Tobacco and pregnancy

Neighborhood context and birth outcomes: Going beyond neighborhood disadvantage, incorporating affluence

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Neighborhood affluence protects against the risk of poor birth outcome.

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The protective effect of affluence holds for Whites, Blacks, Hispanics and Asians.

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Mediation of these pathways by prenatal smoking varies by racial group.

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The discourse on neighborhoods and birth outcomes should include affluence.

Ovotoxicity of cigarette smoke: A systematic review of the literature

This study reviews the scientific literature on the noxious effects of cigarette smoke on the ovarian follicle, and the cumulative data on the impact of smoking on in vitro fertilization (IVF) cycle outcome. There is a close association between tobacco smoke and accelerated follicle loss, abnormal follicle growth and impairment of oocyte morphology and maturation. There is an increasing amount of evidence indicating that smoke can directly derange folliculogenesis. Increased cellular apoptosis or autophagy, DNA damage and abnormal crosstalk between oocyte and granulosa cells have been implicated in the demise of ovarian follicles. It becomes increasingly clear that maternal smoking can exert multigenerational effects on the ovarian function of the progeny. Growing evidence suggests that cigarette smoke is associated with decreased results after IVF. Further research is needed to better define the molecular mechanisms behind smoking-induced ovarian disruption.

Neonatal abstinence syndrome: Neurobehavior at 6 weeks of age in infants with or without pharmacological treatment for withdrawal

Use and abuse of prescription opioids and concomitant increase in Neonatal Abstinence Syndrome (NAS), a condition that may lead to protracted pharmacological treatment in more than 60% of infants, has tripled since 2000. This study assessed neurobehavioral development using the NICU Network Neurobehavioral Scale in 6-week old infants with prenatal methadone exposure who did (NAS+; n = 23) or did not (NAS-; n = 16) require pharmacological treatment for NAS severity determined by Finnegan Scale. An unexposed, demographically similar group of infants matched for age served as comparison (COMP; n = 21). NAS+, but not NAS- group, had significantly lower scores on the regulation (p < .01) and quality of movement (p < .01) summary scales than the COMP group. The NAS+ and NAS- groups had higher scores on the stress-abstinence scale than the COMP group (p < .05). NAS diagnosis (NAS +) was associated with poorer regulation and quality of movement at 6 weeks of age compared to infants without prenatal methadone exposure from the same demographic.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada

BACKGROUND

Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada.

METHODS

We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010.

RESULTS

Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants.

INTERPRETATION

First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

Prenatal tobacco exposure, birthweight, and offspring psychopathology

Although prenatal tobacco exposure (PTE) is associated with several adverse offspring mental health outcomes, mechanisms remain unclear. We test whether associations between PTE and offspring psychopathology are explained by birthweight, one of the earliest-occurring outcomes of PTE. The analysis focuses on 238 offspring from a family study of depression with (1) collected prenatal histories and (2) at least one clinical interview in adulthood to assess psychiatric problems. Exposure was categorized by maternal smoking of ≥10 cigarettes daily/nearly daily; diagnostic outcomes were confirmed by clinicians using the best-estimate procedure, blind to exposure. After adjusting for potential confounders, PTE was associated with 0.7lb(9%) lower birthweight (p=0.0002), increased rates of disruptive behavior disorders [males: OR=2.66(1.15,6.16), and (trend) substance use disorders [females: OR=2.23(0.98,5.09)], and decreased rates of mood disorders (males: OR=0.42(0.17,0.98)]. Birthweight was not independently associated with diagnoses and did not mediate the association between exposure and psychopathology. Maternal smoking has long-term adverse consequences for offspring. Although birthweight cannot be manipulated, smoking is a modifiable risk factor. Thus, cessation efforts focused on pregnant women may not only improve maternal wellbeing, but also mitigate adverse proximal (e.g., birthweight) and long-term (psychopathology) outcomes in offspring.

Postnatal Cardiovascular Consequences in the Offspring of Pregnant Rats Exposed to Smoking and Smoking Cessation Pharmacotherapies

Approximately 20% of pregnant women smoke despite intentions to quit. Smoking cessation drugs, such as nicotine replacement therapy (NRT) and bupropion, are recommended treatments. Adverse cardiovascular outcomes in offspring have raised concerns about NRT's safety during pregnancy. However, the effect of bupropion is unknown. Using a rat model, we determined whether NRT and bupropion interventions during pregnancy are safer than continued smoking on offspring's cardiovascular function. Male offspring of controls and dams exposed to cigarette smoke (1.6 packs/day, inhalation), nicotine (2 mg/kg/d subcutaneously), and bupropion (13 mg/kg twice daily orally) were assessed for fetoplacental weight, cardiac function, blood pressure, and vascular reactivity. Fetoplacental weights were decreased and spontaneous beating and intracellular calcium in neonatal cardiomyocytes were increased in smoking, nicotine, and bupropion offspring; however, these effects were more accentuated in smoking followed by nicotine and bupropion offspring. Increased heart rate and decreased cardiac output, stroke volume, and left ventricular percent posterior wall thickening were observed in smoking, nicotine, and bupropion offspring. The left ventricular mass was reduced in smoking and nicotine but not in bupropion offspring. Blood pressure was higher with decreased endothelium-dependent relaxation and exaggerated vascular contraction to angiotensin II in smoking and nicotine offspring, with more pronounced dysfunctions in smoking than nicotine offspring. Maternal bupropion did not impact offspring's blood pressure, endothelium-dependent relaxation, and vascular contraction. In conclusion, maternal nicotine intervention adversely affects offspring's cardiovascular outcomes, albeit less severely than continued smoking. However, bupropion causes cardiac derangement in offspring but does not adversely affect blood pressure and vascular function.

Tobacco use among people living with HIV: analysis of data from Demographic and Health Surveys from 28 low-income and middle-income countries

BACKGROUND

Tobacco use among people living with HIV results in excess morbidity and mortality. However, very little is known about the extent of tobacco use among people living with HIV in low-income and middle-income countries (LMICs). We assessed the prevalence of tobacco use among people living with HIV in LMICs.

METHODS

We used Demographic and Health Survey data collected between 2003 and 2014 from 28 LMICs where both tobacco use and HIV test data were made publicly available. We estimated the country-specific, regional, and overall prevalence of current tobacco use (smoked, smokeless, and any tobacco use) among 6729 HIV-positive men from 27 LMICs (aged 15-59 years) and 11 495 HIV-positive women from 28 LMICs (aged 15-49 years), and compared them with those in 193 763 HIV-negative men and 222 808 HIV-negative women, respectively. We estimated prevalence separately for males and females as a proportion, and the analysis accounted for sampling weights, clustering, and stratification in the sampling design. We computed pooled regional and overall prevalence estimates through meta-analysis with the application of a random-effects model. We computed country, regional, and overall relative prevalence ratios for tobacco smoking, smokeless tobacco use, and any tobacco use separately for males and females to study differences in prevalence rates between HIV-positive and HIV-negative individuals.

FINDINGS

The overall prevalence among HIV-positive men was 24·4% (95% CI 21·1-27·8) for tobacco smoking, 3·4% (1·8-5·6) for smokeless tobacco use, and 27·1% (22·8-31·7) for any tobacco use. We found a higher prevalence in HIV-positive men of any tobacco use (risk ratio [RR] 1·41 [95% CI 1·26-1·57]) and tobacco smoking (1·46 [1·30-1·65]) than in HIV-negative men (both p<0·0001). The difference in smokeless tobacco use prevalence between HIV-positive and HIV-negative men was not significant (1·26 [1·00-1·58]; p=0·050). The overall prevalence among HIV-positive women was 1·3% (95% CI 0·8-1·9) for tobacco smoking, 2·1% (1·1-3·4) for smokeless tobacco use, and 3·6% (95% CI 2·3-5·2) for any tobacco use. We found a higher prevalence in HIV-positive women of any tobacco use (RR 1·36 [95% CI 1·10-1·69]; p=0·0050), tobacco smoking (1·90 [1·38-2·62]; p<0·0001), and smokeless tobacco use (1·32 [1·03-1·69]; p=0·030) than in HIV-negative women.

INTERPRETATION

The high prevalence of tobacco use in people living with HIV in LMICs mandates targeted policy, practice, and research action to promote tobacco cessation and to improve the health outcomes in this population.

FUNDING

South African Medical Research Council and the UK Medical Research Council.

