Spontaneous cessation of smoking and alcohol use among low-income pregnant women

Women, Infants, and Children enrollment and pregnancy-related behaviors and outcomes among Medicaid recipients in the United States

BACKGROUND

Nearly 40% of pregnant women in 2016 were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Prior studies have investigated nutritional behaviors among WIC participants and access to WIC breastfeeding counseling services. However, there are no (few?) nationally representative, large-scale analyses of WIC users and pregnancy behaviors. Thus, the present study aims to examine associations between WIC use and select pregnancy outcomes among Medicaid enrollees.

METHODS

We examined pregnancy-related behaviors and outcomes using 2018 U.S. Birth Certificates for Medicaid patients aged 18-45 years (N = 1 159 263). Outcomes included prenatal care (PNC) adequacy, breastfeeding initiation, cigarette use, and gestational weight gain. Standard binary and multinomial logistic regressions were used to estimate odds ratios (OR) and 95% confidence intervals (CIs).

RESULTS

After adjustment, WIC users had statistically significant increased odds of adequate PNC (adjusted OR [AOR] = 1.31 [95% CI 1.30, 1.32]), cigarette use (quit smoking during pregnancy 1.09 [1.07, 1.11]; smoked throughout pregnancy 1.16 [1.14, 1.18], and exceeding recommendations of weight gain 1.07 [1.06, 1.08]) compared with non-WIC users. WIC enrollees also experienced decreased odds of breastfeeding initiation (0.85 [0.85, 0.86]) compared with non-WIC users.

CONCLUSIONS

The study underscores the value of the WIC program in improving access to PNC. Yet, low-income women remain at risk for smoking during pregnancy and exceeding the recommended amount of weight gain. Breastfeeding initiation is lower than anticipated among WIC participants. Additional studies are needed to investigate WIC program efficacy.

Racial/ethnic variations in alcohol and cigarette use by pregnancy status among 20- to 44-year-old women, NHANES 2001–2018

Objectives:

This study examines alcohol consumption and smoking behaviors by pregnancy status and race/ethnicity in order to inform improved interventions designed to assist women of all races to avoid alcohol and tobacco use during pregnancy for their health and to prevent potential fetal exposure.

Methods:

This retrospective secondary data analysis utilized nationally representative National Health and Nutrition Examination Survey data between 2001 and 2018. Smoking and alcohol use were evaluated by race/ethnicity and pregnancy risk. Sexual behavior, reproductive health, and prescription drug use determined pregnancy risk, categorized as low pregnancy risk, at risk of becoming pregnant, and pregnant. Binary and multinomial multivariable logistic regression were used to examine associations.

Results:

The final sample consisted of 10,019 women of which 11.8% were Mexican American, 7.7% other Hispanic, 65.5% white, and 15% black (weighted percentages). White low pregnancy risk and pregnancy risk smoked most frequently in respective pregnancy risk groups (p < 0.001). Among pregnant women, smoking prevalence was highest among black women (14.0%, p < 0.01). Pregnancy risk women were more likely to smoke and pregnant women were less likely to smoke compared with low pregnancy risk. Low pregnancy risk and pregnancy risk Hispanics had a lower prevalence of binge drinking, but prevalence decreased less among pregnant Hispanics than other racial/ethnic groups. In adjusted analyses, pregnancy risk black women had more than 2 times the odds of combined smoking and alcohol consumption compared with low pregnancy risk black women.

Conclusion:

Women who may become pregnant need interventions and improved policy to prevent alcohol use and smoking. Culturally appropriate alcohol and smoking cessation interventions before pregnancy and improved contraception access are needed.

Two screening instruments for collecting alcohol-related information from expectant mothers and fathers: Testing the reliability of the Parent Alcohol Screening Questionnaire and the Social Support for an Alcohol-Free Pregnancy Questionnaire

The aim is to test the reliability of two alcohol screening instruments: (1) The Parent Alcohol Screening Questionnaire (PASQ5), and (2) the Social Support for an Alcohol-free Pregnancy (SSAFP) questionnaire. This is a cohort study from the south of Sweden using repeated surveys during pregnancy. To examine if responses differed according to different data collection methods, two cohorts consisting of 289 expectant mothers and 141 fathers completed the PASQ5 both verbally (weeks 6-7) and in writing (week 12) within regular antenatal visits. One of the cohorts (n = 137/64) also completed the SSAFP in week 12 and later in week 33. The third cohort, consisting of 179 and 133 expectant mothers and fathers, respectively, completed the PASQ5 and the SSAFP twice in late pregnancy (week 31 + 33). Eight of 10 items in the PASQ5 were stable for both expectant mothers and expectant fathers when comparing verbal versus written-delivered formats. Eight of 10 questions in the PASQ5 were stable when assessing the items in a test-retest analysis in late pregnancy for expectant mothers and nine of 10 questions were stable for fathers. The SSAFP items showed high internal consistency (0.86) for expectant mothers and excellent internal consistency (0.94) for expectant fathers. Most SSAFP items (17 of 21 for expectant mothers and 18 of 22 for expectant fathers) were also stable in a test-retest scenario in late pregnancy. Both the PASQ5 and SSAFP are reliable tools and may be helpful for clinicians who aim to have a deeper dialogue about alcohol consumption during pregnancy. These tools may also be helpful for researchers aiming to better understand a person's changes in alcohol intake and/or their social support network.

Correlates of continued cannabis use during pregnancy

BACKGROUND

Cannabis use is increasingly common among pregnant women despite concern that it may be linked to adverse maternal and infant outcomes. Determining whether variables associated with cannabis use predict whether women continue or quit using during pregnancy may inform strategies to reduce prenatal use.

METHODS

Pregnant women who regularly used cannabis before pregnancy (n = 296) were recruited via Facebook. After finding out they were pregnant, 41 % reported quitting, 13 % quit then relapsed, 32 % reduced use, and 15 % continued use at the same rate. Differences among these four cannabis use status groups (quit, relapsed, reduced, continued) in sociodemographics, cannabis use, cigarette use, perceived risk/benefit, delay discounting, and communications about cannabis with their doctor were assessed.

RESULTS

Compared to those who quit, continuing use during pregnancy was associated with being unemployed (Relative Risk (RR) = .32, 95 %CI [.13, .78]), using cigarettes pre-pregnancy (RR = 3.43, 95 %CI [1.32, 8.94]), being in an earlier trimester (RR = 4.38, 95 %CI [1.18, 16.23]), less perceived risk (RR = .79, 95 %CI [.74, .85]), and more days per week of use pre-pregnancy (RR = .10, 95 %CI [.01, .84]). Unintended pregnancy, shorter time to cannabis use after waking pre-pregnancy, using cannabis more times per day pre-pregnancy, and greater perceived benefits of use had significant bivariate associations with continued use during pregnancy, but did not retain significance in a multinomial model.

CONCLUSIONS

Identification of these correlates provides potential targets for prevention of or intervention for prenatal cannabis use. However, much more research is needed to understand prenatal cannabis use and its effects in order to better educate women and healthcare providers, and to design optimal public health strategies.

Smoking and drinking habits of women in subsequent pregnancies after specific advice about the dangers of these exposures during pregnancy

BACKGROUND

Although women are informed about the dangers of drinking and smoking during pregnancy when they book for antenatal care, it is uncertain whether this advice is accepted, or whether attempts are made to apply it in subsequent pregnancies.

OBJECTIVES

To assess how pregnant women respond to the advice to refrain from smoking and drinking during pregnancy in subsequent pregnancies.

METHODS

Research staff were trained to obtain accurate prospective information on smoking and drinking during pregnancy in a prospective study, using well-standardised methods. Care was taken to inform participants about the dangers of smoking and drinking during pregnancy. They were also given pamphlets on these dangers in their own language and a list of telephone numbers where they could find help to quit should they need it. This information was repeated at subsequent study visits (ranging from 1 to 3, depending on the gestational age at which they enrolled). Gestational age was determined by early ultrasound. Z-scores of birthweight for gestational age were determined according to the INTERGROWTH-21st study. Pregnancy outcomes of women who enrolled twice (n=888) or three times (n=77) in the Safe Passage Study were compared with those of women in the first enrolment (n=889).

