Agreement between laboratory tests and self-reports of alcohol, tobacco, caffeine, marijuana and other drug use in post-partum women

Head circumference at birth and exposure to tobacco, alcohol and illegal drugs during early pregnancy

AIMS

We aimed to assess the effects of exposure to tobacco smoke, alcohol and illegal drugs during early pregnancy on the head circumference (HC) at birth of otherwise healthy neonates.

METHODS

A follow-up study from the first trimester of pregnancy to birth was carried out in 419 neonates. An environmental reproductive health form was used to record data of substance exposure obtained during the first obstetric visit at the end of the first trimester. A multiple linear regression model was created for this purpose.

RESULTS

Alcohol intake during pregnancy and medical ionizing radiation exposure were the most significant predictors of HC. The mothers' alcohol consumption increased with the mothers' and fathers' education level, net family income and fathers' alcohol consumption. In contrast, maternal smoking decreased with increasing mothers' and fathers' education level and net family income. About 13% of the surveyed embryos were exposed to illegal drugs.

CONCLUSIONS

Mild to moderate alcohol consumption diminishes the at-birth HC of theoretically healthy newborns in a linear form. There was no threshold dose. We perceived a need for increasing the awareness, and for training, of health care professionals and parents, in regard to risks of alcohol consumption and for recommending abstinence of these substances in both parents during pregnancy. It should also be remembered that medical ionizing radiation should be performed only during the first half of the cycle in fertile women. We think that our study has an important social impact as it affords data for implementing policies for promoting "healthy pregnancies".

Prenatal exposure to alcohol and school problems in late childhood: A longitudinal prospective study

The population-based Seattle Longitudinal Prospective Study on Alcohol and Pregnancy unites the fields of developmental psychopathology and behavioral teratology. Examining prenatal biological influences on childhood learning problems, this report is the first to extend earlier findings of alcohol-related deficits into late childhood. This follow-up study of 458 singletons assesses the degree to which children's classroom behavior and achievement difficulties at age 11 are predicted by prenatal alcohol exposure across the full spectrum of maternal use. Partial least squares statistical techniques are used to summarize complex multiple measures of exposure and outcome as latent variables. Accounting for many factors potentially important in development, analyses reveal a significant and subtle dose-response relationship between prenatal alcohol exposure and children's school performance a decade later. Maternal binge drinking (five or more drinks per occasion) and drinking during very early pregnancy are particularly salient for children's poorer school performance. A wide variety of problematic classroom behaviors, including attentional, activity, information-processing, and academic difficulties, are salient for prenatal alcohol exposure. Considered within the body of data on alcohol teratogenesis, these findings suggest that prenatal alcohol exposure has an enduring and predictable relationship with developmental difficulties through late childhood. Clinical, research, and public health implications are discussed.

Nonreporting of cannabis use: Predictors and relationship to treatment outcome in methadone maintained patients

Underreporting of drug use is common and influenced by multiple factors. Cannabis (THC) use nonreporting and its relationship to heroin and cocaine use were investigated in 690 patients enrolled in 25- to 29-week clinical trials of contingency management plus methadone maintenance. Urine specimens and self-reports of drug use were collected 3 times/week. Potential predictors of THC use nonreporting were analyzed by multiple logistic regression; relationships between THC use nonreporting and % cocaine- and opiate-positive urines were analyzed by multiple regression. Compared to non-THC users (n=317), patients with THC-positive urines (n=373) were more likely to be male and have more years of THC use, but were not different on other characteristics. Nonreporting to user ratios were: THC 191/373 (51.2%); opiates 17/686 (2.5%); cocaine 21/681 (3.1%). Predictors of THC use nonreporting were low rate of THC-positive urines during treatment, fewer days of THC use in the last 30 before treatment, African-American race, and absence of antisocial personality disorder. Nonreporting of THC use was associated with significantly greater opiate and cocaine use. Contingency management decreased cocaine use in THC nonreporters to the level of reporters. Nonreporting of THC use is a significant predictor of greater cocaine and heroin use. This association can be eliminated with contingency management therapy.

