly, beig Māori (p<.000) ad to a lesser degree havig lower educatio achievemet (p<.0029) were also sigificatly associated with smokig durig a uplaed compared to a plaed pregacy. Multiparous mothers were also more likely to be smokers tha primiparas (: 95 CI vs 8.3: CI ). Exposure to cigarette smoke from someoe smokig i the same room as them was far more commo for youger wome (OR 3.2: 95 CI.6-6.4) ad Maori wome (OR.9: 95 CI.4-2.5) However, the opposite was the case for wome with plaed pregacies, where exposure to someoe else s smokig was reported by oly 3 (95 CI ) compared with uplaed pregacies (3.4: 95 CI ). For plaed pregacies, someoe else smokig i the same room at the mother was substatively less. The fidigs clearly suggest that there are differeces i a rage of cotextual ad behavioural factors related to smokig before ad durig pregacy. The role of low educatioal achievemet, beig youg, Maori ad multiparous all featured i cotiuig to smoke. Uderstadig what other factors both cotribute ad ifluece these differet populatios to cotiue smokig is eeded. 4 P age

5 Recommedatios The fidigs from this research has idetified that further uderstadig is eeded. We recommed the followig poits be explored:. Firstly, a i-depth ivestigatio ito the factors that ifluece Maori wome whom cotiue to smoke durig pregacy, particularly multiparous mothers, eeds to be explored. Uderstadig what, if ay, differeces exist across the age groups will also be importat. Lakes District Health have idetified that they have a populatio that appears to have etreched smokig behaviours irrespective of the implemetatio of a rage of itervetios to support cessatio. It is proposed that Lakes District Health is a ideal locatio to develop ad implemet a Kaupapa Research approach to explorig the cotributig factors that are ifluecig this cotiued smokig behaviour. The learigs would form a key part to uderstadig the drivers of cotiued smokig behaviour ad therefore form ew kowledge to iform the developmet of additioal itervetios, particularly for Maori. 2. Secodly, the exploratio of the other factors that may cotribute to cotiued smokig durig pregacy such as parter smokig status, beig sigle, chages i parter state, or depressio may also help build a better picture o what barriers wome ad families are facig. The GUiNZ study offers a ideal opportuity to broade the variables of aalyses ad examie what ad if other factors have a ifluece o smokig behaviour. I additio, as the GUiNZ data is a rich source of ogoig iformatio we also recommed that Wave two of the GUiNZ data is aalysed to explore, for example, if smokig rates icrease sice the child is bor. Evidece suggests that smokig restarts post-partum irrespective of the quit success durig pregacy. Uderstadig the cotext with which this occurs ca provide isights ito the developmet of strategies to support wome (ad their whaau) to remai quit. 5 P age

6 . Itroductio Tobacco smoke exposure i pregacy (materal smokig ad secod-had smoke exposure) is oe of the sigle most importat prevetable risks for materal, fetal ad ifat health. 2-4 I this paper we preset ew data o tobacco smoke exposure i pregacy for New Zealad wome.. Materal Smokig durig Pregacy Smokig prevalece i the geeral populatio i developed coutries has declied more rapidly i recet years compared to developig coutries, 5 however, globally 22 of the world s adult populatio are estimated to be curret smokers (36 me ad 8 wome). 6 Prevalece of exposure to SHS is equally cocerig: the Global Adult Tobacco Survey foud that almost oe half of reproductive-aged wome (5 49 years) ( 470 millio people) from 4 low ad middle ecoomy coutries were exposed to SHS i their homes. 7 Similar to the iteratioal picture, the umbers reported as curret smokers is decliig i New Zealad from 25 i 996/97 to 8 202/3. 8 However, the rates of declie are differet amogst differet populatios, with Māori, Pacific Peoples ad Asia groups chagig little over the same period. I a aalysis of smokig prevalece at registratio ad discharge from a lead materity care from , ad i a MoH report o materity care, 8.7 wome were still smokig, ad this was sigificatly higher for sub groups such as Maori, youg wome, livig i most deprived areas ad beig multiparous (20.4). 0 Smokig durig pregacy is associated with a rage of health risks for the baby ad pregacy icludig adverse fetal developmet,,2 birth complicatios 3,4, atepartum haemorrhage 5 ad pre-term delivery. 6 Smokig durig pregacy also has deleterious effects o childre i the early eoatal ad preschool periods with respiratory morbidity (such as asthma) beig more commo. 7 Harms have also bee reported to cotiue through the child s life course ito adulthood with some studies, reportig that adolescet experiece of metal illess was associated with materal smokig. 8 I a systematic review ad meta-aalysis, a positive associatio betwee materal smokig durig pregacy with obesity ad metabolic disorders i the adult offsprig was foud. 9 Aother study foud a associatio of icreased cardiovascular disease risk i the adulthood offsprig of wome who smoked durig pregacy. 4 I a 202 meta-aalysis, the authors idetified a 2 to 85 icrease i icidet asthma (strogest effect from preatal materal smokig o asthma i childre aged </=2 years, OR.85, 95 CI , 5 studies). 20 There is also evidece of a dose respose relatioship. A UK study 2 reported that heavier materal smokig durig pregacy (greater tha 0 cigarettes per day) was associated with shorter stature ad obesity i offsprig compared to o-smokers (OR 2.76 (95 CI )), with the adjusted odds ratio for short stature i childre higher if both parets were heavy smokers (OR 4.28 ( ). A Spaish study examied smokig through-out each trimester ad foud that wome still smokig i the third trimester were at higher risk of givig birth to a baby uder 3000g compared to their o-smokig couterparts (OR 5.94, CI 95:.94_8.6). 22 However, most studies used self-reported smokig status ad cosumptio levels with differet metrics, cotributig to ucertaity ad a rage of fidigs across may similar studies. Nevertheless, the majority of these studies do observe a cosistetly icreased risk of lower birth weight babies amogst materal smokers. 6 P age