RESULTS

The proportion of drinkers did not change significantly (p=0.058) from the first to the second and third enrolments (63.8%, 59.0% and 54.6%, respectively). A similar trend was found for smokers (73.3%, 72.2% and 68.4%, respectively). Cannabis use was reported by 15.1%, 9.7% and 12.0% (p<0.005) of women, respectively, and use of methamphetamine by 10.1%, 6.6% and 12.7% (p<0.005). There was an increase in the rate of preterm births from 15.5% to 17.5% and 24.7%, respectively, but the increase was not significant. Although mean birthweight was lower in the third enrolment compared with the second, the difference was not significant. The z-score of birthweight for gestational age was significantly lower in the second enrolment compared with the first.

CONCLUSIONS

Detailed information on the adverse effects of smoking and drinking during pregnancy was not effective in the population studied. Other methods to reduce or stop these toxic exposures should therefore be investigated. A short inter-pregnancy interval, as demonstrated by three enrolments in 7.5 years, is associated with preterm labour and fetal growth restriction, and is probably indicative of the role played by confounders such as poor socioeconomic conditions and drug exposure during pregnancy.

Tobacco and Nicotine Cessation During Pregnancy: ACOG Committee Opinion, Number 807

Pregnant women should be advised of the significant perinatal risks associated with tobacco use, including orofacial clefts, fetal growth restriction, placenta previa, abruptio placentae, preterm prelabor rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function. Children born to women who smoke during pregnancy are at an increased risk of respiratory infections, asthma, infantile colic, bone fractures, and childhood obesity. Pregnancy influences many women to stop smoking, and approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy. Smoking cessation at any point in gestation benefits the pregnant woman and her fetus. The greatest benefit is observed with cessation before 15 weeks of gestation. Although cigarettes are the most commonly used tobacco product in pregnancy, alternative forms of tobacco use, such as e-cigarettes or vaping products, hookahs, and cigars, are increasingly common. Clinicians should advise cessation of tobacco products used in any form and provide motivational feedback. Although counseling and pregnancy-specific materials are effective cessation aids for many pregnant women, some women continue to use tobacco products. Clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions. Available cessation-aid services and resources, including digital resources, should be discussed and documented regularly at prenatal and postpartum follow-up visits.

Prevalence and patterns of cigarette smoking before and during early and late pregnancy according to maternal characteristics: the first national data based on the 2003 birth certificate revision, United States, 2016

BACKGROUND

The objective of this study was to examine the prevalence of smoking by intensity status before pregnancy and during early (first and second trimester) and late (third trimester) pregnancy according to race/ethnicity, age, and educational attainment of women who gave birth in the United States in 2016.

METHODS

This cross-sectional study was based on the 2016 National Center for Health Statistics (NCHS) Natality File of 3,956,112 live births, the first year that it became 100% nationally representative. Self-reported smoking data were used to create new seven smoking intensity status categories to capture natural variability in smoking patterns during pregnancy and to identify maternal smokers by race/ethnicity, age, and educational attainment. The risk of smoking at low and high intensity in early pregnancy was estimated in multivariable logistic regression analyses.

RESULTS

Nearly 9.4% of women reported smoking before pregnancy and 7.1% during pregnancy, both at high and low intensity, and smoking rates were higher in the first trimester (7.1%) than in the second (6.1%) or the third (5.7%) trimester. Non-Hispanic White women, women 20-24 years old, and women with less than a high school education were the strongest predictors of smoking anytime during pregnancy. The odds of smoking in early pregnancy at high intensity were 88% lower (aOR 0.12, 95% CI: 0.11, 0.13) for Hispanic women, compared to non-Hispanic White women; 16% higher (aOR 1.16, 95% CI: 1.12, 1.21) for women 20-24 years old and 16% lower (aOR 0.84, 95% CI: 0.80, 0.89) for women ≥35 years old, compared to women 25-29 years old; as well as 13% higher (aOR 1.13, 95% CI: 1.09, 1.18) for women with less than a high school education and 92% lower (aOR 0.08, 95% CI: 0.08, 0.09) for women with a bachelor's degree or higher, compared to women with a high school diploma.

CONCLUSIONS

Despite the high prevalence of high intensity smoking before and during pregnancy, future intervention strategies need to focus on the proportion of low intensity quitters and reducers, who are ready to stop smoking. Continual monitoring of trends in smoking intensity patterns is necessary, including neonatal outcomes over time.

Smoke-Free Moms: Financial Rewards for Smoking Cessation by Low-Income Rural Pregnant Women

INTRODUCTION

Maternal smoking places the child at risk during pregnancy and postpartum. Most women who quit smoking do so early when they first learn of pregnancy. Few low-income women quit once they enter prenatal care. The purpose of this study is to test in a clinical prenatal care setting the effectiveness of the Smoke-Free Moms intervention, which provides pregnant women a series of financial incentives for smoking cessation.

STUDY DESIGN

A prospective nonrandomized controlled trial that collected control population data of smoking-cessation rates at each clincal visit during pregnancy and postpartum with usual smoking counseling in 2013-2014. In 2015-2016, the same data were collected during the implementation of the Smoke-Free Moms intervention of financial incentives. Data analysis occurred in 2017.

SETTING/PARTICIPANTS

Women who were smoking at the first prenatal visit at four federally qualified health centers in rural New Hampshire.

INTERVENTION

All women received 5A's smoking counseling from clinic staff. At each clinic visit, with point-of-care confirmed negative urinary cotinine, intervention women received gift cards.

MAIN OUTCOME MEASURES

Cotinine confirmed smoking cessation without relapse: (1) during pregnancy and (2) smoking cessation in both pregnancy and postpartum.

RESULTS

Of 175 eligible pregnant women enrolled, 134 women were followed to the postpartum visit (Intervention n=66, Control n=68). The quit rates during pregnancy did not differ between groups (Intervention 36.4%, Control 29.4%, p=0.46). However, significantly more intervention mothers quit and continued as nonsmokers postpartum (Intervention 31.8%, Control 16.2%, p=0.04). In a logistic regression model including baseline sociodemographic, depressed mood, stress, and readiness to quit items, confidence in being able to quit predicted both cessation outcomes. The financial incentive intervention was an independent predictor of cessation in pregnancy through postpartum.

CONCLUSIONS

Financial incentives with existing smoking-cessation counseling by staff in low-income clinical prenatal programs led to cessation that continued during the postpartum period. Further study in larger populations is indicated.

Continued smoking versus spontaneous quitting among pregnant women living in a high risk environment

OBJECTIVES

In Hungary, 37% of women living in poverty were smokers in 2012. There are no valid data of pregnant women's spontaneous smoking cessation.

METHODS

Our retrospective cohort study (2009-2012) targeted the most underdeveloped regions with an estimated 6-8.5% of Roma population. The sample (N = 12,552) represented 76% of the target population i.e. women in four counties in a year delivering live born babies. Chi-square probe and multivariable logistic regression model (p < 0.05) were used to assess relationship between socio-demographic characteristics and spontaneous cessation.

RESULTS

Prior to pregnancy, the overall smoking rate was 36.8%. That of women in deep poverty and Roma was 49.7% and 51.1%, respectively. 70.3% of smokers continued smoking during the pregnancy. Among them 80.6% lived in deep poverty. Spontaneous quitting rate was 23.0%. Factors correlated with continued smoking included being Roma (OR = 1.95), undereducated (OR = 2.66), living in homes lacking amenities (OR = 1.48), and having regularly smoking partner (OR = 2.07). Cessation was promoted by younger age (≤ 18 years) (OR = 0.18), being married (OR = 0.50), and the first pregnancy.

CONCLUSIONS

Tailored cessation programmes are needed for Roma, older, low-income, and multiparous women who are less likely to quit on their own. Engaging husbands/partners is essential to reduce smoking among pregnant women and second-hand smoke exposure.

Preconception and antenatal knowledge and beliefs about gestational weight gain

BACKGROUND

Prevention of excessive gestational weight gain during pregnancy is difficult; targeting women before pregnancy may be more effective.