Perspective on pre- and post-natal agro-food exposure to persistent organic pollutants and their effects on quality of life

BACKGROUND

Adipose tissue constitutes a continual source of internal exposure to organic pollutants (OPs). When fats mobilize during pregnancy and breastfeeding, OPs could affect foetal and neonatal development, respectively.

SCOPE AND APPROACH

The main aim of this review is to deal with pre- and post-natal external exposure to organic pollutants and their effects on health, proposing prevention measures to reduce their risk. The goal is the development of a biomonitoring framework program to estimate their impact on human health, and prevent exposure by recommending some changes in personal lifestyle habits.

KEY FINDINGS AND CONCLUSIONS

It has been shown that new studies should be developed taking into account their cumulative effect and the factors affecting their body burden. In conclusion, several programs should continuously be developed by different health agencies to have a better understanding of the effect of these substances and to develop a unified public policy.

Maternal smoking during pregnancy and risk of stillbirth: results from a nationwide Danish register-based cohort study

INTRODUCTION

Maternal smoking during pregnancy has been associated with an increased risk of stillbirth. Only a few studies have been conducted to determine whether smoking affects the risk of antepartum and intrapartum stillbirth differently or whether smoking cessation in early pregnancy reduces the risk. Previous results are inconclusive. We addressed these questions in a large Danish population-based cohort study.

MATERIAL AND METHODS

From the Danish Medical Birth Register, we identified 841 228 singleton births in Denmark between 1997 and 2010 and gathered detailed information on maternal smoking during pregnancy and the vital status of the infant. Associations (odds ratios with 95% confidence intervals) between maternal smoking and risk of stillbirth overall and separately for antepartum and intrapartum stillbirth were analyzed using logistic regression models (generalized estimating equations), adjusting for potential confounders.

RESULTS

Any smoking during pregnancy increased the risk of stillbirth, both overall (odds ratio 1.42, 95% confidence interval 1.30-1.55) and for antepartum (odds ratio 1.38, 95% confidence interval 1.25-1.53) and intrapartum (odds ratio 1.52, 95% confidence interval 1.18-1.96) stillbirths. Women who quit smoking at the beginning of the second trimester at the latest had no increased risk of stillbirth overall (odds ratio 1.03, 95% confidence interval 0.80-1.32).

CONCLUSIONS

Maternal smoking during pregnancy increases the risk of stillbirth, both overall and for antepartum and intrapartum stillbirth separately. Women who quit smoking in the beginning of their pregnancy reduce their risk compared with that of non-smokers.

Maternal smoke exposure decreases mesenchymal proliferation and modulates Rho-GTPase-dependent actin cytoskeletal signaling in fetal lungs

The present study tested the hypothesis that maternal smoke exposure results in fetal lung growth retardation due to dysregulation in various signaling pathways, including the Wnt (wingless-related integration site)/β-catenin pathway. Pregnant female C57BL/6J mice were exposed to cigarette smoke (100-150 mg/m³) or room air, and offspring were humanely killed on 12.5, 14.5, 16.5, and 18.5 d post coitum (dpc). We assessed lung stereology with Cavalieri estimation; apoptosis with proliferating cell nuclear antigen, TUNEL, and caspase assays; and gene expression with quantitative PCR (qPCR) and RNA sequencing on lung epithelium and mesenchyme retrieved by laser capture microdissection. Results demonstrated a significant decrease in body weight and lung volume of smoke-exposed embryos. At 16.5 dpc, the reduction in lung volume was due to loss of lung mesenchymal tissue correlating with a decrease in cell proliferation (n = 10; air: 61.65% vs. smoke: 44.21%, P < 0.05). RNA sequence analysis demonstrated an alteration in the Wnt pathway, and qPCR confirmed an increased expression of secreted frizzled-related protein 1 (sFRP-1) [n = 12; relative quantification (RQ) 1 vs. 2.33, P < 0.05] and down-regulation of Cyclin D1 (n = 7; RQ 1 vs. 0.61, P < 0.05) in mesenchymal tissue. Furthermore, genome expression studies revealed a smoke-induced up-regulation of Rho-GTPase-dependent actin cytoskeletal signaling that can lead to loss of tissue integrity.-Unachukwu, U., Trischler, J., Goldklang, M., Xiao, R., D'Armiento, J. Maternal smoke exposure decreases mesenchymal proliferation and modulates Rho-GTPase-dependent actin cytoskeletal signaling in fetal lungs.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Does environmental cigarette smoke affect breastfeeding behavior?

BACKGROUND:

Exposure of lactating women to environmental cigarette smoke may increase cotinine in breast milk, which in turn may reduce the volume of milk and the duration of breastfeeding.

OBJECTIVES:

To assess the relationship between exposure to environmental cigarette smoke and breastfeeding behavior.

MATERIALS AND METHODS:

This prospective cohort study was conducted on 290 mothers in Babol - Iran, who had been breastfeeding for 3–5 days after delivery. The lactating mothers were divided into two groups: those exposed to environmental cigarette smoke, and those free from smoke exposure. The study questionnaire included demographic data, information on environmental cigarette smoke, and breastfeeding behavior. Data was collected through telephone interviews at 2, 4, and 6 months of follow-up. Statistical analysis included descriptive statistics, and test of significance using Chi-square test, t-test, log-rank test, and Cox proportional hazards model.

RESULTS:

The continuation of breastfeeding for the group of exposed mothers and the unexposed group was (mean ± standard deviation) 5.57 ± 0.098 and 5.58 ± 0.109, respectively in 6 months of follow-up. There was no significant difference between the two groups (P = 0.93). The percentage of exclusive breastfeeding at 6 months in the group exposed to cigarette smoke was 65% compared to 76% of the nonexposed group. However, the difference was not statistically significant (P = 0.149).

CONCLUSIONS:

In this study, no significant association was observed between the group exposed to environmental cigarette smoke and the nonexposed group in breastfeeding behavior, although the percentage of exclusive breastfeeding at 6 months was less in the group exposed to environmental cigarette smoke. Further exploratory studies are needed.

Use of human milk in the assessment of toxic metal exposure and essential element status in breastfeeding women and their infants in coastal Croatia

Pregnant and lactating women and infants are vulnerable population groups for adverse effects of toxic metals due to their high nutritional needs and the resultant increased gastrointestinal absorption of both, essential and toxic elements. Although breastfeeding is recommended for infants worldwide, as human milk is the best source of nutrients and other required bioactive factors, it is also a pathway of maternal excretion of toxic substances including toxic metals and thus a source of infant exposure. The aim of this research was to assess health risks in breastfeeding women in the coastal area of the Republic of Croatia and their infants (N=107) due to maternal exposure to Cd and Pb via cigarette smoking, and Hg via seafood and dental amalgam fillings, and their interaction with essential elements. Biological markers of exposure were the concentrations of main toxic metals Pb, Cd and Hg in maternal blood and three types of breast milk throughout lactation stages. Biological markers of effects were the levels of essential elements Ca, Fe, Cu, Zn and Se in maternal serum and breast milk. With regard to cigarette smoking as a source of exposure to Cd and Pb, there were effects of smoking on Cd concentration in blood and correlations between the smoking index and Cd concentrations in maternal blood (ρ=0.593; P<0.001) and mature milk (ρ=0.271; P=0.011) and Pb concentration in transitional milk (ρ=0.280; P=0.042). Regarding fish, we found correlations between weekly consumption frequency and total Hg concentrations in maternal blood (ρ=0.292; P=0.003) and mature milk (ρ=0.303; P=0.003). The number of dental amalgam fillings correlated with total Hg concentrations in colostrum (ρ=0.489; P=0.005) and transitional milk (ρ=0.309; P=0.018). As for the essential element status, only Se levels in maternal serum decreased by 10% in persons who continued smoking during pregnancy compared to non-smokers. In conclusion, the levels of main toxic metals Cd, Pb and Hg and essential elements Ca, Fe, Cu, Zn and Se in maternal blood and three types of breast milk samples in the studied area of coastal Croatia showed no risk of disrupted essential element levels with regard of toxic metal exposure in both breastfeeding women and their infants.

Doppler screening and predictors of adverse outcomes in high risk pregnancies affected by tobacco

OBJECTIVE

The purpose of this study was to investigate associations between Doppler measurements and adverse outcomes in an obstetric population with high tobacco use.

METHODS

This retrospective study included patients with Doppler data (umbilical systolic/diastolic velocity ratios (S/D), uterine S/D, uterine left/right ratio index (RI)). Receiver operator characteristic curve analysis determined cut-off elevated Doppler indices. Stepwise logistic regression was used to predict adverse outcomes.