7 .2 Exposure to Secod Had Smoke Exposure of o-smokers to secod had smoke (SHS) is also associated with harms. 23 Similarly, whe o-smokig pregat wome are exposed to SHS there is evidece of harmful effects o fetal developmet ad o the health of the child. A meta-aalyses of studies of SHS durig pregacy ad adverse birth outcomes i Chiese peoples by Li, Dai, Zhao, Ya 24 foud icreases i health related risks preterm ad at birth that were similar as for those wome who actively smoked. Aother meta-aalysis idetified a associatio betwee materal exposure to SHS ad a icrease risk of eural tube defects i offsprig. 25 West et al. foud a icreased risk of cardiovascular disease amogst adult offsprig amogst those exposed to SHS durig pregacy ad ifacy. 26 Other relatioships are also evidet, for example the relatioship betwee SHS ad childhood asthma is also widely recogised 20 as is low birth weight i offsprig. 27 Aother report by the WHO examiig the global burde of disease related to SHS estimated that of all deaths attributable to SHS, 28 occur i childre, ad 47 i wome. 28 The WHO 202 report o Evirometal Health Iequalities i Europe oted a iverse social gradiet with higher exposure to SHS both i the home ad at work for those socioecoomically disadvataged ad self-reportig a low social positio. 29 A New York study idetified wome with lower educatioal achievemet ad from margialised ethicities as beig more exposed to SHS whe pregat tha their couterparts 30 ad a Australia study reported beig female, aged uder 45 ad low socioecoomic status were associated to higher exposure to SHS withi the home. 3 With regard to exposure to SHS i NZ, exposure to SHS amogst o-smokers is greatest amogst youg childre, Māori ad low socioecoomic groups. Māori childre are 2.6 times more likely to be exposed to SHS i the home ad car compared to o-māori childre; childre livig i the most deprived eighbourhoods are 7.8 times more likely to be exposed to SHS i the home ad 3.9 times more likely to be exposed to SHS i the car. Māori are more likely tha o-māori to be exposed for loger hours. 32 They are also more likely to be exposed i the home but likely to have a household smokig ba. 33 Pacific o-smokers are twice as likely as o-pacific o-smokers to experiece SHS exposure, particularly i their cars. Coversely, Asia childre were the least likely of ay ethic group to be exposed to SHS either at home or i a car. 33 Data o SHS exposure of pregat wome are limited. Give the rates of daily smokig amogst males aged reported by Statistics NZ, 34 ad the evidece of smokig i the home as show i a variety of research studies, 32,35,36 it is highly likely that may osmokig pregat wome are exposed to SHS. Exposure is likely to be disproportioally greater for Māori wome due to higher Maori smokig, ad similarly for those experiecig high levels of deprivatio. Ideed, i a small study of Māori wome who were pregat smokers all the wome also lived with smokers ad smokig was the orm amogst their whaau, frieds, ad co-workers. 37 Participats remarked that this eviromet made beig smoke-free a difficult cocept to adopt P age