AIMS

In order to generate knowledge that may influence the development of effective interventions to promote healthy weight in reproductive-aged women, this study aimed to explore knowledge and belief formation regarding gestational weight gain for preconception and pregnant women.

MATERIALS AND METHODS

Women ≥18 years (preconception n = 265; pregnant women at 16 weeks gestation n = 271) completed questionnaires assessing knowledge and beliefs about gestational weight gain. Responses were categorised according to the 2009 Institute of Medicine gestational weight gain recommendations.

RESULTS

Preconception women exhibited poorer gestational weight gain knowledge than pregnant women, yet only half of pregnant women reported accurate gestational weight gain knowledge within the Institute of Medicine recommendations. Beliefs about gestational weight gain were also inaccurate for both preconception and pregnant women, with 34.1% of pregnant and 44.6% of preconception women expecting to gain less than recommendations. Gestational weight gain knowledge accounted for about half of the variance in gestational weight gain beliefs.

CONCLUSIONS

Overall, the large inaccuracies in gestational weight gain knowledge and beliefs reported by both preconception and pregnant women suggest significant gaps in dissemination of gestational weight gain advice throughout the reproductive life phase. Knowledge is an important part of belief formation that can lead to appropriate weight gain. Hence, health professionals and policy makers should actively pursue opportunities to improve gestational weight gain knowledge in reproductive-aged women.

Tobacco and Alcohol Consumption Rates among Chinese Women of Reproductive Age in 2004⁻2011: Rate and Sociodemographic Influencing Factors

Background: Smoking and alcohol consumption have become major public health problems among Chinese women. In this study we explore the behavioral trends in smoking and alcohol consumption of Chinese women. We also explored the changes in the sociodemographic factors that affect the smoking and alcohol consumption behaviors of Chinese women at different reproductive stages. Methods: We used the Chinese Health and Nutrition Survey data for 2004 to 2011 to investigate the trends and influential factors of tobacco and alcohol consumption among Chinese women. Data for tobacco and alcohol consumption (consumption of beer or any other alcoholic beverage and smoking of cigarettes) were extracted using questionnaires. We applied the χ² test to examine the trends of alcohol and tobacco consumption among Chinese women over the period of 2004 to 2011. We conducted two penalized logistic regressions with age as the continuous and classification variable (18–23, 24–29, 30–44, and 45–49 years), and independent variables included residence, age, and marital status. Results: Drinking rates among Chinese women significantly changed over the period of 2004 to 2011 (p = 0.018). Age was related to tobacco consumption rates for 2009 and 2011 (p < 0.05). Marital status was associated with tobacco consumption rates for 2004, 2009, and 2011 (p < 0.05). Tobacco and alcohol consumption rates from 2004 to 2011 were positively correlated (p < 0.05). Over the period of 2004 to 2011, alcohol consumption rates were higher among women living in urban areas than those among women living in rural areas (p < 0.05). High educational attainment was related to alcohol consumption. Educational attainment levels of secondary or primary schooling and university or above were related to alcohol consumption rates for 2004 to 2011 (p < 0.05). Employed women were more likely to consume alcohol than unemployed women in 2004, 2006, and 2011 (p < 0.05). Data from 2004 to 2011 showed that tobacco and alcohol use were correlated (p < 0.05) and that women aged 45–49 years old were more likely to consume tobacco than other women (p < 0.05); Conclusions: The drinking behavior of Chinese women changed considerably over the period of 2004 to 2011. Our results provide further insight on the smoking and drinking behaviors of Chinese women at different reproductive stages and the factors that influence such behaviors. Therefore, our findings on trends and factors that influence rates of tobacco and alcohol use allow for a better understanding of the smoking and drinking behaviors of Chinese women.

Impact of maternal prenatal smoking on fetal to infant neurobehavioral development

Despite recent emphasis on the profound importance of the fetal environment in "programming" postnatal development, measurement of offspring development typically begins after birth. Using a novel coding strategy combining direct fetal observation via ultrasound and actocardiography, we investigated the impact of maternal smoking during pregnancy (MSDP) on fetal neurobehavior; we also investigated links between fetal and infant neurobehavior. Participants were 90 pregnant mothers and their infants (52 MSDP-exposed; 51% minorities; ages 18-40). Fetal neurobehavior at baseline and in response to vibro-acoustic stimulus was assessed via ultrasound and actocardiography at M = 35 weeks gestation and coded via the Fetal Neurobehavioral Assessment System (FENS). After delivery, the NICU Network Neurobehavioral Scale was administered up to seven times over the first postnatal month. MSDP was associated with increased fetal activity and fetal limb movements. Fetal activity, complex body movements, and cardiac-somatic coupling were associated with infants' ability to attend to stimuli and to self-regulate over the first postnatal month. Furthermore, differential associations emerged by MSDP group between fetal activity, complex body movements, quality of movement, and coupling, and infant attention and self-regulation. The present study adds to a growing literature establishing the validity of fetal neurobehavioral measures in elucidating fetal programming pathways.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Committee Opinion No. 721: Smoking Cessation During Pregnancy

Smoking is the one of the most important modifiable causes of poor pregnancy outcomes in the United States, and is associated with maternal, fetal, and infant morbidity and mortality. The physical and psychologic addiction to cigarettes is powerful; however, the compassionate intervention of the obstetrician-gynecologist can be the critical element in prenatal smoking cessation. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. A short counseling session with pregnancy-specific educational materials and a referral to the smokers' quit line is an effective smoking cessation strategy. The 5A's is an office-based intervention developed to be used under the guidance of trained practitioners to help pregnant women quit smoking. Knowledge of the use of the 5A's, health care support systems, and pharmacotherapy add to the techniques providers can use to support perinatal smoking cessation. The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically.

Developing a Biomarker Feedback Intervention to Motivate Smoking Cessation During Pregnancy: Phase II MAW Study

INTRODUCTION

The prevalence of smoking during pregnancy for Alaska Native (AN) women is more than triple that of non-Native Alaska women. In this qualitative study, we solicited input from AN women and others to determine how best to present findings from an earlier study demonstrating a strong correlation between biomarkers for maternal smoking (cotinine) and neonatal exposure to a tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) to motivate cessation.

METHODS

We developed a brochure incorporating generalized biomarker information. Using in-depth individual interviews with pregnant and postpartum AN women and partners/family members, we explored applicability and acceptability of the information. Postpartum women, who had participated in the earlier correlation study, additionally received their individual biomarker results. We assessed whether being presented general or individual biomarker information would motivate cessation using content analysis.

RESULTS

We conducted 39 interviews: 16 pregnant women, 12 postpartum women, and 11 partners/family members. Overall, participants agreed the biomarker information was new, but understandable as presented. Postpartum women shared that learning their personal results inspired them to want to quit or cut back smoking while pregnant women indicated the generalized correlation information was less helpful in motivating cessation.

CONCLUSION

Generalized information about fetal exposure to carcinogens may be more effective in motivating pregnant women to quit smoking when combined with individual cotinine testing.

IMPLICATIONS

Using feedback from this study, we refined and are currently evaluating an intervention incorporating generalized correlation information from Phase I and cotinine testing to determine its effectiveness in motivating smoking cessation among pregnant AN women.

Correlates of partner support to abstain from prenatal alcohol use: a cross-sectional survey among Dutch partners of pregnant women

Partners can play an important role, but are often ignored in interventions targeting the prevention of prenatal alcohol use. A better understanding of the correlates of partner support to abstain from prenatal alcohol use can help to make a better use of partner support. The aim of this study was to identify correlates of this support by analysing differences between partners reporting low versus high support. An online cross-sectional study among 237 Dutch partners of pregnant women was conducted. Respondents were recruited through Dutch midwifery practices in September-October 2009. Questionnaires were based on the I-Change Model. Chi-square and t-test showed that partners reporting high support were more likely to desire their partner to abstain from alcohol use and to have received advice from their pregnant spouse or midwife that abstinence was desirable. They also had stronger perceptions that the baby would experience harm from prenatal alcohol use and that harm could be more severe, and they saw more advantages and fewer disadvantages of providing support. They also reported more influence from their social environment encouraging their support, had greater self-efficacy and had a stronger intention to support their partner during the remainder of the pregnancy compared to partners reporting low support. Health professionals may improve their alcohol advice by discussing the advantages and disadvantages of support with the partner and by encouraging couples to discuss and propose solutions for the situations in which partners find it difficult not to support alcohol abstinence. By providing an insight into important correlates of partner support, this study expands the research area aiming to reduce prenatal alcohol use.