RESULTS

338 of 745 patients (45.4%) had adverse outcomes. Doppler artery indices identified significant associations with IUGR, preeclampsia, low birth weight, pre-term birth and composite adverse outcome variable. An elevated Umbilical S/D was 2.1 (95% Confidence Interval (CI): 1.5-2.9; p<0.001) times was more likely to have an adverse outcome. For left uterine artery S/D and nulliparity, the odds ratios were 1.8 (95% CI: 1.3-2.5) and 1.4 (95% CI: 1.0-1.9), respectively.

CONCLUSION

Umbilical and uterine left S/D indices and nulliparity are significant independent predictors of adverse outcomes.

A tailored video intervention to reduce smoking and environmental tobacco exposure during and after pregnancy: Rationale, design and methods of Baby's Breath

Low-cost interventions to decrease environmental tobacco smoke (ETS) exposure of pregnant women and their newborns are needed to lower health risks of exposed fetuses and infants. Baby's Breath is a tailored video intervention developed and tested in a randomized controlled trial. The study aimed to test the efficacy of tailored video versus usual care approaches to reduce the ETS exposure of fetuses of low-income women during and after pregnancy; and to assess this intervention separately among non-smoking and smoking women. Participating women, recruited early in pregnancy, who spoke English, were at least 18years old, smoke exposed (current smokers, quit smoking on their own, or were exposed to smoke of others), pregnant with only one baby, and had access to a telephone and video player, were randomized to experimental or control conditions. Intervention participants received newsletters containing content aimed at smoking cessation and avoidance (5 during and 3 after pregnancy), in addition to videos (3 during and 2 after pregnancy) individually tailored on behavioral theory-based survey questions. Comparison participants received newsletters and videos on healthy pregnancy topics. Outcomes included salivary cotinine of both mother and baby (32weeks gestation and 6months postpartum) as well as self-reported ETS exposure and avoidance behaviors. This study may demonstrate the efficacy of a low-cost intervention to decrease ETS exposure, and will fill an important gap in describing the utility of this innovative intervention technology, as well as demonstration of potential benefits to this type of intervention.

The 100 most cited articles in ectopic pregnancy: a bibliometric analysis

Ectopic pregnancy (EP) remains a major gynecological emergency and is a cause of morbidity or even mortality in women. As a consequence, top citation analysis of EP research in database of the Science Citation Index Expanded is needed to assess the publication trends of leading countries/territories and institutes as well as the research hotspots of EP. A total of 4881 articles relevant to EP were retrieved in the database of the Science Citation Index Expanded from 1965 to present, in which the 100 top-cited articles were selected for further analysis. The number of citations ranged from 81 to 482 (131.57 ± 69.76), with a time span of 40 years between 1969 and 2009. These citation classics came from 14 countries, and 65 of the articles came from the United States. Yale University in Connecticut led the list of classics with six papers. The 100 top-cited articles were published in 32 journals, in which the journal of Fertility and Sterility published the most (23 papers). Stovall TG and Ling FW published the highest number of studies (6 papers each). Articles that originated in the United States and that were published in high-impact journals were most likely to be cited in the field of EP research. Bibliometric analysis was used to provide a historical perspective on the progress in EP research over the past 50 years. Citation analysis is a feasible tool to comprehensively recognize the advances of EP research in the past and future research.

The influence of maternal smoking on transferrin sialylation and fetal biometric parameters

OBJECTIVES

Transferrin is a glycosylated protein responsible for transporting iron, an essential metal responsible for proper fetal development. Tobacco is a heavily used xenobiotic having a negative impact on the human body and pregnancy outcomes. Aims of this study was to examine the influence of tobacco smoking on transferrin sialic acid residues and their connection with fetal biometric parameters in women with iron-deficiency.

METHODS

The study involved 173 samples from pregnant women, smokers and non-smokers, iron deficient and not. Transferrin sialylation was determined by capillary electrophoresis. The cadmium (Cd) level was measured by atomic absorption and the sialic acid concentration by the resorcinol method.

RESULTS

Women with iron deficiencies who smoked gave birth earlier than non-smoking, non-iron-deficient women. The Cd level, but not the cotinine level, was positively correlated with transferrin sialylation in the blood of iron-deficient women who smoked; 3-, 4-, 5- and 6-sialoTf correlated negatively with fetal biometric parameters in the same group.

CONCLUSION

It has been shown the relationship between Cd from tobacco smoking and fetal biometric parameters observed only in the iron deficient group suggests an additive effect of these two factors, and indicate that mothers with anemia may be more susceptible to Cd toxicity and disturbed fetal development.

Which measures of cigarette dependence are predictors of smoking cessation during pregnancy? Analysis of data from a randomized controlled trial

AIMS

To examine the ability of different common measures of cigarette dependence to predict smoking cessation during pregnancy.

DESIGN

Secondary analysis of data from a parallel-group randomized controlled trial of physical activity for smoking cessation. The outcomes were biochemically validated smoking abstinence at 4 weeks post-quit and end-of-pregnancy.

SETTING

Women identified as smokers in antenatal clinics in 13 hospital trusts predominantly in southern England, who were recruited to a smoking cessation trial.

PARTICIPANTS

Of 789 pregnant smokers recruited, 784 were included in the analysis.

MEASUREMENTS

Using random-effect logistic regression models, we analysed the effects of baseline measures of cigarette dependence, including numbers of cigarettes smoked daily, Fagerström Test of Cigarette Dependence (FTCD) score, the two FTCD subscales of Heaviness of Smoking Index (HSI) and non-Heaviness of Smoking Index (non-HSI), expired carbon monoxide (CO) level and urges to smoke (strength and frequency) on smoking cessation. Associations were adjusted for significant socio-demographic/health behaviour predictors and trial variables, and area under the receiver operating characteristic (ROC) curve was used to determine the predictive ability of the model for each measure of dependence.

FINDINGS

All the dependence variables predicted abstinence at 4 weeks and end-of-pregnancy. At 4 weeks, the adjusted odds ratio (OR) (95% confidence interval) for a unit standard deviation increase in FTCD was 0.59 (0.47-0.74), expired CO = 0.54 (0.41-0.71), number of cigarettes smoked per day 0.65 (0.51-0.84) and frequency of urges to smoke 0.79 (0.63-0.98); at end-of-pregnancy they were: 0.60 (0.45-0.81), 0.55 (0.37-0.80), 0.70 (0.49-0.98) and 0.69 (0.51-0.94), respectively. HSI and non-HSI exhibited similar results to the full FTCD.

CONCLUSIONS

Four common measures of dependence, including number of cigarettes smoked per day, scores for Fagerström Test of Cigarette Dependence and frequency of urges and level of expired CO, all predicted smoking abstinence in the short term during pregnancy and at end-of-pregnancy with very similar predictive validity.

Hepcidin and Iron Metabolism in Pregnancy: Correlation with Smoking and Birth Weight and Length

To estimate the effect of tobacco smoking on iron homeostasis and the possible association between hepcidin and the neonatal birth weight and length, concentrations of serum hepcidin and selected iron markers were measured in 81 healthy pregnant women (41 smokers and 40 nonsmokers). The smoking mothers had significantly lower concentrations of serum hepcidin (p < 0.001), iron (p < 0.001), and hemoglobin (p < 0.05), but higher erythropoietin (p < 0.05) levels compared with non-smoking pregnant women. Logistic regression analysis showed the highest negative impact of the number of cigarettes smoked per day (β = -0.46; p < 0.01) and positive impact of ferritin level (β = 0.47; p < 0.001) on serum hepcidin concentration. The birth weight and the body length of smoking mothers' infants were significantly lower than in tobacco abstinent group (p < 0.001). In multiple regression analysis, birth body weight (β = 0.56; p < 0.001) and length (β = 0.50; p < 0.001) were significantly related to maternal hepcidin values. Tobacco smoking affected hepcidin level in serum of pregnant women in a dose-dependent manner. Low concentrations of iron and hemoglobin in maternal serum coexisting with high level of erythropoietin suggest that smoking could lead to subclinical iron deficiency and chronic hypoxia not only in mothers but also in fetus. Low serum hepcidin concentration in smoking pregnant women might be associated with lower fetal birth weight and length.

Influence of tobacco smoking on transferrin sialylation during pregnancy in smoking and non-smoking women with iron deficiency

OBJECTIVES

Tobacco smoking influence on proteins is leading to despaired foetal nourishment. Transferrin, is an essential metal-binding protein responsible for iron transport and proper foetal development. This study examines influence of tobacco smoking on transferrin sialic acid residues and its connection to foetal nourishment at women with iron deficiency.