8 .3 Growig Up i New Zealad Data The Growig Up i NZ (GUiNZ) cohort study offers a uique opportuity to capture ad examie smokig behaviour ad exposure to SHS over time. This paper focuses o the data reported at the first data collectio poit which eded i Jue 200, that is durig the ateatal period or before the child was bor. The aim of this paper is to preset i detail the patters of pregacy ad exposure to tobacco smoke to better uderstad the profile of smokers ad the at risk groups by examiig the iter-relatioships betwee smokig ad other variables. 8 P age

9 2 Methods The methodology of GUiNZ is reported elsewhere 38 however i brief, GUiNZ is a logitudial study that has recruited ad collected iformatio from pregat mothers ad their parters from before childre are bor ad aims to cotiue to collect iformatio util the child turs five. All participats had a expected delivery date betwee 25 th April 2009 ad 25 th March 200. I total, 6,822 pregat wome erolled ad completed a computer-assisted face-toface ateatal iterview. The cohort is comparable to the most recet New Zealad atioal birth statistics with regard to materal age, ethicity, parity, ad socioecoomic idicators Measuremets Smokig There were three poits of focus with regard to smokig questios withi the GUiNZ survey. Two were specific for the mother ad oe for the parter. For the purposes of this paper we oly looked at the questios for the Mother. These are:. About ow smokig status. a. Did you smoke regularly that is, every day before you were aware you were pregat? [Yes; o; do t kow] b. How may cigarettes did you smoke per day, o average, before this pregacy? c. Are you curretly smokig? [Yes; o; do t kow] d. How may cigarettes do you smoke per day, o average? 2. Exposure to SHS. a. Does ayoe curretly regularly smoke i the same room as you? [Yes; o do t kow] b. How ofte? [Rarely (less tha oce a week); occasioally (a few times a week); ofte (almost or every day of the week); do t kow] Ethicity Ethicity was self-prioritised ad coded ito six Level categories i lie with Statistics New Zealad s codig criteria: Europea; Māori; Pacific Peoples; Asia; Middle Easter, Lati America ad Africa (MELAA); ad Other. 40 For the purpose of presetig smokig data, we combied the categories of MELAA ad Other due to small umbers. Social-ecoomic positio Socio-ecoomic deprivatio was measured usig the 2006 New Zealad Deprivatio Idex (NZDep2006), ad area-level (eighbourhood) idex costructed from ie Cesus 2006 variables (meas-tested beefits; household icome; home owership; sigle-paret family; employmet; qualificatios; household overcrowdig; access to a telephoe; ad, access to a car). 4,42 We aggregated summary deprivatio scores as quitiles, with represetig the least deprived eighbourhoods ad 5 the most deprived eighbourhoods. Highest educatioal qualificatio was coded as: o qualificatios; secodary school completio; diploma/trade certificatio; bachelors degree; or higher degree. 9 P age

10 2.2 Statistical Aalyses All statistical aalyses used SAS versio 9.3 (SAS Istitute, Cary, Idiaa,). We used descriptive statistics to examie associatios betwee mothers smokig with demographics, pregacy period (before or durig), plaed/uplaed pregacy, ad parity. Where multiple regressio modellig was used, variables were etered oly if they were sigificat covariates i uivariate aalyses. Where respose umbers are too small (=<0), they have ot bee preseted. 0 P age

11 3. Results I total, 946 mothers reportig smokig either before or durig pregacy (=,387) smoked before pregacy ad 9.9 (=559) said they smoked durig pregacy. Table presets the demographics of these mothers by smokig before ad durig pregacy. I uivariate aalyses, beig youger, Māori or Pacific, more deprived, ad less educated were all associated with beig a smoker, both before ad durig pregacy. P age