Translating Efficacy Research to Effectiveness Studies in Practice: Lessons From Research to Promote Smoking Cessation in Community Health Centers

Researchers and their community partners have been challenged by funders and political entities to translate what is learned in research into practice. Such translation is more challenging than it appears, and it is important to systematically make use of opportunities available to learn about facilitators and barriers to the implementation of effectiveness research in real-world settings. This article presents a case study of the process evaluation undertaken as part of Quit Together, a randomized trial of the effectiveness of an intervention to improve smoking cessation and relapse prevention among low-income pregnant and postpartum women who receive care at community health centers (CHCs). The analysis considers areas of program implementation failure that may need critical rethinking. The article demonstrates the importance of process-monitoring methods to examine context factors of collaborative research, outlines lessons learned and the challenges of research carried out in CHCs, and summarizes implications for researchers and for practitioners.

Predictors of alcohol and other drug use among pregnant women in a peri-urban South African setting

BACKGROUND

Alcohol and other drugs (AOD) use among pregnant women have been associated with adverse health outcomes for mother and child, during and after pregnancy. Factors associated with AOD use among women include age, poverty, unemployment, and interpersonal conflict. Few studies have looked at demographic, economic, and psychosocial factors as predictors of AOD use among pregnant women in low-income, peri-urban settings. The study aimed to determine the association between these risk factors and alcohol and drug use among pregnant women in Hanover Park, Cape Town.

METHODS

The study was undertaken at a Midwife Obstetric Unit providing primary-level maternity services in a resource-scarce area of South Africa. 376 adult women attending the unit were recruited and a multi-tool questionnaire administered. Demographic, socioeconomic and life events data were collected. The Expanded Mini-International Neuropsychiatric Interview Version 5.0.0 was used to assess alcohol abuse and other drugs use, depression, anxiety, and suicidal ideation. Descriptive and bivariate analyses were conducted to examine the associations between predictor variables. Non-parametric tests, Wilcoxon sum of rank test, Fisher Exact and two sample T test and multicollinearity tests were performed. Logistic regression was conducted to identify associations between the outcome of interest and key predictors. A probability value of p ≤ 0.05 was selected.

RESULTS

Of the total number of pregnant women sampled, 18 % reported current AOD use. Of these, 18 % were currently experiencing a major depressive episode, 19 % had a current anxiety diagnosis, and 22 % expressed suicidal ideation. Depression, anxiety, suicidality, food insecurity, interpersonal violence, relationship dynamics, and past mental health problems were predictors of AOD use.

CONCLUSIONS

This study has confirmed the vulnerability of pregnant women in low-income, peri-urban settings to alcohol abuse and other drugs use. Further, the association between diagnosed depression and anxiety, suicidality, and AOD use among these women may reflect how complex environmental factors support the coexistence of multiple mental health problems. These problems place mothers and their infants at high risk for poor health and development outcomes. The results have implications for planning appropriate interventions.

Factors Associated with Early Pregnancy Smoking Status Among Low-Income Smokers

OBJECTIVES

To compare pregnant women who are current smokers at their first prenatal visit with those who recently quit smoking in the 90 days prior to their first prenatal visit (i.e., spontaneous quitters) to identify differences between them and factors that predict their intake smoking status.

METHODS

One hundred and thirty participants were enrolled in this cross-sectional research study. The sample was drawn from a population of pregnant women attending their first prenatal visit at a low-income obstetrics clinic in Baltimore, Maryland; the large majority of which have characteristics that previous research has identified as putting them at high-risk of continued smoking during pregnancy. Participants were recruited through referrals from clinical staff. Intake data collection occurred between March and December, 2013.

RESULTS

Of the 130 pregnant women enrolled in the study, 126 had complete intake data. The sample included 86 current smokers and 40 recent quitters. The large majority of participants were African American with an average age of 26. Current smokers were significantly more likely than recent quitters to have: more depression symptoms; self-perceived stress; internalizing and externalizing disorder symptoms; substance use disorders; and tobacco dependence. The most significant predictors of smoking status at first prenatal visit were depressive symptoms, readiness to quit, and number of children.

CONCLUSIONS

for Practice Differences were identified at intake among this sample of pregnant women already considered to be at high-risk for continued smoking throughout their pregnancy. This study identified relevant factors associated with whether or not a woman had recently quit smoking in early pregnancy or was continuing to smoke at her first prenatal visit. Knowledge of these factors may benefit physicians in understanding and promoting smoking cessation throughout the perinatal period and specifically intervening to decrease depressive symptoms and increasing readiness to quit may improve outcomes.

Understanding Inequalities of Maternal Smoking--Bridging the Gap with Adapted Intervention Strategies

Women who are generally part of socially disadvantaged and economically marginalized groups are especially susceptible to smoking during pregnancy but smoking rates are underreported in both research and interventions. While there is evidence to support the short-term efficacy of nicotine replacement therapy (NRT) use in pregnancy, long-term abstinence rates are modest. Current health strategies and interventions designed to diminish smoking in pregnancy have adopted a simplified approach to maternal smoking-one that suggests that they have a similar degree of choice to non-pregnant smokers regarding the avoidance of risk factors, and overlooks individual predictors of non-adherence. As a result, interventions have been ineffective among this high-risk group. For this reason, this paper addresses the multiple and interacting determinants that must be considered when developing and implementing effective strategies that lead to successful smoking cessation: socioeconomic status (SES), nicotine dependence, social support, culture, mental health, and health services. Based on our review of the literature, we conclude that tailoring cessation programs for pregnant smokers may ultimately optimize NRT efficacy and reduce the prevalence of maternal smoking.

Systematic Review of Interventions for Racial/Ethnic-Minority Pregnant Smokers

INTRODUCTION

Large disparities exist in smoking rates during pregnancy by racial/ethnic status.

AIMS

The current review examined controlled studies that predominantly included racial/ethnic-minority pregnant smokers for providing smoking cessation treatment.

METHODS

Two authors independently conducted the literature searches in the standard databases using a combination of the keywords with minority, pregnancy, smoking, and cessation identifiers.

RESULTS

The searches identified nine articles that met the inclusion criteria. Only two studies exclusively targeted specific minority groups. Most of them provided some form of brief smoking cessation counseling, with two combining with incentives and one combining with pharmacotherapy. Two studies provided intensive cognitive interventions. Pregnant smokers of American Indian or Alaska Native, Hispanic subgroups, and Asian or Pacific Islander are under-studied.

CONCLUSIONS

Future studies to treat minority pregnant smokers could target under-studied minority groups and may need to directly and intensely target smoking behavior, address cultural and psychosocial issues in an individualized and comprehensive manner, and analyze cost-benefit of an intervention.

Comparison of nicotine dependence indicators in predicting quitting among pregnant smokers

Research in the general population of smokers indicates that across various measures of nicotine dependence, time to first cigarette (TTFC) is the strongest single-item predictor of quitting success. Whether those findings generalize to pregnant smokers is unclear. To investigate this matter, we compared TTFC with cigarettes per day (CPD) and the Heaviness of Smoking Index (HSI; Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994) in predicting late-pregnancy abstinence among 289 pregnant women enrolled in 4 smoking-cessation trials assessing the efficacy of financial incentives. Logistic regression was used to compare predictors, with model fit measured using the c statistic (range = 0.5, poor prediction to 1.0, perfect prediction). In simple regressions, model fit was comparable across the 3 measures although strongest for CPD alone (c = 0.70, 0.68, 0.66 for CPD, HSI, and TTFC, respectively). In a stepwise multiple regression, treatment was entered first (c = 0.67), then CPD (c = 0.77), quit attempts prepregnancy (c = .81), TTFC (c = .82), and quit attempts during pregnancy (c = .83). We saw no evidence supporting TTFC as the optimal predictor of quitting among pregnant smokers. Instead, the evidence supported using CPD and TTFC together or CPD alone if using only a single predictor.