METHODS

The study involved 190 samples from pregnant women in 1st, 2nd and 3rd trimester. Women were divided in terms of tobacco smoking and iron deficiency.

RESULTS

During pregnancy, the levels of 2-, 5- and 6-sialo transferrin were increasing while 3- and 4-sialo transferrin were decreasing in all groups. Transferrin isoforms showed positive correlation with lowered iron stores in the blood of non-smoking women.

CONCLUSION

Tobacco smoking has an influence on number of sialic acids residues in the transferrin and seems to change conversion of Tf isoforms, and this may disturb iron transport and in consequence influence on foetal development and nourishment.

AHR2 morpholino knockdown reduces the toxicity of total particulate matter to zebrafish embryos

The zebrafish embryo has been proposed as a 'bridge model' to study the effects of cigarette smoke on early development. Previous studies showed that exposure to total particulate matter (TPM) led to adverse effects in developing zebrafish, and suggested that the antioxidant and aryl hydrocarbon receptor (AHR) pathways play important roles. This study investigated the roles of these two pathways in mediating TPM toxicity. The study consisted of four experiments. In experiment I, zebrafish embryos were exposed from 6h post fertilization (hpf) until 96hpf to TPM0.5 and TPM1.0 (corresponding to 0.5 and 1.0μg/mL equi-nicotine units) in the presence or absence of an antioxidant (N-acetyl cysteine/NAC) or a pro-oxidant (buthionine sulfoximine/BSO). In experiment II, TPM exposures were performed in embryos that were microinjected with nuclear factor erythroid 2-related factor 2 (Nrf2), AHR2, cytochrome P450 1A (CYP1A), or CYP1B1 morpholinos, and deformities were assessed. In experiment III, embryos were exposed to TPM, and embryos/larvae were collected at 24, 48, 72, and 96hpf to assess several genes associated with the antioxidant and AHR pathways. Lastly, experiment IV assessed the activity and protein levels of CYP1A and CYP1B1 after exposure to TPM. We demonstrate that the incidence of TPM-induced deformities was generally not affected by NAC/BSO treatments or Nrf2 knockdown. In contrast, AHR2 knockdown reduced, while CYP1A or CYP1B1 knockdowns elevated the incidence of some deformities. Moreover, as shown by gene expression the AHR pathway, but not the antioxidant pathway, was induced in response to TPM exposure, providing further evidence for its importance in mediating TPM toxicity.

The Influence of Tobacco Smoke on Protein and Metal Levels in the Serum of Women during Pregnancy

Background

Tobacco smoking by pregnant women has a negative effect on fetal development and increases pregnancy risk by changing the oxidative balance and microelements level. Smoking affects the concentration, structure and function of proteins, potentially leading to various negative effects on pregnancy outcomes.

Methodology/Principal Findings

The influence of tobacco smoke on key protein fractions in smoking and non-smoking healthy pregnant women was determined by capillary electrophoresis (CE). Concentrations of the proteins α1-antitrypsin, α1-acid glycoprotein, α2-macroglobulin and transferrin were determined by ELISA tests. Total protein concentration was measured by the Biuret method. Smoking status was established by cotinine levels. Cadmium (Cd) and Zinc (Zn) concentrations were determined by flame atomic absorption spectrometry and the Zn/Cd ratio was calculated based on these numbers. Smoking women had a 3.7 times higher level of Cd than non-smoking women. Zn levels decreased during pregnancy for all women. The Zn/Cd ratio was three times lower in smoking women. The differences between the changes in the protein profile for smoking and non-smoking women were noted. Regarding proteins, α1-antitrypsin and α2-macroglobulin levels were lower in the non-smoking group than in the smoking group and correlated with Cd levels (r = -0.968, p = 0.032 for non-smokers; r = −0.835, p = 0.019 for smokers). Zn/Cd ratios correlated negatively with α1-, α2- and β-globulins.

Conclusions/Significance

Exposure to tobacco smoke increases the concentration of Cd in the blood of pregnant women and may lead to an elevated risk of pregnancy disorders. During pregnancy alter concentrations of some proteins. The correlation of Cd with proteins suggests that it is one of the causes of protein aberrations.

The Effects of Chewing Betel Nut with Tobacco and Pre-pregnancy Obesity on Adverse Birth Outcomes Among Palauan Women

The small Pacific Island nation of Palau has alarmingly high rates of betel nut with tobacco use and obesity among the entire population including pregnant women. This study aimed to determine the effects of betel nut with tobacco use and pre-pregnancy obesity on adverse birth outcomes. This study used retrospective cohort data on 1171 Palauan women who gave birth in Belau National Hospital in Meyuns, Republic of Palau between 2007 and 2013. The exposures of interest were pre-pregnancy obesity and reported betel nut with tobacco use during pregnancy. The primary outcomes measured were preterm birth and low birth weight among full-term infants. A significantly increased risk for low birth weight among full-term infants was demonstrated among those women who chewed betel nut with tobacco during pregnancy when other known risk factors were controlled for. Additionally, pre-pregnancy obesity was associated with a significantly increased risk for preterm birth when other known risk factors were controlled for. Both betel nut with tobacco use and pre-pregnancy obesity were associated with higher risks for adverse birth outcomes. These findings should be used to drive public health efforts in Palau, as well as in other Pacific Island nations where these studies are currently lacking.

The London Exercise And Pregnant smokers (LEAP) trial: a randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation

BACKGROUND

Smoking during pregnancy is the main preventable cause of poor birth outcomes. Improved methods are needed to help women to stop smoking during pregnancy. Pregnancy provides a compelling rationale for physical activity (PA) interventions as cessation medication is contraindicated or ineffective, and an effective PA intervention could be highly cost-effective.

OBJECTIVE

To examine the effectiveness and cost-effectiveness of a PA intervention plus standard behavioural support for smoking cessation relative to behavioural support alone for achieving smoking cessation at the end of pregnancy.

DESIGN

Multicentre, two-group, pragmatic randomised controlled trial and economic evaluation with follow-up at the end of pregnancy and 6 months postnatally. Randomisation was stratified by centre and a computer-generated sequence was used to allocate participants using a 1 : 1 ratio.

SETTING

13 hospitals offering antenatal care in the UK.

PARTICIPANTS

Women between 10 and 24 weeks' gestation smoking five or more cigarettes a day before pregnancy and one or more during pregnancy.

INTERVENTIONS

Participants were randomised to behavioural support for smoking cessation (control) or behavioural support plus a PA intervention consisting of supervised treadmill exercise plus PA consultations. Neither participants nor researchers were blinded to treatment allocation.

MAIN OUTCOME MEASURES

The primary outcome was self-reported, continuous smoking abstinence between a quit date and end of pregnancy, validated by expired carbon monoxide and/or salivary cotinine. Secondary outcomes were maternal weight, depression, birth outcomes, withdrawal symptoms and urges to smoke. The economic evaluation investigated the costs of the PA intervention compared with the control intervention.

RESULTS

In total, 789 women were randomised (n = 394 PA, n = 395 control). Four were excluded post randomisation (two had been enrolled twice in sequential pregnancies and two were ineligible and randomised erroneously). The intention-to-treat analysis comprised 785 participants (n = 392 PA, n = 393 control). There was no significant difference in the rate of abstinence at the end of pregnancy between the PA group (7.7%) and the control group (6.4%) [odds ratio for PA group abstinence 1.21, 95% confidence interval (CI) 0.70 to 2.10]. For the PA group compared with the control group, there was a 33% (95% CI 14% to 56%), 28% (95% CI 7% to 52%) and 36% (95% CI 12% to 65%) significantly greater increase in self-reported minutes of moderate- and vigorous-intensity PA from baseline to 1 week, 4 weeks and 6 weeks respectively. Accelerometer data showed that there was no significant difference in PA levels between the groups. There were no significant differences between the groups for change in maternal weight, depression, withdrawal symptoms or urges to smoke. Adverse events and birth outcomes were similar between the groups except for there being significantly more caesarean births in the control group than in the PA group (28.7% vs. 21.3%; p < 0.023). The PA intervention was less costly than the control intervention by £35 per participant. This was mainly attributable to increased health-care usage in the control group. However, there was considerable statistical uncertainty around this estimate.