12 Table. Mothers smokig pre- ad durig pregacy by demographic characteristics MOTHERS SMOKING Before pregacy Durig pregacy 2 Odds ratio Odds ratio p-value (N=6,807) (95 CI) (95 CI) (N=5,664) (95 CI) (95 CI) p-value TOTAL, ( ) ( ) or less ( ) ( ) ( ) ( ) Age group ( ) (.6-3.5) (2.2-5.) ( ) < ( ) ( ) ( ) ( ) < or older ( ) ( ) Māori ( ) (.8-2.6) ( ) ( ) Pacific ( ) ( ) (.0-6.0) ( ) Ethicity Asia ( ) ( ) < <0.000 MELAA & Other ( ) ( ) NZ Europea ( ) ( ) (least deprived) ( ) ( ) (2.2-6.) (. -.9) ( ) ( ) NZDep < ( ) (.0 -.8) ( ) (.0-2.5) < ( ) (. -.9) ( ) (.3-3.0) 5 (most deprived) ( ) (.6-2.6) ( ) (.9-4.4) No sec school qualificatio ( ) ( ) Sec school / NCEA ( ) ( ) ( ) ( ) Highest Diploma / Trade cert / NCEA < educatio ( ) ( ) (.3-4.5) ( ) <0.000 Bachelor s degree ( ) ( ) ( ) (0.0-0.) Higher degree ( ) ( ) (0.6-2.) (0.0-0.) Notes:. Relates to questio: Did you smoke regularly that is every day before you were aware you were pregat? 2. Relates to questio: Are you curretly smokig? NB: These results relate to mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. 2 P age

13 Of the wome who reported they were curretly smokig (=533), 40. (=222) reported that they smoked 4 or less cigarettes per day, 3. (= 72) smoked betwee 5 ad 9 per day ad 28.8 smoked 0 or more per day. Give the small umbers i each subgroup, we used regressio aalyses to ivestigate differeces betwee smokig 9 or less ad 0 ad above (Table 2). The fidigs show that whe other factors were cotrolled for, older wome (aged years; OR 0.7: 95 CI: ; (p )) ad beig Maori (OR.2, 95 CI: (p<0.000)) were associated with smokig 0 or more cigarettes per day. Table 2: Average umber of cigarettes smoked per day by demographic characteristics NUMBER OF CIGARETTES PER DAY 9 or less 2 0 or more Odds ratio (95 CI) (N=553) (95 CI) (N=553) (95 CI) p-value 3 TOTAL ( ) ( ) or less ( ) ( ) ( ) Age group ( ) ( ) (0. -.5) ( ) ( ) ( ) 40 or older Māori ( ) ( ) ( ) Pacific 82 5 ( ) ( ) ( ) Ethicity <.000 Asia MELAA & Other NZ Europea ( ) ( ) (least deprived) ( ) ( ) ( ) ( ) NZDep ( ) ( ) ( ) ( ) ( ) ( ) 5 (most deprived) ( ) ( ) ( ) No sec school qualificatio ( ) ( ) Sec school / NCEA ( ) ( ) ( ) Highest Diploma / Trade educatio cert / NCEA 5-6 ( ) ( ) ( ) Bachelor s degree ( ) Higher degree 84.6 ( ) These results relate to:. The questio: How may cigarettes do you smoke per day, o average? ; Mothers who idicated that they were curretly smokig; ad, Mothers who were iterviewed durig pregacy -others who were iterviewed post-partum were excluded from these aalyses. 2. As this questio was oly asked of mothers who idicated that they curretly smoke, 9 or less icludes those who respoded zero. 3. Outcome beig modelled is 0 or more. 3 P age

14 Tables 3 ad 4 preset the uadjusted fidigs for the umber of cigarettes smoked by plaed or uplaed pregacy ad by parity. Amog wome with uplaed pregacies uplaed smokig 0 or more was more commo(3.2) tha amog wome with plaed pregacies (20.7) (Table 3) Table 4 shows that multiparous wome were more likely to smoke 0 or more cigarettes (32.) tha their primipara couterparts (22.6 (=95)). Table 3: Number of cigarettes per day by plaed / uplaed pregacy Materal self-reported Plaed pregacy Uplaed pregacy average daily cigarette cosumptio (N=35) (95 CI) (N=44) (95 CI) 9 or less ( ) ( ) 0 or more ( ) ( ). These results relate to: - The questio: How may cigarettes do you smoke per day, o average? ; - Mothers who idicated that they were curretly smokig; ad, - Mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. Table 4: Number of cigarettes per day by parity Materal self-reported First pregacy Subsequet pregacies average daily cigarette cosumptio (N=95) (95 CI) (N=358) (95 CI) 9 or less ( ) ( ) 0 or more ( ) ( ). These results relate to: - The questio: How may cigarettes do you smoke per day, o average? ; - Mothers who idicated that they were curretly smokig; ad, - Mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. 3. Plaed versus Uplaed Pregacy o cotiued smokig Smokig before pregacy was greater whe that pregacy was uplaed. This was more proouced if you were youger (p<.000), had lower educatio achievemet (p<.00) ad were Māori (p<.00). We also examied if there were differeces i the same variables for those cotiuig to smoke while pregat betwee plaed or uplaed pregacy. We used regressio modellig to test for the ifluecig factors. After adjustig for all covariates i the regressio aalysis, beig Māori (p<.000) ad to a lesser degree havig lower educatio achievemet (p<.0029) were also foud to feature sigificatly i cotiuig to smokig durig a uplaed pregacy compared to plaed, while age was less importat (p<.05) (Table 5) 4 P age