Receipt and Timing of Pregnancy-Related Preventive Health Messages Vary by Message Type and Maternal Characteristics

Purpose.

To determine when women receive pregnancy-related preventive health messages and to examine differences in receipt timing by maternal characteristics.

Design.

The cross-sectional secondary analyses used data from the Pregnancy Risk Assessment Monitoring System (PRAMS).

Setting.

The study used PRAMS responses from Maryland, Michigan, New Jersey, Ohio.

Subjects.

Study participants were women with a recent live birth.

Measures.

Health messages included mental health, safe medications, smoking, alcohol, and illegal drugs. The timing of message receipt was categorized as early (preconceptionally and prenatally) or late (prenatally only/never).

Analysis.

Weighted χ2 tests and multivariable logistic regression were used for analysis.

Results.

Among n = 3446, women with unintended pregnancies received all messages, except safe medications, significantly more early vs. late compared with women intending pregnancies (all p < .01). In multivariable analyses, there were no significant associations between timing of receipt and pregnancy intention, parity, preconception insurance status, or adequacy of prenatal care for any of the health messages. Hispanic women had increased odds of receiving the messages early compared with non-Hispanic white women, as did high school graduates vs. women with more education and women with lower household incomes vs. women with higher incomes.

Conclusions.

Women who may be perceived to be at higher risk of adverse pregnancy outcomes and/or engaging in high-risk behavior (minorities, lower education, lower income) appear to be getting messages early more often than do other women; messages are not reaching all women equally.

Knowledge and attitudes of adults towards smoking in pregnancy: results from the HealthStyles© 2008 survey

Smoking during pregnancy is causally associated with many adverse health outcomes. Quitting smoking, even late in pregnancy, improves some outcomes. Among adults in general and reproductive-aged women, we sought to understand knowledge and attitudes towards prenatal smoking and its effects on pregnancy outcomes. Using data from the 2008 HealthStyles© survey, we assessed knowledge and attitudes about prenatal smoking and smoking cessation. We classified respondents as having high knowledge if they gave ≥ 5 correct responses to six knowledge questions regarding the health effects of prenatal smoking. We calculated frequencies of correct responses to assess knowledge about prenatal smoking and estimated relative risk to examine knowledge by demographic and lifestyle factors. Only 15 % of all respondents and 23 % of reproductive-aged women had high knowledge of the adverse effects of prenatal smoking on pregnancy outcomes. Preterm birth and low birth weight were most often recognized as adverse outcomes associated with prenatal smoking. Nearly 70 % of reproductive-aged women smokers reported they would quit smoking if they became pregnant without any specific reasons from their doctor. Few respondents recognized the benefits of quitting smoking after the first trimester of pregnancy. Our results suggest that many women lack knowledge regarding the increased risks for adverse outcomes associated with prenatal smoking. Healthcare providers should follow the recommendations provided by the American Congress of Obstetricians and Gynecologists, which include educating women about the health risks of prenatal smoking and the benefits of quitting. Healthcare providers should emphasize quitting smoking even after the first trimester of pregnancy.

Receiving Versus Being Denied a Pregnancy Termination and Subsequent Alcohol Use: A Longitudinal Study

AIM

Research finds women who terminate pregnancies are at risk of subsequent problematic alcohol use, but methodological and conceptual problems are common. This study examines the relationship between receiving versus being denied termination and subsequent alcohol use.

METHODS

Data are from a prospective, longitudinal study of US women seeking pregnancy terminations. Participants presented just before a facility's gestational limit and received terminations (Near Limits, n = 452) or just beyond the limit and were denied terminations (Turnaways, n = 231).

RESULTS

Groups did not differ in alcohol use before pregnancy recognition. One week after termination-seeking (Turnaways still pregnant, Near Limits not), Turnaways had lower odds of any and binge alcohol use, but did not differ on 1+ problem symptoms. Over 2.5 years, both Near Limits and Turnaways increased any and binge alcohol use, with Turnaways increasing more rapidly. The groups did not converge again on any or binge use. For Near Limits, any alcohol use surpassed the pre-pregnancy recognition level, but binge use did not. Changes in problem symptoms over time were not evident for either group.

CONCLUSION

While women who had a termination were more likely to report any and binge alcohol use than women who had a child, this difference was due to a reduction in consumption among women having the child rather than an increase in consumption among women having a termination. Thus, assertions that having a termination leads women to increase alcohol use to cope with having had a termination are not supported.

A content analysis of self-reported barriers and facilitators to preventing postpartum smoking relapse among a sample of current and former smokers in an underserved population

To characterize the barriers and facilitators thatprevent postpartum relapse and maintain smoking abstinence among a socioeconomically underserved population, recruited through Philadelphia-area women, infants, and children clinics, in-person interviews were conducted with 30 women who had quit smoking for one or more pregnancies in the past 3 years to retrospectively describe their attempts to remain abstinent during the postpartum period. Responses were analysed using the constructs from the Cognitive-Social Health Information Processing model, which identifies the cognitive, affective and behavioral factors involved in goal-oriented self-regulatory actions, in the context of a vulnerable population of women. Motherhood demands were a significant source of relapse stress. Stresses associated with partner and family relationships also contributed to relapse. The presence of other smokers in the environment was mentioned by many women in our sample as affecting their ability to remain smoke-free postpartum. Participants reported four main strategies that helped them to successfully cope with postpartum cravings and relapses, including being informed of smoking risks, maintaining goal-oriented thoughts, focusing on their concerns about the baby's health and receiving positive social support from families and friends. Results provide guidance for the design of smoking relapse interventions that may address the unique stressors reported by underserved postpartum women.

Identifying high-risk subgroups for alcohol consumption among younger and older pregnant women

AIMS

Recent studies indicate that older women are more likely to consume alcohol during pregnancy, but subgroups at highest risk within the context of maternal age have not been identified. This study identifies subgroups at risk for alcohol use during pregnancy among three age categories using classification and regression trees (CART) analysis.

METHODS

Using the 2002-2009 Pregnancy Risk Assessment Monitoring System (PRAMS) dataset (311,428 records of U.S. women), logistic regression and classification trees were constructed separately for age groups, ≤24, 25-29, and ≥30 years.

RESULTS

Overall, 6.5% of women reported drinking alcohol during the last trimester of pregnancy. Alcohol consumption by age group was: 3.7% for ≤24, 5.7% for 25-29, and 10.1% for ≥30 years of age. Women ≤24 years were at greater risk of consuming alcohol if they also smoked (5.8%). Among nonsmokers, higher levels of education and being Hispanic were associated with a 35% increase in alcohol use. Distinct high-risk subgroups emerged for the 25-29-year-old group. Specifically, 12.8% of non-obese women who reported having experienced abuse during pregnancy also reported drinking alcohol in the last trimester. About 16% of women ≥30 years with at least 16 years of education, White or Hispanic with normal or underweight BMI, drank alcohol during their last trimester.

CONCLUSIONS

Given limited health care resources for prevention and treatment, the early identification of high-risk groups for prenatal alcohol use is critical. This study provides evidence that risk factors contributing to alcohol consumption during pregnancy may differ by maternal age.

Alcohol use before and during unwanted pregnancy

BACKGROUND

There is little information about pregnancy-related changes in alcohol use and factors contributing to changes among women with unwanted pregnancies. This study describes changes in alcohol use from before pregnancy recognition to during pregnancy and identifies important predictors of alcohol use severity among women with unwanted pregnancies.

METHODS

Data are from the Turnaway Study of 956 women seeking pregnancy termination at 30 U.S. facilities between 2008 and 2010, some of whom were denied care because they were past the gestational limit of the facility where they were recruited and were still pregnant at the baseline interview, 1 week after termination seeking. Predictors of alcohol use severity (a latent variable) were identified.