CONCLUSIONS

During pregnancy, offering an intervention combining supervised exercise and PA counselling does not add to the effectiveness of behavioural support for smoking cessation. Only 10% of participants had PA levels accessed by accelerometer and it is, therefore, unclear whether or not the lack of an effect on the primary outcome is the result of insufficient increases in PA. Research is needed to identify the smoking populations most suitable for PA interventions and methods for increasing PA adherence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48600346.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 84. See the NIHR Journals Library website for further project information.

Fetal Exposure to Carcinogens With Tobacco Use in Pregnancy: Phase 1 MAW Study Findings

INTRODUCTION

The high prevalence of smoking and smokeless tobacco (ST) use during pregnancy in Alaska Native (AN) women is concerning due to the detrimental effects of these products to the mother and the developing fetus. We sought to correlate maternal cotinine levels with fetal exposure to a tobacco-specific carcinogen to incorporate in a biomarker feedback intervention to motivate tobacco cessation during pregnancy.

METHODS

Demographic and tobacco use data were collected from a convenience sample of pregnant AN smokers, ST users, and non-users. Maternal and neonatal urine were collected at delivery. Maternal urine cotinine and neonatal urine total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL, a tobacco-specific carcinogen) levels in smokers and ST users were analyzed and their correlations determined by Spearman correlation coefficients.

RESULTS

During 2012-2014, we enrolled 64 non-users, 54 smokers, and 30 ST (20 homemade iqmik; 10 commercial ST) users (n = 148). Analyses of paired maternal-infant urine samples obtained for 36 smokers demonstrated a moderate to strong correlation (r = 0.73, P < .001) between maternal cotinine and infant NNAL levels. The correlation was not significant for 25 iqmik users (r = 0.36, P = .17) or 9 commercial ST users (r = 0.60, P = .09). No analysis was conducted for 55 non-users with cotinine and NNAL levels < limits of quantification.

CONCLUSIONS

There is a moderate to strong correlation between maternal smoking and fetal exposure to the tobacco-specific carcinogen NNAL.

IMPLICATIONS

The correlation between maternal smoking and fetal carcinogen exposure may provide an education tool to help motivate smoking cessation among pregnant AN women. Further investigation is warranted to determine correlations between maternal commercial ST and iqmik use and neonatal NNAL.

Testing Causal Effects of Maternal Smoking During Pregnancy on Offspring's Externalizing and Internalizing Behavior

Maternal smoking during pregnancy (SDP) is associated with increased risk of externalizing and internalizing behaviors in offspring. Two explanations (not mutually exclusive) for this association are direct causal effects of maternal SDP and the effects of genetic and environmental factors common to parents and offspring which increase smoking as well as problem behaviors. Here, we examined the associations between parental SDP and mother rated offspring externalizing and internalizing behaviors (rated by the Child Behavior Checklist/2-3) at age three in a population-based sample of Dutch twins (N = 15,228 pairs). First, as a greater effect of maternal than of paternal SDP is consistent with a causal effect of maternal SDP, we compared the effects of maternal and paternal SDP. Second, as a beneficial effect of quitting smoking before pregnancy is consistent with the causal effect, we compared the effects of SDP in mothers who quit smoking before pregnancy, and mothers who continued to smoke during pregnancy. All mothers were established smokers before their pregnancy. The results indicated a greater effect of maternal SDP, compared to paternal SDP, for externalizing, aggression, overactive and withdrawn behavior. Quitting smoking was associated with less externalizing, overactive behavior, aggression, and oppositional behavior, but had no effect on internalizing, anxious depression, or withdrawn behavior. We conclude that these results are consistent with a causal, but small, effect of smoking on externalizing problems at age 3. The results do not support a causal effect of maternal SDP on internalizing behaviors.

Newborns health in the Danube Region: Environment, biomonitoring, interventions and economic benefits in a large prospective birth cohort study

BACKGROUND

The EU strategy for the Danube Region addresses numerous challenges including environment, health and socioeconomic disparities. Many old environmental burdens and heavily polluted areas in Europe are located in the Danube Region, consisting of 14 countries, with over 100 million people. Estimating the burden of environmental exposures on early-life health is a growing research area in Europe which has major public health implications, but the data from the Danube Region are largely missing.

AIM

This review presents an inventory of current environmental challenges, related early-life health risks, and knowledge gaps in the Danube Region, based on publicly available databases, registers, and literature, as a rationale and incentive for a new integrated project. The review also proposes the concept for the project aiming to characterize in utero exposures to multiple environmental factors and estimate their effect on early-life health, evaluate economic impact, as well as identify interventions with a potential to harness social norms to reduce emissions, exposures and health risks in the Danube Region.

METHODS

Experts in environmental epidemiology, human biomonitoring and social science in collaboration with clinicians propose to establish a new large multi-center birth cohort of mother-child pairs from Danube countries, measure biomarkers of exposure and health in biological samples at birth, collect centrally measured climate, air and water pollution data, conduct pre- and postnatal surveys on lifestyle, indoor exposures, noise, occupation, socio-economic status, risk-averting behavior, and preferences; and undertake clinical examinations of children at and after birth. Birth cohort will include at least 2000 newborns per site, and a subset of at least 200 mother-child pairs per site for biomonitoring. Novel biomarkers of exposure, susceptibility, and effect will be applied, to gain better mechanistic insight. Effects of multiple environmental exposures on fetal and child growth, respiratory, allergic, immunologic, and neurodevelopmental health outcomes will be estimated. Parent's willingness to pay for reducing health risks in children will be elicited by survey, while values of cost-of-illness will be gathered from literature and national statistics. Effects of risk reducing interventions will be examined.

CONCLUSIONS

The proposed project would provide novel estimates of the burden of early childhood diseases attributable to environmental exposures and assess health impacts of different intervention scenarios in the Danube Region, in an integrated approach combining human biomonitoring, epidemiological and social science research.

Parental smoking during pregnancy and the risk of gestational diabetes in the daughter

BACKGROUND

Fetal exposure to parental smoking may have long-term impact on the development of disease in adulthood. We examined the association of parental smoking during pregnancy with risk of gestational diabetes mellitus (GDM) in the daughter.

METHODS

We included 15,665 singleton pregnancies from 10,152 women in the Nurses' Health Study II cohort whose mothers participated in the Nurses' Mothers' Cohort Study. Data on maternal and paternal smoking during pregnancy and associated covariates were recalled by the mothers. GDM diagnosis was self-reported by the daughters and was validated by medical record review in a previous study. We used log-binomial models with generalized estimating equations to estimate relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

We observed a positive association between maternal heavy smoking during pregnancy and risk of GDM in the daughter. The multivariable-adjusted RRs (95% CIs) of GDM among women whose mothers did not smoke during pregnancy, continued smoking 1-14, 15-24, and ≥ 25 cigarettes/day were 1.00 (reference), 1.05 (0.81-1.35), 1.27 (0.95-1.70) and 1.98 (1.18-3.30), respectively (P for trend = 0.01). Further adjustment for the women's perinatal variables, adult-life characteristics and body mass index during various periods of life modestly attenuated the association. No association was observed between paternal smoking during the pregnancy period and risk of GDM in the daughter.

CONCLUSIONS

Maternal heavy smoking (≥ 25 cigarettes/day) during pregnancy was associated with higher risk of gestational diabetes in the daughter. Further studies are warranted to confirm our findings and to elucidate the underlying mechanisms.

The Human Cost of Tobacco Chewing Among Pregnant Women in India: A Systematic Review and Meta-analysis

BACKGROUND

In India, smokeless tobacco (SLT) use among pregnant women is high and its adverse effects on pregnancy outcomes have not been properly documented in.

OBJECTIVES

To collate available evidence on the association between SLT use and three adverse pregnancy outcomes, i.e. low birth weight, preterm birth and stillbirth among women in India.

SEARCH STRATEGY

A systematic search was conducted in MEDLINE, IndMed, Web of Science, Google Scholar and major journals. Two authors independently reviewed the studies and extracted data.

SELECTION CRITERIA

Inclusion criteria were English articles published till December 2014, case control, case cohort or cohort, and exposure and outcome variables meeting predefined criteria. Exclusion criteria were case series, case reports, cross-sectional designs, risk estimate not restricted/adjusted for smoking with or without adjustment for other factors and duplicate data. Qualitative synthesis was followed by meta-analysis. Attributable burden was estimated using the population attributable fraction method.

MAIN RESULTS

Pooled odds ratio was significant for all three outcomes: low birth weight (1.88, 95 % CI 1.38, 2.54), preterm birth (1.39: 1.01, 1.91) and stillbirth (2.85: 1.62, 5.01). We found that 0.87 million low birth weight babies, 0.19 million preterm births and 0.12 million stillbirths occurring annually in India could be attributed to maternal SLT use.