15 Table 5: Mothers Smokig durig pregacy by plaed/uplaed pregacy DURING pregacy Plaed Uplaed Odds ratio (95 CI) (N=3,488) (95 CI) (N=2,56) (95 CI) p-value 2 TOTAL ( ) ( ) or less ( ) ( ) ( ) Age group ( ) ( ) ( ) ( ) ( ) ( ) or older ( ) ( ) Māori ( ) ( ) ( ) Pacific 26 7 ( ) ( ) ( ) Ethicity <.000 Asia MELAA & Other NZ Europea ( ) ( ) (least deprived) ( ) ( ) ( ) ( ) ( ) NZDep ( ) ( ) ( ) ( ) ( ) ( ) 5 (most deprived) ( ) ( ) ( ) No sec school qualificatio ( ) ( ) Sec school / NCEA ( ) ( ) ( ) Highest Diploma / Trade educatio 5 70 cert / NCEA 5-6 ( ) ( ) ( ) Bachelor s degree ( ) ( ) ( ) Higher degree Relates to questio: Are you curretly smokig? NB: These results relate to mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. 2. Outcome beig modelled is Uplaed pregacy. 3.2 Parity ad Smokig While the survey did ot capture if mothers smoked durig earlier pregacies, Table 7 reports uadjusted smokig resposes by parity status. There was little differece i smokig betwee the parity groups (first-bor 20.5: 95 CI ) v subsequet 20.3: 95 CI ) or durig pregacy (first-bor 8.3: 95 CI ) v subsequet : 95 CI However, whe idepedetly cotrollig for age, ethicity, deprivatio ad educatioal achievemet; cotiuig to smoke durig pregacy was more likely i multiparous wome who were Maori ad Pacific (Table 6). 5 P age

16 Table 6: Mothers smokig durig pregacy by parity Demographic characteristics (N=2,396) TOTAL 98 Age group Ethicity 9 or less First-bor (95 CI) 8.3 ( ) 78.8 ( ) 33.4 ( ) 8.5 ( ) DURING pregacy (N=3,268) or older Māori 77 Pacific ( ) 27.6 ( ) 59 7 Subsequet (95 CI).0 (0.0-2.) 2.2 ( ) 66.6 ( ) 8.5 ( ) 92.3 ( ) 67.4 ( ) 72.4 ( ) Asia 0 - MELAA & Other Odds ratio (95 CI) p-value (0.0-0.) 0.2 ( ) 0.6 ( ).9 (.2-2.9) 2.2 (.3-3.9) - - <.000 <.000 NZ Europea ( ) ( ) (least deprived) ( ) ( ) ( ) ( ) NZDep ( ) ( ) ( ) ( ) ( ) (0. -.) 5 (most deprived) ( ) ( ) ( ) No sec school qualificatio ( ) ( ) Sec school / NCEA ( ) ( ) ( ) Highest Diploma / Trade <.000 educatio 8 4 cert / NCEA 5-6 ( ) ( ) ( ) Bachelor s degree ( ) ( ) Higher degree Relates to questio: Are you curretly smokig? NB: These results relate to mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. 2. Outcome beig modelled is subsequet pregacy. 3.3 Exposure Secod had Smoke Seve percet of the 5664 wome reported beig exposed to SHS from someoe smokig i the same room. For plaed pregacies, someoe else smokig i the same room at the mother was substatively less (3: 95 CI ) tha for uplaed pregacies (3.4: 95 CI )). However, whe parity was examied irrespective of plaed or uplaed, that differece was ot apparet, (primigravida mothers (8., CI ) versus multiparous mothers (6.2, 95 CI )). Adjustig for age, ethicity, deprivatio ad educatioal status, the youger the mother (9 years or less (OR 3.2: 95 CI.6-6.4; p<.000), beig Maori (OR.9: 95 CI:.4-2.5; p<.000), mothers livig i high deprivatio (OR CI: ; p<.000) ad those 6 P age