RESULTS

About 56% of the total sample reported any alcohol use the month before pregnancy recognition, with 23% reporting 6 or more drinks on an occasion. Among the total sample, 35% of those drinking before pregnancy recognition had quit and 20% had reduced 1 week after termination seeking. Among those denied terminations and still pregnant, 71% had quit and 14% had reduced. In a multivariate model predicting alcohol severity, younger age, still pregnant, 1 or more previous births, later gestation, childhood physical abuse, and marijuana and other drug use were associated with lower severity; having completed college, tobacco use, and recent physical violence were associated with higher severity.

CONCLUSIONS

The proportion of the total sample drinking before pregnancy recognition is similar to national samples of women of childbearing age, while the proportion binge drinking appears higher. Of women denied terminations, who were still pregnant, the proportion having quit is similar to other populations of pregnant women. More research is needed to examine whether pregnant women may be substituting alcohol for marijuana and other drugs. Interventions focusing on alcohol use severity during pregnancy may need to also focus on tobacco.

Predictors of smoking cessation counseling adherence in a socioeconomically disadvantaged sample of pregnant women

Implementing and evaluating smoking cessation interventions in underserved populations has been found difficult due to high rates of non-adherence to the prescribed protocol. To understand better the barriers to cessation participation, we studied low-income inner-city pregnant women who were enrolled in either a standard or highly intensive quit smoking counseling program. The results showed that 1) in the prenatal phase, non-attendance was predicted by a greater number of cigarettes smoked per day; 2) in the postpartum follow-up phase, non-attendance was predicted by lower educational level and higher self-efficacy for quitting smoking; and 3) participants with more children living at home were at increased risk of rescheduling the postpartum follow-up session. These findings suggest that innovative delivery strategies are needed more effectively to assess and address risk factors for non-adherence to smoking cessation trials among underserved minority pregnant/postpartum smokers.

Continued smoking and continued alcohol consumption during early pregnancy distinctively associated with personality

Pregnancy is a unique period to quit smoking and alcohol consumption and although motivated, not all women succeed at this. We investigated the associations of personality with continued smoking and continued alcohol consumption during early pregnancy. In addition, we studied whether antenatal anxiety and depressive symptoms can explain these associations. Two antenatal measurements from the population-based Pregnancy Anxiety and Depression cohort study were used. Pregnant women in their first trimester were recruited via midwifery practices and hospitals. We analyzed a sample of women who continued (n=101) or quit smoking (n=254), and a sample of women who continued (n=110) or quit alcohol consumption (n=1230). Measures included questions about smoking, alcohol consumption, the NEO-Five Factor Inventory (personality), the State Trait Anxiety Inventory, and the Edinburgh Postnatal Depression Scale. We found associations between continued alcohol consumption and higher levels of openness to experience, and lower levels of conscientiousness (p<0.05). The association between conscientiousness and continued alcohol consumption was partly explained by both anxiety and depressive symptoms. No associations between personality and continued smoking emerged. This study contributes to the limited literature on personality differences between women who continue and quit smoking and alcohol consumption during early pregnancy. General population studies have not confirmed the association between openness to experience and alcohol consumption which implies that pregnancy is indeed a unique period. Increased insight in how personality influences continued smoking and alcohol consumption during pregnancy can help health professionals to improve lifestyle interventions targeted at pregnant women.

Smoking cessation during pregnancy and postpartum: practice patterns among obstetrician-gynecologists

OBJECTIVES

To assess current obstetrician-gynecologist (ob-gyn) practice patterns related to the management of and barriers to smoking cessation during pregnancy and postpartum.

METHODS

A smoking cessation questionnaire was mailed to 1024 American College of Obstetricians and Gynecologists Fellows in 2012. χ(2) analyses were used to assess for categorical differences between groups, Pearson r was used to conduct correlational analysis, and analysis of variance was used to assess for mean differences between groups.

RESULTS

The analyses included 252 practicing ob-gyns who see pregnant patients who returned a completed survey. Ob-gyns estimated that 23% of their patients smoke before pregnancy, 18% smoke during first trimester, 12% during second trimester, and 11% during third trimester. They approximated that 32% quit during pregnancy, but 50% return to smoking postpartum. A large majority of ob-gyns feel that it is important for pregnant and postpartum women to quit smoking, and report asking all pregnant patients about tobacco use at the initial prenatal visit. Fewer ob-gyns follow-up on tobacco use at subsequent visits when the patient has admitted to use at a prior visit. The primary barrier to intervention was reported as time limitations, though other barriers were noted that may be addressable through the provision of additional training and resources offered to physicians.

CONCLUSIONS

Compared with findings from a similar study conducted in 1998, physicians are less likely to adhere to the 5 As smoking cessation guideline at present. As we know that brief intervention is effective, it is imperative that we work toward addressing practice gaps and providing additional resources to address the important public health issue of smoking during pregnancy and postpartum.

Nutrition Information-seeking Behaviour of Low-income Pregnant Maghrebian Women

Purpose

Nutrition information-seeking behaviour was explored among low-income pregnant Maghrebian women living in Montreal. Environmental factors likely to influence nutrition information-seeking behaviour during pregnancy are discussed.

Methods

Data were collected in face-to-face interviews with 14 primigravid pregnant women recruited via the Montreal Diet Dispensary, a nonprofit agency with the mission of promoting health among low-income pregnant women. Data collection was part of a larger project on pregnant women’s nutrition decision-making.

Results

Environmental factors likely to influence informationseeking behaviour were identified. They were grouped within two major themes: culture and interactions with individuals from the social environment. The culture theme was divided into three minor themes: eating habits, food beliefs, and religious beliefs. The interactions with individuals from the social environment theme was divided into two minor themes: interactions with health care providers and interactions with family members.

Conclusions

Understanding the influence of these environmental factors should help registered dietitians tailor communication strategies to pregnant immigrant women’s specific information needs.

The many faces of tobacco use among women

Smoking is still considered to be mainly a male problem. However, it is estimated that there are approximately 250 million women worldwide who smoke cigarettes and millions more women who use smokeless tobacco products. This article addresses the many facets of tobacco use among women. The aim of the paper is to increase recognition among clinicians and researchers of the specific characteristics of female tobacco use. Together with providing epidemiological data on the distribution of tobacco use among women and data from population-based analyses on sociocultural factors that influence it, the article presents tobacco use during pregnancy as a particularly important public health problem. Further, the article points out sex-related differences (ie, physiological, psychological, or behavioral) between male and female tobacco use. A special focus is on the important role of ovarian hormones. Adverse effects of tobacco use to women and their children as well as tobacco-related morbidities and comorbidities are presented, and women's greater susceptibility to tobacco constituents as compared to men is stressed. Awareness of these differences can contribute to improvement of the effectiveness of smoking cessation programs addressed both to the specific female population and to an individual smoking woman.

Stressful events and continued smoking and continued alcohol consumption during mid-pregnancy

Aim

to examine whether the severity of different categories of stressful events is associated with continued smoking and alcohol consumption during mid-pregnancy. Also, we explored the explanation of these associations by anxiety and depressive symptoms during pregnancy. Finally, we studied whether the severity of stressful events was associated with the amount of cigarettes and alcohol used by continued users.

Method

we conducted a cross-sectional analysis using data from a population-based prospective cohort study. Pregnant women were recruited via midwifery practices throughout The Netherlands. We analyzed women who continued smoking (n = 113) or quit (n = 290), and women who continued alcohol consumption (n = 124) or quit (n = 1403) during pregnancy. Smoking, alcohol consumption, and perceived severity of stressful events were measured at 19 weeks of gestation. The State Trait Anxiety Inventory and the Edinburgh Postnatal Depression Scale were filled out at 14 weeks of gestation. Odds ratios were calculated as association measures and indicated the relative increase for the odds of continuation of smoking and alcohol consumption for the maximum severity score compared to the minimum score.