CONCLUSION

There was a suggestive evidence of SLT use associated with adverse pregnancy outcomes among women in India. Further studies in this field are required to generate more conclusive evidence.

To quit or not: Vulnerability of women to smoking tobacco

Tobacco smoking is currently on the rise among women, and can pose a greater health risk. In order to understand the nature of the increase in smoking prevalence among women, we focused on the vulnerability of women to smoking behaviors--smoking cessation or tobacco addiction--and performed a systematic review of the socioeconomic and intrinsic factors as well as tobacco ingredients that affect women's susceptibility to smoking tobacco. We observed that nicotine and other tobacco components including cocoa-relatives, licorice products, and menthol aggravate tobacco addiction in women rather than in men. Various genetic and epigenetic alterations in dopamine pathway and the pharmaco-kinetics and -dynamic factors of nicotine also showed potential evidences for high susceptibility to tobacco addiction in women. Therefore, we suggest systemic approaches to prevent tobacco smoking-related health risks, considering gene-environment-gender interaction.

The Association of Maternal Lifestyle with Birth Defects in Shaanxi Province, Northwest China

BACKGROUND

The main objective was to investigate the burden of birth defects among alive infants and explore the impact of maternal lifestyle during pregnancy on the burden of birth defects in Northwest China.

METHODS

A stratified multi-stage sampling method was used to study infants born during 2010-2013 (and their mothers) in Shaanxi province of Northwest China. Socio-demographic information was collected using a structured questionnaire, and medical records from the local hospitals were used to determine the final diagnosis of birth defects. Poisson regression analysis was performed to assess the association between maternal lifestyles during pregnancy and the burden of birth defects, while adjusting for potential confounders.

RESULTS

We sampled 29098 infants, of whom 629 (i.e. 216.17 per 10000) were observed to have congenital defects. Cardiovascular system defects (77.32 per 10000) were found to be the most common. Mothers who had ever consumed alcohol during pregnancy were found to have infants with a higher prevalence of some categories of birth defects, including nervous system (Prevalence Rate Ratio, PRR:14.67, 95% CI: 1.94, 110.92), cardiovascular system (PRR:3.22, 95% CI: 1.02, 10.16) and oral clefts (PRR:9.02, 95% CI: 2.08, 39.10) in contrast to infants of mothers without any alcohol consumption. Maternal passive smoking during pregnancy lead to the increased burden of malformations of eye, ear, face and neck (PRR:1.95, 95% CI: 1.15, 3.33), cardiovascular system (PRR:1.70, 95% CI: 1.25, 2.31) and respiratory system (PRR:9.94, 95% CI: 2.37, 41.76) in their newborns. Further, tea or coffee consumption during pregnancy was positively correlated with the burden of specific birth defects, such as cardiovascular system (PRR: 2.44, 95% CI: 1.33, 4.46) and genital organs (PRR:14.72, 95% CI: 1.87, 116.11) among infants.

CONCLUSIONS

The prevalence of birth defects was high in Shaanxi province of Northwest China. The unhealthy lifestyles of mothers during pregnancy may increase the prevalence of congenital malformations. These findings in future may have some important implications for prevention of birth defects in Northwest China.

Teratogenic, bioenergetic, and behavioral effects of exposure to total particulate matter on early development of zebrafish (Danio rerio) are not mimicked by nicotine

Cigarette smoke has been associated with a number of pathologies; however, the mechanisms leading to developmental effects are yet to be fully understood. The zebrafish embryo is regarded as a 'bridge model'; however, not many studies examined its applicability to cigarette smoke toxicity. This study examined the effects of total particulate matter (TPM) from 3R4F reference cigarettes on the early development of zebrafish (Danio rerio). Zebrafish embryos were exposed to two concentrations of TPM (0.4 and 1.4 μg/mL equi-nicotine units) or nicotine at equivalent doses. The exposures began at 2h post-fertilization (hpf) and lasted until 96 hpf. Several physiological parameters were assessed during or after the exposure. We show that TPM increased mortality, delayed hatching, and increased the incidence of deformities in zebrafish. TPM exposure also increased the incidence of hemorrhage and disrupted the angiogenesis of the major vessels in the brain. Moreover, TPM exposure reduced the larval body length, decreased the heart rate, and reduced the metabolic rate. Biomarkers of xenobiotic metabolism and oxidative stress were also affected. TPM-exposed zebrafish also differed behaviorally: at 24 hpf the embryos had a higher frequency of spontaneous contractions and at 144 hpf the larvae displayed swimming hyperactivity. This study demonstrates that TPM disrupts several aspects of early development in zebrafish. The effects reported for TPM were not attributable to nicotine, since embryos treated with nicotine alone did not differ significantly from the control group. Collectively, our work illustrates the utility of zebrafish as an alternative model to evaluate the toxic effects of cigarette smoke constituents.

The unborn smoker: association between smoking during pregnancy and adverse perinatal outcomes

OBJECTIVE

To evaluate a possible dose-response relationship between active maternal smoking during pregnancy and adverse perinatal outcome.

DESIGN

Retrospective cohort study.

SETTING

Population-based in Montreal, Quebec, Canada.

POPULATION

Women who gave birth to a liveborn or stillborn infant during the period of January 2001 to December 2007.

METHODS

Active smokers of different daily cigarette consumption (n=1646) were identified through maternal self-reporting. The reference group comprised 19,292 non-smoking women who delivered during the same period.

MAIN OUTCOME MEASURES

Birth weight, preterm delivery rate, fetal and neonatal mortality and morbidity, and congenital malformations.

RESULTS

Preterm delivery rate was significantly higher in the smoking group compared with controls (22.2% vs. 12.4%, P<0.05), as was intrauterine fetal demise (1.4% vs. 0.3%, P<0.05). Newborns of active smokers were more likely to weigh less (3150±759 g vs. 3377±604 g, P<0.05), suffer from respiratory distress syndrome (2.5% vs. 1.3%, P<0.05), suffer from a cardiac malformation (1.5% vs. 0.8%, P<0.05), and die (neonatal death 1.2% vs. 0.6%, P<0.05). A dose-response relationship was demonstrated between levels of daily cigarette smoking and several adverse outcomes. Using multiple regression models, smoking was found to be an independent predictor of preterm delivery (odds ratios (OR) 1.9, 95% confidence intervals (95%CI) 1.6-2), and intrauterine fetal demise (OR 2.4, 95%CI 1.4-4.2).

CONCLUSION

Any amount of daily smoking appears to harm the fetus and newborn. As pregnancy may be a "window of opportunity" for behavioural changes, efforts to promote smoking cessation should be encouraged.

Prenatal Second-Hand Smoke Exposure Measured with Urine Cotinine May Reduce Gross Motor Development at 18 Months of Age

OBJECTIVE

To evaluate the association of second-hand smoke exposure of pregnant mothers using urine cotinine with the neurodevelopment of their children at 18 months of age in the mother-child cohort in Crete (Rhea Study).

STUDY DESIGN

Selected participants were Greek mothers with singleton pregnancies, had never smoked, and had available urine cotinine measurements in pregnancy, and their children for whom a neurodevelopmental assessment was completed. We performed face-to-face interviews twice during pregnancy and postnatally, and assessed children's neurodevelopment at 18 months of age using the Bayley Scales of Infant and Toddler Development, Third Edition. We used linear regression and generalized additive models.

RESULTS

Of 599 mothers, 175 (29%) met the inclusion criteria. Maternal urine cotinine levels were low (mean: 10.3 ng/mL, SD: 11.7 ng/mL). Reported passive smoking from different sources was strongly associated with urine cotinine levels. A negative association was observed between cotinine levels in pregnancy and child's gross motor function (beta = -3.22 per 10 ng/mL, 95% CI -5.09 to -1.34) after adjusting for factors potentially associated with neurodevelopment; results were similar in both sexes. A negative association was also observed for cognitive and receptive communication scales but the effect was small and not statistically significant.

CONCLUSIONS

Maternal exposure during pregnancy to second-hand smoke measured through urine cotinine was associated with a decrease in gross motor function among 18-month-old children, even at low levels of exposure.

Induced abortions and birth outcomes of women with a history of severe psychosocial problems in adolescence

OBJECTIVE

To increase knowledge on the reproductive health of women who have been placed in a residential school, a child welfare facility for adolescents with severe psychosocial problems.