[Caffeine intake and food sources of caffeine and prematurity: a case-control study]

Caffeine (1,3,7-trimethylxanthine) is an alkali that easily crosses the placental barrier and can interfere in the growth and development of fetal cells and compromise fetal oxygenation. Considering the widespread consumption of foods containing caffeine in Brazil, the aim of this study was to evaluate the association between total caffeine consumption (including its food sources) and prematurity. A case-control study of 140 cases (newborns with gestational age less than 37 weeks) and 162 controls (newborns with 37 weeks gestational age or greater) evaluated caffeine consumption during pregnancy. Intake measurement used a semi-quantitative food frequency questionnaire based on the following foods: coffee, tea, and powdered chocolate. Total caffeine consumption (including food sources) during pregnancy was not associated with prematurity, and most intakes were less than 300 mg/ day. Caffeine consumption in the present study does not support guidelines against caffeine consumption by Brazilian pregnant women.

Maternal alcohol consumption during pregnancy and physical outcomes up to 5 years of age: a longitudinal study

AIM

To examine whether alcohol exposure in pregnancy affects weight and head circumference (HC) at birth and 5 years, and whether these effects are independent of cigarette exposure in pregnancy and social disadvantage.

STUDY DESIGN

The Mater-University Study of Pregnancy (MUSP) involves a prospective cohort of 8556 mothers who were enrolled at first antenatal visit. The quantity and frequency of alcohol consumption in early and late pregnancy and a measure of binge drinking in early pregnancy were recorded. Weight and HC were measured on children seen at birth and at 5 years. Level of cigarette use in early pregnancy and maternal age and level of education and family income were also measured.

RESULTS

Light and moderate alcohol consumption in early or later pregnancy had no independent effects on weight or HC at birth or 5 years. Binge drinking in early pregnancy was not associated with restricted HC, and there was no effect modification by concurrent cigarette use in early pregnancy. An apparent effect of alcohol in late pregnancy on birth weight was due to confounding by cigarette use, with social risk being an independent predictor.

CONCLUSION

Alcohol ingestion up to moderate levels in pregnancy was not associated with deficits in either weight or HC at birth or at 5 years.

Correspondence among patients' self-reports, chart records, and audio/videotapes of medical visits

This pilot study examined the covariation of patients' self-reports of instrumental and affective aspects of communication during physician-patient visits with 2 other sources of data: medical chart records and audio/videotapes. Participants were 17 community-based (nonuniversity) primary-care physicians and 77 of their patients, ages 50 to 80. Patients were interviewed by telephone within 1 week after their medical visits. Thirty-five of these visits were audio- and videotaped. Patients were asked to report on their receipt of specific cancer screening in the previous 2 years, the occurrence of instrumental communication events during the visit (e.g., recommendations), their affect, and their visit experiences and communication with their physicians. Results showed (a) noteworthy disagreements between patients' self-reports and medical charts regarding cancer screening; (b) better agreement of patients' self-reports with videotape records than with chart records regarding physicians' recommendations; (c) accurate recognition of patients' self-reported affect, communication, and visit experiences by third-party raters of both audiotapes and videotapes; and (d) similar correlations of audio- and videotape ratings with patients' self-reports as well as substantial correlations between audio and video ratings. The implications of these findings are discussed, and recommendations are made for future research.

Serum caffeine and paraxanthine as markers for reported caffeine intake in pregnancy

PURPOSE

Previous studies of maternal caffeine use and pregnancy outcome have relied on self-reported use. Even if these were perfectly accurate, inter-individual differences in caffeine metabolism result in a relatively weak correlation between caffeine intake and serum concentration. The purpose of this study was to determine whether the serum concentration of caffeine or its primary metabolite, paraxanthine, obtained at an unknown time during working hours, is useful to distinguish between pregnant women who report consuming small and large amounts of caffeine.

METHODS

We selected from the Birmingham fetal growth study 60 women with normal pregnancy outcomes who reported consuming < or = 0.8 mg/kg/day of caffeine in a 24-hour dietary recall, 60 who consumed 0.81-2.5 mg/kg/day, 60 who consumed 2.51-5.0 mg/kg/day and 59 who consumed > or = 5.01 mg/kg/day. These women had serum drawn for storage during regular clinic hours on the same day as the recall interview. Caffeine and paraxanthine were measured in the stored serum using high performance liquid chromatography.