Findings

severity of the following stressful event categories was associated with continued alcohol consumption: ‘conflict with loved ones’ (OR = 10.4, p<0.01), ‘crime related’ (OR = 35.7, p<0.05), ‘pregnancy-specific’ (OR = 13.4, p<0.05), and the total including all events (OR = 17.2, p<0.05). Adjustment for potential confounders (age, parity and educational level) did not notably change the estimates. There was no association of anxiety and depressive symptoms with continued smoking or alcohol consumption. No associations emerged for continued smoking and severity of stressful events. The amount of cigarettes and alcohol consumption among continued users was not associated with severity of stressful events.

Conclusions

Our findings may be relevant for health care providers, in particular midwives and general practitioners. The impact of stressful events may be considered when advising pregnant women on smoking and alcohol consumption.

Low-income women's recommendations for promoting early pregnancy recognition

INTRODUCTION

This study explored low-income women's perspectives on how to promote early recognition of pregnancy as one strategy to address community residents' concerns related to unintended pregnancy. Unintended pregnancy, which is more prevalent among low-income women and minorities, has been associated with various adverse pregnancy outcomes.

METHODS

This study used the ideological perspective of community-based participatory research. Six focus groups were conducted in 3 low-income, urban, medically underserved neighborhoods with ethnically diverse populations. Neighborhood women who were either pregnant or had experienced a pregnancy within 3 years were invited to participate in the study. A structured interview guide focused the discussion on how to promote early recognition of pregnancy within the existing context of unintended pregnancies in the neighborhoods. Focus-group sessions were audiotaped, then transcribed verbatim; the data were analyzed using an open-coding template approach assisted by QSR NVivo 8 software.

RESULTS

Forty-one women aged 18 to 44 years participated in the study. Thirty-nine percent were African American, 24.4% were Hispanic/Latino, 19.5% were American Indians, and 17.1% were white. Three primary themes were identified: 1) women should know the menstrual/ovulation and pregnancy-related changes that occur in their bodies; 2) women should be prepared to confirm their pregnancies early, as soon as they suspect they may be pregnant; and 3) both information and emotional support are needed for pregnancy-related issues. "Knowing your body" was the strongest advice to promote early recognition of pregnancy.

DISCUSSION

The participants in this study suggested that education about reproductive changes should be initiated during early adolescence and in the preconception period. Early testing and confirmation of pregnancy should also be promoted, especially for women who have unprotected intercourse. Local resources for information and emotional support during pregnancy should be accessible to women.

A prospective study of prevalence and predictors of concurrent alcohol and tobacco use during pregnancy

Concurrent drinking and smoking during pregnancy is a major public health concern. Changes in these behaviours are under-researched, although essential if effective interventions are to be implemented. Hence this paper investigated characteristics of women who decreased concurrent drinking and smoking during pregnancy. 1,591 women were identified as pregnant at one of three surveys from 2000 to 2006 of the Australian Longitudinal Study on Women's Health and not pregnant at the previous survey. Relative risks (RRs) were calculated for concurrent drinkers and smokers before pregnancy of (1) decreasing drinking, (2) decreasing smoking and (3) decreasing drinking and smoking during pregnancy. Three hundred and fifty-four women (22%) were concurrent drinkers and smokers before pregnancy; of these women, 73% decreased drinking, 72% decreased smoking and 53% decreased drinking and smoking during pregnancy. Decreased concurrent drinking and smoking was significantly higher among women who had at least 12 years education (RRs: 1.5-1.6), who drank at least 1-2 days/week (RRs: 1.5-1.6) and who had 3 or more drinks per occasion (RRs: 1.6-1.8), and significantly lower among heavy smokers, mothers of other children (RRs: 0.8) and disadvantaged women: those stressed about money, with poor mental health, low social support and experience of partner violence (RRs: 0.6-0.7). Clearly programs are needed to tackle concurrent drinking and smoking during pregnancy. Given many pregnancies are unplanned, these programs should target drinking and smoking before and during pregnancy, as well as disadvantaged women, to reduce the deleterious effects of concurrent substance use on their babies and themselves.

Nicotine addiction in light smoking African American mothers

Although African Americans (AA) smoke fewer average cigarettes per day (CPD) than European Americans (EA), they carry a disproportionate tobacco related morbidity and mortality burden.

OBJECTIVE

To evaluate ethnic differences in markers of nicotine addiction, including rates of lifetime nicotine dependence (ND) symptoms, current smoking and smoking during pregnancy across different levels of peak lifetime cigarette consumption.

METHODS

Data from 237 EA (N=118) and AA (N=119) mothers participating in the Missouri Family Study (2003-2005), an ethnically diverse family study of offspring outcomes in high and low risk families, were used to contrast prevalence of ND symptoms and other smoking behaviors between EA and AA women at low (1-10 CPD), moderate (11-19 CPD), and high (≥ 20 CPD) levels of lifetime peak daily cigarette consumption.

RESULTS

Compared with EA smokers, AAs had lower lifetime prevalence of DSM-IV ND (68% v. 54%, p<.05), consumed fewer CPD during their heaviest lifetime consumption (18% EA v. 58% AA smoked ≤ 10 CPD, p<.0001), but did not differ in overall rates of smoking during pregnancy or current smoking. However, stratifying by categories of peak lifetime daily cigarette use, AA mothers who smoked ≤ 10 CPD reported greater lifetime ND symptoms and current smoking than their EA counterparts. In addition, nearly two-thirds of AA mothers in this smoking category smoked during pregnancy and 30% smoked throughout an entire pregnancy. The respective prevalence estimates in EA mothers were 38% and 0%.

CONCLUSIONS

Stratifying the sample into categories of lifetime peak daily cigarette use revealed significant ethnic/racial differences in smoking prevalence during pregnancy that were obscured in overall analysis. Substantial public health risks warranting clinical attention exist among light smokers, particularly AA women.

Impact of smoking exposure change on infant birth weight among a cohort of women in a prenatal smoking cessation study

INTRODUCTION

Despite the known harmful effects of smoking during pregnancy, the highly addicted find it difficult to quit. Decreased smoking may be regarded as a means of harm reduction. There is limited information on the benefits of smoking reduction short of quitting. This study used salivary cotinine to assess the impact of change in smoking exposure on birth weight in full-term infants.

METHODS

In a prenatal smoking cessation study, smoking status was validated by saliva cotinine at baseline and end of pregnancy (EOP). Salivary cotinine ≥15 ng/ml defined active smoking. Based on salivary cotinine, women were grouped as nonsmoking/quit, light exposure (<150 ng/ml), and heavy exposure (≥150 ng/ml) at baseline and EOP. EOP and baseline smoking status were stratified to form smoking exposure change groups. Mean birth weight was compared among those who quit, reduced, maintained, and increased.

RESULTS

Smoking cessation was associated with a 299 g increase in birth weight compared with sustained heavy smoking, p = .021. Reduced exposure from heavy to light was associated with a 199 g increase in birth weight compared with sustained heavy exposure, a 103 g increase compared with increased exposure, and a 63 g increase compared with sustained light exposure. Differences among continuing smokers were not statistically significant.

CONCLUSIONS

Although not statistically significant, the increase in infant birth weight associated with reduction from heavy to light exposure suggests potential for benefit. The only statistically significant comparison was between quitters and sustained heavy smokers, confirming that smoking cessation should remain the goal for pregnant women.

Smoking cessation in pregnant women with mental disorders: a cohort and nested qualitative study

OBJECTIVE

To investigate whether 1) pregnant smokers with mental disorders are less likely to accept referrals to smoking cessation services compared with pregnant smokers without disorders; 2) they experience specific barriers to smoking cessation.

DESIGN

Cohort study supplemented by cross-sectional survey and nested qualitative study.

SETTING

Three maternity services, London, UK.

POPULATION

Pregnant smokers with and without mental disorders.

METHODS

Case notes were examined on a cohort of 400 consecutive pregnant smokers; data were triangulated with routinely collected data on 845 pregnant smokers at two other sites; 27 pregnant smokers were interviewed using qualitative methods.

MAIN OUTCOME MEASURES

Acceptance of referral to smoking cessation services; perceived barriers to quitting.