17 with low educatioal achievemet (p<.000) were sigificat factors i mothers reportig havig someoe smokig i the same room as them (Table 7). Table 7: Exposure to secod had smoke by demographic characteristics EXPOSURE TO SECOND-HAND SMOKE DURING PREGNANCY Demographic characteristics Yes No Odds ratio (95 CI) (95 CI) (95 CI) p-value 2 TOTAL ,270 ( ) ( ) or less ( ) ( ) (.6-6.4) Age group ,967 (9. -.7) ( ) ( ) ,93 ( ) ( ) ( ) < or older (.9-7.9) ( ) Māori ( ) ( ) (.4-2.5) Pacific ( ) ( ) ( ) Ethicity Asia ( ) ( ) (0.5 -.) <0.000 MELAA & Other ( ) ( ) NZ Europea ,00 (3.7-5.) ( ) (least deprived) (.0-2.8) ( ) ,042 ( ) ( ) ( ) NZDep ( ) ( ) (.0-3.2) < ,094 (5.2-8.) ( ) ( ) 5 (most deprived) ,254 ( ) ( ) ( ) No sec school qualificatio ( ) ( ) Sec school / NCEA ,23 ( ) ( ) ( ) Highest Diploma / Trade cert / ,573 educatio NCEA 5-6 ( ) ( ) ( ) <0.000 Bachelor s degree ,277 (.5-3.2) ( ) ( ) Higher degree ( ) ( ) These results relate to:. The questio: Does ayoe curretly regularly smoke i the same room as you? ; Mothers who were iterviewed durig pregacy - mothers who were iterviewed post-partum were excluded from these aalyses. 2. Outcome beig modelled is Does ayoe curretly regularly smoke i the same room as you? - Yes. 7 P age

18 4 Discussio Beig youger, beig less well educated ad livig i high deprivatio cotiue to be highly related to smokig before ad durig pregacy. These factors are similar to those reported i various iteratioal research, 43,44,45 ad those reported i MoH materity report 0 ad a Midwifery research study, 9 both udertake durig a similar time period. Like other studies 46 multiparous wome were also more likely to cotiue to smoke durig pregacy ad smoke more per day tha primipara wome. While first time pregacy appears to be a motivator for smokig cessatio it does ot seem to hold true for multiparous wome. A fidig also reported i other studies 9 ad may be related to smokig behaviour such as beig more depedet smokers but also cotextual factors such as less social support, fiacial pressures ad low self-cofidece. 47 Uderstadig the cotextual factors that cotribute to their lower quit rates is importat to explore especially as they are highly likely to be cotributig to the wider family s (icludig older childre) exposure to SHS as well as their ubor child. A plaed pregacy was positively associated with ot smokig durig pregacy or if still smokig, a lower cosumptio of cigarettes (< 9 cigarettes/day). Arguably this may sigal that wome (ad families) may have plaed a wider healthy strategy which icluded smokig cessatio whe plaig to start or add to their family. It is ot kow if these wome (ad families) also have greater ad /or earlier iteractios with health professioals ad as such are exposed to early cessatio advice, support ad treatmet. Util relatively recetly, cuttig dow rather tha quittig was the domiat message to pregat smokers by health professioals reported i a recet systematic review 48 ad reflects a earlier fidig i NZ. 49 It is critical that a cosistet message ad a subsequet supportive eviromet is provided if chages to these rates are to happe. It will also be importat to explore the ext GUiNZ data wave for smokig rates as iteratioal research has foud that wome ofte resume smokig i the days or weeks followig the birth. 9 While there is a high awareess of the harms of smokig o themselves ad their ubor child the lived cotext of the pregat wome plays a large part i smokig cessatio. While it is ot possible to determie who actively cut dow i this study, research suggests that adoptio of a cuttig dow approach versus quittig is more commo i wome with low educatioal achievemet, greater deprivatio ad beig Maori ethicity. 48,50,5 4. Secod Had Smoke Wider social cotexts (frieds, family, work) are importat factors i supportig or impedig behavioural chage activities. 52 While oly 7 of our cohort reported aother perso smokig i the same room it was uivariately correlated with beig youger, most deprived, lower educatioal achievemet ad Maori; hece, uderstadig these cotexts i more detail is importat for itervetio strategies to be successful. Exploratio of the GUiNZ parter resposes ad the other cotextual details captured i GUiNZ data is eeded. This may help provide further isights ito the factors ad cotexts for the wome who cotiued to smoke (ad those who do t). Also, more i-depth qualitative research with multiparous wome who stopped smokig ad those who did ot is eeded to explore their motivatios ad situatioal cotexts. This may highlight where additioal itervetios could be focused ad therefore reduce the burde of SHS o other childre still livig at home Equity Our fidigs also highlight that beig Maori was a sigle costat cosistetly correlated to smokig before ad durig pregacy or beig exposed to SHS. The impact of high rates of smokig is evidet for Maori health related outcomes across the life course from the ew- 8 P age