RESULTS

The weighted kappa coefficient between strata of caffeine intake and quartiles of serum paraxanthine was 0.58 among smokers and 0.53 among nonsmokers, versus 0.44 and 0.51, respectively, for quartiles of serum caffeine. The Pearson correlation coefficient between intake and paraxanthine was 0.50 for smokers and 0.53 for nonsmokers, and 0.37 and 0.51, respectively, for serum caffeine. These values are comparable to the correlation between reported smoking and serum cotinine in pregnancy.

CONCLUSIONS

The serum concentrations of paraxanthine, and to a lesser degree, caffeine are useful to distinguish between women with varying levels of caffeine intake.

Social support in worksite smoking cessation: qualitative analysis of the EASE project

PURPOSE

Mobilize and study social support in EASE, a worksite smoking cessation program.

DESIGN

Qualitative study of social support in two pilot and two test worksites.

SETTING

Collaboration with American Lung Association of eastern Missouri to implement program in 12 companies between 1982 and 1985.

SUBJECTS

Ninety-eight participants in cessation clinics at pilot and test sites and 350 randomly sampled respondents from among all 877 employees at test sites.

INTERVENTION

Steering committees included representatives of management and line employees and tailored the program from plans and materials for program promotion, self-help manuals, and a standard curriculum for a Group Comprehensive Clinic.

MEASURES

Implementation and participation from project records. Outcomes and perceptions of social support from surveys of employees.

RESULTS

Twelve to 24 months after program initiation, smoking cessation among active participants ranged from 21% to 41%. Consistent with emphasis on promoting support for quitting throughout the worksite, 10% to 25% of nonparticipants were abstinent at follow-ups, exceeding national base rates. Surveys indicated greater importance of social support than of program's procedures or materials and greater benefits of social ties to nonsmokers than to others attempting to quit. Differences among companies in both reported social support for nonsmoking and cessation rates paralleled differences in Steering Committees' activities and organizational support for the program.

CONCLUSION

Though limited by lack of experimental controls, this qualitative study of active program participants as well as random samples of all employees indicates social support can be a strength of worksite smoking cessation programs.

Maternal drinking during pregnancy: attention and short-term memory in 14-year-old offspring--a longitudinal prospective study

A large and compelling experimental literature has documented the adverse impact of prenatal alcohol exposure on the developing brain of the offspring. This is the first report of adolescent attention/memory performance and its relationship with prenatal alcohol exposure in a population-based, longitudinal, prospective study (n = 462) involving substantial covariate control and "blind" examiners. Prenatal alcohol exposure was significantly related to attention/memory deficits in a dose-dependent fashion. A latent variable reflecting 13 measures of maternal drinking was correlated 0.26 with a latent variable representing 52 scores from 6 tests measuring various components of attention and short-term memory performance. The number of drinks/occasion was the strongest alcohol predictor. Fluctuating attentional states, problems with response inhibition, and spatial learning showed the strongest association with prenatal alcohol exposure. A latent variable reflecting the pattern of attention/memory deficits observed at 14 years correlated 0.67 with a composite pattern of deficits previously detected on neurobehavioral tests administered during the first 7 years of life. The 14-year attention/memory deficits observed in the present study appear to be the adolescent sequelae of deficits observed earlier in development. As is usual in such studies, not all exposed offspring showed deficits.