METHODS

All women (n=291) who lived in the Finnish residential schools on the last day of the years 1991, 1996, 2001 and 2006 were included in this study and compared with matched general population controls. Register-based information on induced abortions and births was collected until the end of the year 2011.

RESULTS

Compared to controls, women with a residential school history had more induced abortions. A higher proportion of their births took place when they were teenagers or even minors. They were more often single, smoked significantly more during pregnancy and had a higher risk of having a preterm birth or a baby with a low birth weight.

CONCLUSIONS

The findings have implications for the planning of preventive and supportive interventions that aim to increase the well-being of women with a residential school history and their offspring.

Predictors of alcohol and tobacco use prior to and during pregnancy in the US: the role of maternal stressors

The purpose of the study was to understand the association between stressful life events prior to conception (PSLEs) and women's alcohol and tobacco use prior to and during pregnancy, and the continuation of such use through pregnancy. Data were from the Early Childhood Longitudinal Study-Birth Cohort (n = 9,350). Data were collected in 2001. Exposure to PSLEs was defined by indications of death of a parent, spouse, or previous live born child, divorce or marital separation, or fertility problems prior to conception. Survey data determined alcohol and tobacco usage during the 3 months prior to and in the final 3 months of pregnancy. Weighted regressions estimated the effect of PSLEs on alcohol and tobacco use at each time point and on the continuation of use, adjusting for confounders. Experiencing any PSLE increased the odds of tobacco use prior to (adjusted odds ratio [AOR] 1.52, 95 % confidence interval (CI) 1.23-1.87) and during pregnancy (AOR 1.57, 95 % CI 1.19-2.07). Women exposed to PSLEs smoked nearly five additional packs of cigarettes in the 3 months prior to pregnancy (97 cigarettes, p = 0.011) and consumed 0.31 additional alcoholic drinks during the last 3 months of pregnancy than unexposed women. PSLEs are associated with tobacco use before pregnancy and alcohol and tobacco use during pregnancy. Alcohol and tobacco screening and cessation services should be implemented prior to and during pregnancy, especially for women who have experienced PSLEs.

Exposure to metals and congenital anomalies: a biomonitoring study of pregnant Bedouin-Arab women

BACKGROUND

The Bedouin-Arab population in Israel comprises a low socio-economic society in transition. Smoking among males and consanguineous marriages are frequent. A previous study showed elevated rates of major malformations within groups from this population residing near an industrial park, where high ambient values of arsenic (As) and nickel (Ni) were detected, compared to groups living in remote localities.

OBJECTIVES

We estimated the extent of exposure to metals in pregnant Bedouin-Arab women in relation to congenital malformations.

METHODS

We collected maternal urine samples from 140 Bedouin women who gave birth in a local hospital. Patient medical history, type of marriage (consanguineous or non-consanguineous), and parental exposure history were collected by interview and medical records.

RESULTS

Aluminum (Al) was detected in 37 women (26.4%), cadmium (Cd) in 2 (1.4%), As in 10 (7.1%), and Ni in 1 woman (0.7%). The detected rate of Cd exposure was low, though more than 92% of the fathers reported smoking. Concentrations of Al were higher for women residing within 10 km of the local industrial park (Prevalence Ratio (PR)=1.12, p-value=0.012) or who reported using a wood burning stove (PR=1.37, p-value=0.011) and cooking over an open fire (PR=1.16, p-value=0.076). Exposure to Al was adversely associated with minor anomalies (OR=3.8, p-value=0.046) after adjusting for history of abortions (OR=6.1, p-value=0.007). Fetuses prenatally exposed to As were born prematurely (p-value=0.001) and at lower weights (pv=0.023).

CONCLUSIONS

The study population of pregnant women is exposed to high levels of metals mainly of household origin. Our findings may be generalized to similar populations in developing countries.

Maternal Smoking Dysregulates Protein Expression in Second Trimester Human Fetal Livers in a Sex-Specific Manner

CONTEXT

Maternal smoking during pregnancy has adverse effects on the offspring (eg, increased likelihood of metabolic syndrome and infertility), which may involve alterations in fetal liver function.

OBJECTIVE

Our aim was to analyze, for the first time, the human fetal liver proteome to identify pathways affected by maternal smoking.

DESIGN

Fetal liver proteins extracted from elective second trimester pregnancy terminations (12-16 weeks of gestation) were divided in four balanced groups based on sex and maternal smoking.

SETTING AND PARTICIPANTS

Livers were collected from 24 morphologically normal fetuses undergoing termination for nonmedical reasons and analyzed at the Universities of Aberdeen and Glasgow.

MAIN OUTCOME MEASURES

Protein extracts were resolved by 2D-PAGE and analyzed with SameSpots software. Ingenuity pathway analysis was used to investigate likely roles of dysregulated proteins identified by tandem liquid chromatography/mass spectroscopy.

RESULTS

Significant expression differences between one or more groups (fetal sex and/or maternal smoking) were found in 22 protein spots. Maternal smoking affected proteins with roles in post-translational protein processing and secretion (ERP29, PDIA3), stress responses and detoxification (HSP90AA1, HSBP1, ALDH7A1, CAT), and homeostasis (FTL1, ECHS1, GLUD1, AFP, SDHA). Although proteins involved in necrosis and cancer development were affected in both sexes, pathways affecting cellular homeostasis, inflammation, proliferation, and apoptosis were affected in males and pathways affecting glucose metabolism were affected in females.

CONCLUSIONS

The fetal liver exhibits marked sex differences at the protein level, and these are disturbed by maternal smoking. The foundations for smoke-induced post-natal diseases are likely to be due to sex-specific effects on diverse pathways.

Physical activity for smoking cessation in pregnancy: randomised controlled trial

OBJECTIVE

To determine the effectiveness of a physical activity intervention for smoking cessation during pregnancy.

DESIGN

Parallel group, randomised controlled, multicentre trial.

SETTING

13 hospitals in England, April 2009 to January 2014.

PARTICIPANTS

789 pregnant smokers, aged 16-50 years and at 10-24 weeks' gestation, who smoked at least one cigarette daily and were prepared to quit smoking one week after enrollment were randomised (1:1); 785 were included in the intention to treat analyses, with 392 assigned to the physical activity group.

INTERVENTIONS

Interventions began one week before a target quit date. Participants were randomised to six weekly sessions of behavioural support for smoking cessation (control) or to this support plus 14 sessions combining supervised treadmill exercise and physical activity consultations.

MAIN OUTCOME MEASURES

The primary outcome was continuous smoking abstinence from the target quit date until end of pregnancy, validated by exhaled carbon monoxide or salivary cotinine levels. To assess adherence, levels of moderate-vigorous intensity physical activity were self reported and in a 11.5% (n=90) random subsample of participants, physical activity was objectively measured by an accelerometer.

RESULTS

No significant difference was found in rates of smoking abstinence at end of pregnancy between the physical activity and control groups (8% v 6%; odds ratio 1.21, 95% confidence interval 0.70 to 2.10). For the physical activity group compared with the control group, there was a 40% (95% confidence interval 13% to 73%), 34% (6% to 69%), and 46% (12% to 91%) greater increase in self reported minutes carrying out physical activity per week from baseline to one week, four weeks, and six weeks post-quit day, respectively. According to the accelerometer data there was no significant difference in physical activity levels between the groups. Participants attended a median of four treatment sessions in the intervention group and three in the control group. Adverse events and birth outcomes were similar between the two groups, except for significantly more caesarean births in the control group than in the physical activity group (29% v 21%, P=0.023).

CONCLUSION

Adding a physical activity intervention to behavioural smoking cessation support for pregnant women did not increase cessation rates at end of pregnancy. During pregnancy, physical activity is not recommended for smoking cessation but remains indicated for general health benefits. Trial registration Current Controlled Trials ISRCTN48600346.

Demographic factors associated with smoking cessation during pregnancy in New South Wales, Australia, 2000-2011

Background

Smoking during pregnancy increases the risk of adverse health outcomes for both the mother and the child. Rates of smoking during pregnancy, and rates of smoking cessation during pregnancy, vary between demographic groups. This study describes demographic factors associated with smoking cessation during pregnancy in New South Wales, Australia, and describes trends in smoking cessation in demographic subgroups over the period 2000 – 2011.

Methods

Data were obtained from the New South Wales Perinatal Data Collection, a population-based surveillance system covering all births in New South Wales. Multivariate logistic regression was used to explore associations between smoking cessation during pregnancy and demographic factors.