RESULTS

Pregnant smokers with a mental disorder recorded by midwives were one-quarter of the cohort (97, 23%), were more likely to accept referral to smoking cessation services (69% versus 56%, adjusted odds ratio 1.70, 95% confidence interval 1.03-2.79), but more likely to still smoke at delivery (69% versus 56%, adjusted odds ratio 2.63, 95% confidence interval 1.41-4.92). Discussion about smoking was documented in 7.7% of subsequent antenatal visits in women with or without mental disorders. Pregnant smokers with diagnosed mental disorders reported that they and health practitioners did not prioritise smoking advice because of concern about adversely impacting mental health.

CONCLUSIONS

Pregnant women with mental disorders appear more motivated, yet find it more difficult, to stop smoking. Prioritisation of mental health over smoking may therefore lead to increasing health inequality for this group. Research into effective smoking cessation interventions is required for those with mental disorders.

Mental health problems, legal involvement, and smoking during pregnancy

The current study examined predictors of past 30-day cigarette use among a US nationally representative sample of pregnant women over the age of 18 (N = 1,782). The study consisted of secondary data analysis of the 2005-2007 survey years of the National Survey on Drug Use and Health (NSDUH). Logistic regression analyses indicated that low-income women, those who experienced mental health problems in the past year, and women who experienced legal problems were more likely to smoke during pregnancy. Limitations to the study as well as implications for future research are discussed.

Alcohol consumption after the recognition of pregnancy and correlated factors among indigenous pregnant women in Taiwan

To examine the rates and factors associated with alcohol consumption after the recognition of pregnancy among indigenous pregnant women, as well as the rates and factors associated with continuing alcohol consumption after the recognition of pregnancy among indigenous pregnant women who drank alcohol before the recognition of pregnancy in 10 hospitals in southern and eastern Taiwan. A total of 806 indigenous women who had just given birth in 10 hospitals in southern and eastern Taiwan were recruited. They were interviewed to collect their substance use information, demographic characteristics, psychological health status, history of physical abuse, and pregnancy history. The rates of alcohol consumption after the recognition of pregnancy in all indigenous pregnant women and the rates of continuing alcohol consumption after the recognition of pregnancy among those who drank alcohol before the recognition of pregnancy were calculated. The factors relating to alcohol consumption and continuing alcohol consumption after the recognition of pregnancy were examined using logistic regression analyses. The results of this study found that 26.6% of indigenous pregnant women drank alcohol at any stage after the recognition of pregnancy, and 52.5% of indigenous pregnant women who drank alcohol before the recognition of pregnancy persisted in drinking alcohol after the recognition of pregnancy. Multiple parities, smoking or chewing betel quid after the recognition of pregnancy, and a higher frequency of drinking alcohol before the recognition of pregnancy were significantly associated with alcohol consumption and continuing alcohol consumption after the recognition of pregnancy. Meanwhile, being single or divorced, and intimate partner violence after the recognition of pregnancy were significantly associated with alcohol consumption after the recognition of pregnancy. High prevalence rates of alcohol consumption and continuing alcohol consumption after the recognition of pregnancy were found among indigenous pregnant women in Taiwan. Early detection of alcohol consumption and effective intervention for alcohol consumption during pregnancy are needed.

Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions

INTRODUCTION AND AIMS

Smoking rates are three times as high for pregnant Indigenous women relative to non-Indigenous women, in Australia. This paper describes Indigenous women's self-reported antenatal smoking behaviour and compares knowledge and attitudes of those who: (i) smoke and don't smoke during pregnancy; and (ii) quit or continued to smoke since the beginning of pregnancy.

DESIGN AND METHODS

Cross-sectional surveys with 264 pregnant Indigenous women in two states collected data on smoking status, antenatal changes, risk knowledge, attitudes to smoking and sociodemographic characteristics. Multivariable logistic regression analyses assessed associations between knowledge and attitude variables and smoking status and antenatal changes in smoking status.

RESULTS

Forty-six per cent of the women (n = 121) reported currently smoking. The majority (68%) who smoked at the beginning of pregnancy reported quitting (21%) or reducing (47%). Relative to smokers, non-smokers had more schooling (P = 0.002), more post-secondary education (P = 0.023), lower parity (P = 0.003), better understanding of smoking-related risks (miscarriage P = 0.01; low birth weight P = 0.003; infant illness P < 0.001; childhood behavioural problems P = 0.007), and less frequently expressed attitudes indicating that quitting was very difficult given other problems they faced. Similar patterns were found for women who quit during pregnancy compared to those who continued smoking.

DISCUSSION AND CONCLUSIONS

Increasing awareness of antenatal smoking risks and the benefits of quitting may motivate women to attempt to quit. However, knowledge alone is unlikely to be sufficient considering the life circumstances of many Indigenous women. Addressing the social environment and daily stressors, particularly those exacerbated by pregnancy, may be critical to supporting quit attempts.

Social-environmental factors related to prenatal smoking

INTRODUCTION

Cigarette smoking during pregnancy is a significant public health issue that has profound effects on maternal and fetal health. Although many women stop smoking upon pregnancy recognition, a large number continue. Given the higher burden of smoking among low-income women, the focus of this study is to examine the impact of pre-conception social-environmental influences on smoking cessation during the first trimester of pregnancy.

METHODS

Pregnant women who presented for prenatal were asked to complete a screening form at their first prenatal appointment. Women who agreed to participate were scheduled for a total of four interviews; a prenatal interview at the end of each trimester and a postnatal interview at 2 months of infant age. The sample for the current report consisted of pregnant women (first trimester) with a partner (N=316).

RESULTS

After controlling for pre-conception heaviness of smoking, a number of social-environmental factors were associated with smoking during the first trimester. Women were more likely to smoke during the first trimester if their partner was a smoker; however, the presence of other household smokers was not associated with increased risk for smoking. Additionally, women with a greater proportion of friends (but not relatives) who smoked and more frequent exposure to environmental tobacco were more likely to smoke.

CONCLUSIONS

This work found differential impacts of the social network on smoking suggesting that understanding relationship type, not simply number of smokers, may be important for smoking cessation efforts. Understanding differences in social network influences on smoking can help to inform interventions.

Analysing recent socioeconomic trends in coronary heart disease mortality in England, 2000-2007: a population modelling study

BACKGROUND

Coronary heart disease (CHD) mortality in England fell by approximately 6% every year between 2000 and 2007. However, rates fell differentially between social groups with inequalities actually widening. We sought to describe the extent to which this reduction in CHD mortality was attributable to changes in either levels of risk factors or treatment uptake, both across and within socioeconomic groups.

METHODS AND FINDINGS

A widely used and replicated epidemiological model was used to synthesise estimates stratified by age, gender, and area deprivation quintiles for the English population aged 25 and older between 2000 and 2007. Mortality rates fell, with approximately 38,000 fewer CHD deaths in 2007. The model explained about 86% (95% uncertainty interval: 65%-107%) of this mortality fall. Decreases in major cardiovascular risk factors contributed approximately 34% (21%-47%) to the overall decline in CHD mortality: ranging from about 44% (31%-61%) in the most deprived to 29% (16%-42%) in the most affluent quintile. The biggest contribution came from a substantial fall in systolic blood pressure in the population not on hypertension medication (29%; 18%-40%); more so in deprived (37%) than in affluent (25%) areas. Other risk factor contributions were relatively modest across all social groups: total cholesterol (6%), smoking (3%), and physical activity (2%). Furthermore, these benefits were partly negated by mortality increases attributable to rises in body mass index and diabetes (-9%; -17% to -3%), particularly in more deprived quintiles. Treatments accounted for approximately 52% (40%-70%) of the mortality decline, equitably distributed across all social groups. Lipid reduction (14%), chronic angina treatment (13%), and secondary prevention (11%) made the largest medical contributions.

CONCLUSIONS

The model suggests that approximately half the recent CHD mortality fall in England was attributable to improved treatment uptake. This benefit occurred evenly across all social groups. However, opposing trends in major risk factors meant that their net contribution amounted to just over a third of the CHD deaths averted; these also varied substantially by socioeconomic group. Powerful and equitable evidence-based population-wide policy interventions exist; these should now be urgently implemented to effectively tackle persistent inequalities.