Elevated frequencies of hprt mutant lymphocytes in cigarette-smoking mothers and their newborns

Maternal cigarette smoking during pregnancy has been associated with increased perinatal mortality and low birth weight. Several epidemiological studies have demonstrated an association between smoking during pregnancy and an elevated risk of hematopoietic cancer in the child, but other studies have failed to confirm this association. We have used an assay for somatic cell mutation to evaluate the in utero effects of exposure to maternal cigarette smoking. Cord blood samples were obtained from 10 newborns whose mothers smoked cigarettes during pregnancy and 10 newborns of non-smoking mothers. Blood samples were also obtained from 5 of the smoking and 5 of the non-smoking mothers. Smoking status was confirmed in all samples by testing the blood plasma for cotinine. The frequency of lymphocytes containing mutations at the hypoxanthine phosphoribosyltransferase (hprt) locus was determined with an autoradiographic assay using cells that had been cryopreserved. The mothers who were smokers had a mean frequency (+/- SE) of 3.08 (+/- 0.55) variant (mutant) cells per 10(6) evaluatable lymphocytes. The frequency (Vf) in non-smokers was 1.07 (+/- 0.17) x 10(-6). The Vf of newborns of smokers was 2.17 (+/- 0.24) x 10(-6), and newborns of non-smokers had a Vf of 0.77 (+/- 0.13) x 10(-6). In both mothers and newborns the difference in Vf between smokers and non-smokers was statistically significant (p < 0.05). Maternal and newborn Vfs were significantly correlated (r = 0.88; p < 0.004), and there was a positive association (r = 0.86; p < 0.001) between the reported number of cigarettes smoked per day and the Vfs. This study provides further evidence that maternal smoking may be hazardous to the future health of children exposed in utero to mutagenic agents in cigarette smoke.

Maternal and neonatal effects of moderate cocaine use during pregnancy

Thirty-four women who reported using cocaine during pregnancy were compared to 600 women who reported no cocaine use during pregnancy and none for the year prior to pregnancy. Subjects were participants in a prospective, longitudinal study of prenatal substance use. The sample consisted of young, predominantly single, low-income women attending a public prenatal clinic. Women were interviewed at the end of their first, second and third trimesters regarding cocaine, alcohol, marijuana, tobacco and other drug use. The majority of the cocaine users were light to moderate users who decreased their use during pregnancy. The cocaine group was more likely to be white and to use alcohol, marijuana, tobacco and other illicit drugs more heavily than the comparison group. The cocaine users had more previous fetal losses but did not differ on other obstetrical complications. Infant growth, morphology and behavior were not affected.

Agreement between two measures of drug use in a low-prevalence population

The present study examined the agreement between two measures of prevalence of drug use in the community: self-report and specific pharmacological analyses of urine samples. The data were collected in the context of a random community survey of health practices and attitudes. A random 20% of the households participating in the health study were targeted for biochemical assay. Compliance with urine delivery was relatively high at 79%. Urine samples were screened qualitatively for cannabinoids and benzodiazepines using the enzyme multiplied immunoassay technique (EMIT) (Syva Diagnostics, Palo Alto, CA). Screening for pharmaceuticals used a standard thin-layer chromatography (TLC) technique. Agreement between the self-report and biochemical assay estimates of prevalence was statistically significant (p less than .05). While self-report of substance use is not a perfect measure of consumption, it remains a relatively economical and reasonably accurate method of obtaining estimates of substance use in community samples.

The effects of maternal drinking in the reproductive period: an epidemiologic review

The major effects of maternal alcohol use during pregnancy are decreased fetal growth, morphologic abnormalities, and CNS impairment. If all three of these are present, with a characteristic facies in the infant, fetal alcohol syndrome (FAS) is diagnosed. FAS occurs only with heavy or alcoholic drinking. The individual components of the syndrome exhibit a dose-response association with ethanol intake in many, but not all studies. Discrepancies in maternal drinking and pregnancy outcome reflect the myriad difficulties of these investigations. Drinking "before" pregnancy also has been linked to decrements in fetal development, possibly because before pregnancy may include the periconceptional period. However, women who are usually abstainers before pregnancy appear to have infants at higher risk of some adverse pregnancy outcomes than women who are light drinkers. Future studies need to construct careful drinking histories to address this and other questions that deal with parents' ethanol use and reproductive health.