Results

Between 2000 and 2011, rates of smoking cessation in pregnancy increased from 4.0% to 25.2%. Demographic characteristics associated with lower rates of smoking cessation during pregnancy included being a teenage mother, being an Aboriginal person, and having a higher number of previous pregnancies.

Conclusions

Between 2000 and 2011, rates of smoking cessation during pregnancy increased dramatically across all demographic groups. However, specific demographic groups remain significantly less likely to quit smoking, suggesting a need for targeted efforts to promote smoking cessation in these groups.

Risk of congenital heart defects in the offspring of smoking mothers: a population-based study

OBJECTIVES

To conduct a population-based study examining the occurrence of congenital heart defects (CHDs) in relation to maternal smoking during the first trimester of pregnancy.

STUDY DESIGN

This retrospective case-control study used Washington State birth certificates from 1989 to 2011 and linked hospital discharge International Classification of Diseases, 9th revision, codes to identify singleton nonsyndromic CHD cases and determine maternal prenatal smoking status. We calculated ORs from multivariate logistic regression models to compare maternal first-trimester smoking status (any and daily number of cigarettes) among 14,128 cases, both overall and by phenotype, and 60,938 randomly selected controls frequency matched on birth year.

RESULTS

Offspring of mothers reporting cigarette use in the first trimester of pregnancy were more likely to be born with a CHD (aOR 1.16 [1.08-1.24]) independent of demographic characteristics and other prenatal risk factors for CHDs. Maternal smoking was most strongly associated with pulmonary valve anomalies (aOR 1.48 [95% CI: 1.15-1.90]), pulmonary artery anomalies (aOR 1.71 [1.40-2.09]), and isolated atrial septal defects (aOR 1.22 [1.08-1.38]). The association between maternal smoking and CHDs was stronger with increasing number of daily cigarettes and among older (35+ years) mothers compared with younger mothers.

CONCLUSIONS

We provide evidence that maternal smoking during pregnancy is a risk factor for select CHD phenotypes. Maternal smoking may account for 1.4% of all CHDs. New findings include a strong dose-dependence of the association and augmented risk in older mothers.

Predictors of intentions to quit smoking in Aboriginal tobacco smokers of reproductive age in regional New South Wales (NSW), Australia: quantitative and qualitative findings of a cross-sectional survey

OBJECTIVES

To assess the predictors of intentions to quit smoking in a community sample of Aboriginal smokers of reproductive age, in whom smoking prevalence is slow to decline.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey involved 121 Aboriginal smokers, aged 18-45 years from January to May 2014, interviewed at community events on the Mid-North Coast NSW. Qualitative and quantitative data were collected on smoking and quitting attitudes, behaviours and home smoking rules. Perceived efficacy for quitting, and perceived threat from smoking, were uniquely assessed with a validated Risk Behaviour Diagnosis (RBD) Scale.

MAIN OUTCOME MEASURES

Logistic regression explored the impact of perceived efficacy, perceived threat and consulting previously with a doctor or health professional (HP) on self-reported intentions to quit smoking, controlling for potential confounders, that is, protection responses and fear control responses, home smoking rules, gender and age. Participants' comments regarding smoking and quitting were investigated via inductive analysis, with the assistance of Aboriginal researchers.

RESULTS

Two-thirds of smokers intended to quit within 3 months. Perceived efficacy (OR=4.8; 95% CI 1.78 to 12.93) and consulting previously with a doctor/HP about quitting (OR=3.82; 95% CI 1.43 to 10.2) were significant predictors of intentions to quit. 'Smoking is not doing harm right now' was inversely associated with quit intentions (OR=0.25; 95% CI 0.08 to 0.8). Among those who reported making a quit attempt, after consulting with a doctor/HP, 40% (22/60) rated the professional support received as low (0-2/10). Qualitative themes were: the negatives of smoking (ie, disgust, regret, dependence and stigma), health effects and awareness, quitting, denial, 'smoking helps me cope' and social aspects of smoking.

CONCLUSIONS

Perceived efficacy and consulting with a doctor/HP about quitting may be important predictors of intentions to quit smoking in Aboriginal smokers of reproductive age. Professional support was generally perceived to be low; thus, it could be improved for these Aboriginal smokers. Aboriginal participants expressed strong sentiments about smoking and quitting.

Prenatal smoking and age at menarche: influence of the prenatal environment on the timing of puberty

STUDY QUESTION

Do prenatal exposure to cigarette smoking and birthweight influence age at menarche (AAM) in a cohort of Australian girls?

SUMMARY ANSWER

We find that prenatal smoke exposure and lower birthweight increase the chance of earlier menarche in accordance with theoretical predictions as do confounding factors of maternal AAM and higher BMI of the girls.

WHAT IS KNOWN ALREADY

Much prior research focuses on the role of the early childhood environment in determining AAM but fewer studies consider the role of the prenatal environment. Those studies that examine the prenatal period find an acceleration of maturation associated with maternal smoking and low birthweight. Life history theory predicts that early life exposure to stressful environments should promote more rapid maturation and that this timing can be established before birth, making the prenatal environment particularly important.

STUDY DESIGN, SIZE, DURATION

Statistical analysis of longitudinal survey data collected from a large cohort (n = 2446) of Australian children using data from birth to 12-13 years of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Owing to missing data, 1493 girls were included in the final analysis. Using cox regression, we examine how (i) maternal cigarette smoking during gestation and (ii) birthweight influence girls' AAM. Cox regression was used because not all girls had reached menarche.

MAIN RESULTS AND THE ROLE OF CHANCE

We find that older maternal AAM (hazards ratio (HR): 0.75, confidence interval (CI) (95%): 0.71-0.79) and higher birthweight (HR: 0.86, CI (95%): 0.75-0.97) lower the chance of earlier menarche; while higher girls' BMI at 8-9 years (HR: 1.12, CI (95%): 1.10-1.15), and maternal cigarette smoking on 'most days' during gestation (HR: 1.40, CI (95%): 1.10-1.79 with 'no smoking' as the reference level) increased the chance of earlier menarche. All factors were statistically significant at P = 0.05.

LIMITATIONS, REASONS FOR CAUTION

Not all girls had reached menarche, necessitating the use of cox regression. As with other longitudinal studies, there was study sample attrition and some missing data, particularly in reports of maternal smoking. In addition, as the degree of bias in the missing data is unknown, possible inaccurate reporting of maternal smoking may influence the results of birthweight on AAM.

WIDER IMPLICATIONS OF THE FINDINGS

Because of the association between younger AAM and higher risk of uterine, endometrial and breast cancer development, our finding adds to the need to consider the stress caused by prenatal smoke exposure as an important health risk. In addition, this study needs to be extended, when the same girls are 14-15 years of age, and on a larger dataset from a younger cohort within the same Australian Government project.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study and there are no competing interests to declare.

Drug Repositioning for Preeclampsia Therapeutics by In Vitro Screening: Phosphodiesterase-5 Inhibitor Vardenafil Restores Endothelial Dysfunction via Induction of Placental Growth Factor

We screened a library of 528 approved drugs to identify candidate compounds with therapeutic potential as preeclampsia treatments via their proangiogenic properties. Using human umbilical vein endothelial cells (HUVECs), we assessed whether the screened drugs induced placental growth factor (PIGF) and restored damaged endothelial cell function. Enzyme-linked immunosorbent assays (ELISAs) were carried out to measure levels of PlGF in conditioned media treated with each drug (100 µmol/L) in the drug library. Tube formation assays were performed using HUVECs to evaluate the angiogenic effects of drugs that induced PlGF. We also performed ELISA, quantitative reverse transcription polymerase chain reaction, and tube formation assays after treatment with a range of concentrations of the candidate drug. Of the drugs that induced PlGF, vardenafil was the only compound that significantly facilitated tube formation in comparison with the control cells (P < .01). Treatment with vardenafil at concentrations of 50, 100, and 250 µmol/L increased expression of PlGF in a dose-dependent manner. Vardenafil (250 µmol/L) significantly improved tube formation which was inhibited in the presence of soluble fms-like tyrosine kinase 1 (100 ng/mL) and/or soluble endoglin (100 ng/mL). Production of PlGF from HUVECs in the presence of sera derived from patients with preeclampsia was significantly elevated by administration of vardenafil (250 µmol/L). By assessing drug repositioning through screening a library of approved drugs, we identified vardenafil as a potential protective agent against preeclampsia. The therapeutic mechanism of vardenafil may involve inhibition of the systemic maternal antiangiogenic state that leads to preeclampsia, in addition to its vasodilating effect. As concentrations used are high and unlikely to be useful clinically, further work is needed before testing it in humans.