19 bor through to adulthood. 54 Some research has foud that Maori are reported to receive ateatal care later i their pregacy. 9 Other factors ifluecig lower cessatio rates are that more-depedet, ad heavier smokers have a greater probability of cotiuig to smoke ad age at smokig iitiatio. 6 I repeated smokig survey s, Maori youth report havig their first cigarette sigificatly earlier tha their No-Maori couterparts ad the prevalece of youg Maori females (5-24 years) was sigificatly higher tha for No- Maori. 55 This may partly accout for the low smokig cessatio rate for Maori durig pregacy. 37 Efforts to support youg Maori ad Pacific wome at their first pregacy to quit is pivotal, as both groups were positively associated with smokig durig subsequet pregacies. The ability to act o iformatio give about smokig i pregacy has bee reported as low by Maori wome. 49,56 This fidig should clearly emphasise that the effectiveess of the curret suite of itervetios is suboptimal for pregat Maori wome regardless of parity ad ew strategies are eeded to reduce sigificat life course harms. 4.3 Itervetios Idigeous research o itervetios by Glover et al. 57,58 ad Walker et al. 36 have set some of the groud work for successful itervetio directios such as coachig ad usig icetives as motivators for chage but more work is eeded. There is a bourgeoig literature o effectiveess of cessatio activities but few o sub groups such as pregat wome or idigeous groups. However, two Cochrae reviews, oe focused o pharmacological itervetios 59 ad the other focused o psychological itervetios 60 have recetly bee published. Both report a mix of itervetios was most effective with Chamberlai et al. 60 fidig a sigificat effect for the use of icetives. Aother Cochrae review examiig itervetios for idigeous populatios was equivocal for effectiveess, ad cocluded that more rigorous trials are required to bridge the gap betwee tobacco related health disparities i Idigeous ad o-idigeous populatios. 6 Other strategies that emerged showig some effectiveess focused o egagig with early i their ateatal care. This is especially relevat for Maori ad Pacific wome ad their families. While NZ has a sigificat array of smokig cessatio itervetio programmes based o ad cotributig to, the evidece pool of effectiveess there are few that have a specific focus o pregat wome. Hapū Mama which is part of the Aukati Kaipaipa programme desiged to support mothers ad their whaau/family to be smoke free ad a mix of cessatio services for pregat wome explicitly fuded by the three metro Aucklad DHBs, ad their couterparts i Caterbury, Hawke s Bay ad Souther District Health Board were the oly oes foud. Furthermore, while ot specific to mothers, a earlier study of the awareess ad perceived effectiveess of smokig cessatio services for those livig i high deprivatio areas has bee reported to be low. 62 This is importat as our fidigs show that Maori, ad deprivatio were associated with smokig durig pregacy ad the kowledge gap o how to quit is a importat gap to address. 9 P age

20 5 Coclusio Reducig materal tobacco smoke exposure has the potetial to have a positive health effect that far exceeds the immediate health of both mother ad ifat. Effective itervetios to support smokig cessatio are supported by a large amout of research. However, there is a oticeable paucity of evidece o the effectiveess of these itervetios for specific populatio groups such as pregat wome. While there is emergig evidece for effective strategies for pregat wome 60 overall for NZ, these groups have see little fall i smokig prevalece i the last decade. If this cotiues smokig will become cocetrated i commuities already margialised by their health, their ethicity or their ecoomic status, ad health iequalities will become more etreched. 20 P age

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