Alcohol and pregnancy. An epidemiologic perspective

This article considers maternal use of alcohol during pregnancy, from an epidemiologic perspective. In general, maternal use of alcohol during pregnancy has been associated with a number of effects in offspring including fetal alcohol syndrome, a reduction in birth weight, effects on behavior, and other late effects. It is apparent from the existing literature that the epidemiologic dimensions of these effects are poorly defined and hampered by methodologic problems. Assessment of both outcome and exposure can be difficult, and there is great potential for uncontrolled confounding. Additionally, it is unclear whether the apparent teratogenicity of alcohol results from direct, acute effects of alcohol on the developing fetus, or results from chronic effects of excessive alcohol intake in the mother. This article concludes with recommendations for further research, which may help clarify the complexity of effects associated with maternal use of alcohol during pregnancy.

Drinking and smoking at 3 months postpartum by lactation history

A spontaneous decrease in maternal drinking and smoking often occurs during pregnancy. The present study was conducted to determine if these lower levels of maternal drinking and smoking during pregnancy persist into the postpartum period, and if so, to determine if they are related to breastfeeding. Drinking and smoking were estimated in three cohorts of postpartum women who had been followed since pregnancy. The first group never breastfed their infants; the second group breastfed for less than 1 month; the third group breastfed for more than three months. (Women who weaned between one and three months were not studied). Drinking and smoking in all three groups decreased sharply during pregnancy but rose again in the 3 months after delivery, though not to levels that were reported before conception. Usual drinking in the third month postpartum did not differ significantly among the three lactation groups. However, women who were still nursing were less likely to report occasional episodes of heavy drinking (binges) in this month than women who had weaned early or never breastfed. Women nursing in the third month postpartum were also significantly less likely to smoke during the month; if smoking, they were less likely to smoke heavily. These differences in postpartum drinking and smoking were not due entirely to habits before conception or to the influence of other potentially confounding variables.

The validity of self-reported abstinence and quality sobriety following chemical dependency treatment

The validity of self-reports from 171 former patients at a 28-day inpatient treatment program was examined by comparing self-report measures of abstinence and current life functioning with concurrent reports by significant others. Strong convergent validation was found, with 92% of significant others agreeing with the self-reports of the former clients. The "quality of sobriety" measures of familial, occupational, social, and emotional adjustment were studied and validated by the convergent validation technique. Discussed is the value of convergent validation in terms of both follow-up success rates and program evaluation. Methodological concerns and resulting limitations of the data are reviewed.

Maternal marijuana use during lactation and infant development at one year

Prenatal marijuana exposure is associated with adverse perinatal effects. Very little is known about the effect of postnatal marijuana exposure on infant development. Postnatal exposure can result from maternal use of marijuana during lactation. Delta-9-tetrahydrocannabinol (THC) transfers and concentrates in the mother's milk and is absorbed and metabolized by the nursing infant. The present study investigated the relationship between infant exposure to marijuana via the mother's milk and infant motor and mental development at one year of age. One hundred and thirty-six breast-fed infants were assessed at one year of age for motor and mental development. Sixty-eight infants were exposed to marijuana via the mother's milk. An additional 68 infants were matched to the marijuana-exposed infants on pre- and postpartum maternal alcohol and tobacco use. Marijuana exposure via the mother's milk during the first month postpartum appeared to be associated with a decrease in infant motor development at one year of age.

Smoking in pregnancy: smokescreen or risk factor? Towards a materialist analysis

This paper considers the topic of women's smoking in pregnancy within the general context of the current health promotion concern about smoking as a public health issue. Drawing on data from an ongoing research project which is investigating the interrelationships between'risk', social support and reproductive health, the paper argues that smoking in pregnancy constitutes an area of women's behaviour which is linked in systematic ways with aspects of their material and social position. Consequently, conventional individualist models of smoking behaviour both fail to explain why pregnant women smoke and are unable adequately to account for the health consequences of this behaviour. The reason for singling out smoking in this analysis inheres not in any detrimental health effect directly attributable to it, but rather to the way in which pregnancy smoking has been socially constructed as a reprehensible feature of women's life-styles.

Maternal alcohol use during breast-feeding and infant mental and motor development at one year

The detrimental effects of maternal drinking during pregnancy on fetal health have been documented. The consequences for infants of maternal drinking during breast-feeding are unknown, but research in animals suggests that the infant could be affected by exposure to alcohol through the mother's milk. In a study of 400 infants born to members of a health maintenance organization, we investigated the relation of the mother's use of alcohol during breast-feeding to the infant's development at one year of age. Mental development, as measured by the Bayley Mental Development Index (MDI), was unrelated to maternal drinking during breast-feeding. However, motor development, as measured by the Psychomotor Development Index (PDI), was significantly lower in infants exposed regularly to alcohol in breast milk (after alcohol exposure during gestation was controlled for), with a dose-response relation (P for linear trend, 0.006). The infants of breast-feeding mothers who had at least one drink daily had a mean PDI score of 98, whereas the infants exposed to less alcohol in breast milk had a mean PDI score of 103 (95 percent confidence interval for the difference of the two means, 1.2 to 9.8). The effect was more pronounced when mothers who supplemented breast-feeding with formula were excluded from the analysis. The association persisted even after we controlled for more than 100 potentially confounding variables, including smoking and other drug use during pregnancy and in the postpartum period. We conclude that ethanol ingested through breast milk has a slight but significant detrimental effect on motor development, but not mental development, in breast-fed infants.

A 12-step treatment approach for marijuana (Cannabis) dependence

Marijuana (Cannabis) dependence (addiction) is a disorder for which treatment is essential and relatively sophisticated. A basic assumption in the treatment model is that marijuana addiction involves pathological processes in the physical, mental (cognitive), and emotional (mood) states of the addicted individual. These pathological processes constitute a disease entity that is diagnosable, treatable, and has a predictable course. One approach for the treatment of marijuana addiction involves physicians, psychologists, counselors, and social workers who treat the disease of marijuana addiction. We present this approach to treatment of marijuana addiction as representative of a popular method but not as the only modality available.

Psychophysiological aspects of caffeine consumption

Caffeine may be the psychoactive compound most widely used in the United States. Caffeine appears in coffee, tea, cola drinks, chocolate bars and cocoa, cold and diet medications, and sleep-prevention compounds; the amount of caffeine varies in different substances and according to preparations. Research on caffeine's effects on alcoholic drinks, alertness, anxiety, heart rate, performance, and sleep is reviewed. Caffeine is usually not harmful, although long-range effects of caffeine have not been thoroughly investigated. Caffeine's effects often have been studied by means of ingestion of coffee but substances other than caffeine may be active in coffee and tea. The placebo effect contributes to some of the effects experienced by coffee-caffeine users.

Father's drinking and infant birth weight: report of an association

Parents' drinking in the month prior to conception was ascertained for 377 infants born to members of a health maintenance organization. If the father had an average of two or more drinks daily, or had at least five drinks on one occasion, a decrease of 137 gm in infant birth weight was predicted, by means of regression analysis. This result was independent of maternal drinking, although infants whose mothers were regular drinkers weighed less at birth. The lower mean birth weights of infants of regular-drinking fathers was not due to parents' smoking, maternal use of caffeine, marijuana, or other drugs, or 21 other measured variables. This is the first report of an association in humans between father's drinking prior to conception and decreased infant birth weight. However, interpretation of this finding is difficult because the biological mechanisms that might underlie it are obscure.

Mother's and father's birthweight as predictors of infant birthweight

Mothers' and fathers' birthweights are each significantly related to their infants' birthweight, even after control for 31 potentially confounding variables. The relationship is stronger for mothers and daughters than for other parent-offspring pairs. Parents' birthweights together account for 2% of the variance in sons', and 5% of the variance in daughters' birthweights. There are interactions of maternal birthweight with maternal adult weight, pregnancy weight gain, and parity; the predicted effect of maternal birthweight on infant birthweight is enhanced when the mother weighs more, gains more weight during pregnancy, or is multiparous. Race and parents' drinking and smoking also modify the predicted effect of parents' birthweights. The correlation between mother and offspring birthweights has been attributed to the mother's own uterine experience and its effect on her later reproductive performance. However, the significant relationship of father and infant birthweights reported in this paper suggests that the fetal genes also play some role in determining size at birth.