Repeated validation of parental self-reported smoking during pregnancy and infancy: a prospective cohort study of infants at high risk for allergy development

A Comparison of Measured Airborne and Self-Reported Secondhand Smoke Exposure in the MADRES Pregnancy Cohort Study

INTRODUCTION

Secondhand smoke (SHS) exposure during pregnancy is linked to adverse birth outcomes, such as low birth weight and preterm birth. While questionnaires are commonly used to assess SHS exposure, their ability to capture true exposure can vary, making it difficult for researchers to harmonize SHS measures. This study aimed to compare self-reported SHS exposure with measurements of airborne SHS in personal samples of pregnant women.

METHODS

SHS was measured on 48-hour integrated personal PM2.5 Teflon filters collected from 204 pregnant women, and self-reported SHS exposure measures were obtained via questionnaires. Descriptive statistics were calculated for airborne SHS measures, and analysis of variance tests assessed group differences in airborne SHS concentrations by self-reported SHS exposure.

RESULTS

Participants were 81% Hispanic, with a mean (standard deviation [SD]) age of 28.2 (6.0) years. Geometric mean (SD) personal airborne SHS concentrations were 0.14 (9.41) µg/m3. Participants reporting lower education have significantly higher airborne SHS exposure (p = .015). Mean airborne SHS concentrations were greater in those reporting longer duration with windows open in the home. There was no association between airborne SHS and self-reported SHS exposure; however, asking about the number of smokers nearby in the 48-hour monitoring period was most correlated with measured airborne SHS (Two + smokers: 0.30 µg/m3 vs. One: 0.12 µg/m3 and Zero: 0.15 µg/m3; p = .230).

CONCLUSIONS

Self-reported SHS exposure was not associated with measured airborne SHS in personal PM2.5 samples. This suggests exposure misclassification using SHS questionnaires and the need for harmonized and validated questions to characterize this exposure in health studies.

IMPLICATIONS

This study adds to the growing body of evidence that measurement error is a major concern in pregnancy research, particularly in studies that rely on self-report questionnaires to measure SHS exposure. The study introduces an alternative method of SHS exposure assessment using objective optical measurements, which can help improve the accuracy of exposure assessment. The findings emphasize the importance of using harmonized and validated SHS questionnaires in pregnancy health research to avoid biased effect estimates. This study can inform future research, practice, and policy development to reduce SHS exposure and its adverse health effects.

A mixed methods exploratory study tackling smoking during pregnancy in an urban Aboriginal and Torres Strait Islander primary health care service

Background

Pregnancy can be a time of joy and a time of significant stress. For many Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) women, cigarette smoking, even during pregnancy, is a socially sanctioned behavioural response to stress. Indigenous women smoke during pregnancy at higher rates than their non-Indigenous counterparts.

Methods

A mixed methods, exploratory study, undertaken in an urban, Indigenous primary health care service, tested the impact and acceptability of a smoking cessation intervention for women pregnant with an Indigenous baby, their significant other (SO), and their primary health care service. The intervention included case management, incentivised smoking cessation support and culturally-based art activities.

Results

Thirty-one pregnant women and 16 SOs participated. Nearly half attempted to quit at least once during the study, 36% (4/11) of pregnant women had quit at the 3 month assessment and two remained smoke free 1 month postpartum. Most participants self-reported a reduction in tobacco smoking. Exhaled CO confirmed this for SOs (mean reduction − 2.2 ppm/assessment wave, 95% CI: -4.0, − 0.4 ppm/assessment wave, p = 0.015) but not for pregnant women. Many participants experienced social and economic vulnerabilities, including housing and financial insecurity and physical safety concerns.

Conclusions

Tobacco smoking is normalised and socially sanctioned in Indigenous communities and smoking is frequently a response to the multitude of stressors and challenges that Indigenous people experience on a daily basis. Smoking cessation interventions for pregnant Indigenous women must be cognisant of the realities of their private lives where the smoking occurs, in addition to the impact of the broader societal context. Narrow definitions of success focussing only on smoking cessation ignore the psychological benefit of empowering women and facilitating positive changes in smoking behaviours. Our smoking cessation intervention supported pregnant women and their SOs to manage these stressors and challenges, thereby enabling them to develop a solid foundation from which they could address their smoking. A broad definition of success in this space is required: one that celebrates positive smoking behaviour changes in addition to cessation.

Effects of Maternal Smoking during Pregnancy on Offspring Externalizing Problems: Contextual Effects in a Sample of Female Twins

Studies of maternal smoking during pregnancy (MSDP) suggest increased risk for cognitive impairment and psychiatric outcomes. However, it is uncertain whether these associations are the direct result of MSDP or related to confounding familial variables associated with MSDP. The current study employed propensity score analysis to examine the effects of MSDP on offspring EXT using data from a large sample of 979 unrelated mothers. Logistic regression models were used to determine the propensity that the offspring of these mothers were likely to be exposed to MSDP [i.e., smoked during only the first trimester (MSDP-EARLY[E]) or smoked throughout their pregnancy (MSDP-THROUGHOUT[T])] given known familial confounders. Analyses focused on the effect of MSDP-E/T on the EXT behavior in offspring of these mothers (N = 1616) were conducted across the distribution of liability for MSDP-E/T and at different levels of risk for MSDP-E/T. MSDP-E/T was associated with offspring EXT problems, but the effects were partly confounded by the familial liability for MSDP. Further, the observed effects were not consistent across all levels of the MSDP risk distribution. These findings suggest a direct association between MSDP and offspring EXT behaviors, and that varied associations observed across studies may be the result of differences in the level of familial confounders that also have an effect on offspring EXT.

Peri-gestational risk factors for pediatric brain tumors in Neurofibromatosis Type 1

BACKGROUND

Individuals with Neurofibromatosis Type 1 (NF1) are strongly predisposed to developing pediatric brain tumors (PBTs), especially optic pathway gliomas (OPGs). Although developmental factors have been implicated in the origins of PBTs in both human and animal studies, associations between early-life factors and PBTs have not been evaluated in individuals with NF1. Our objective was to evaluate associations between peri-gestational characteristics and PBTs in this population.

METHODS

We conducted a cross-sectional study, ascertaining questionnaire and medical record data for 606 individuals<18years old who enrolled in the NF1 Patient Registry Initiative (NPRI) from 6/9/2011-6/29/2015. One hundred eighty-four individuals had reported PBT diagnoses, including 65 who were identified with OPG diagnoses. Cox proportional hazards regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between PBT and OPG diagnoses and peri-gestational characteristics (prematurity, birth weight, parental age, plurality, family history of NF1, assisted reproductive technology, maternal vitamin supplementation, and parental smoking).

RESULTS

We observed no significant associations between any of the assessed characteristics and PBTs overall or OPGs with the exception of birth weight. After controlling for potential confounding variables, we observed a significant positive association between birth weight quartile and OPGs with a HR of 3.32 (95% CI 1.39-7.94) for the fourth (≥3915.5g) compared to the first (≤3020g) quartile (p for trend=0.001).

CONCLUSIONS

Consistent with results for PBTs in the general population, these results suggest that higher birth weights increase OPG risk in individuals with NF1.

Exposure to prenatal smoking and early-life body composition: the healthy start study

OBJECTIVES

To examine associations between exposure to prenatal smoking and early-life changes in fat mass (FM), fat-free mass (FFM), and anthropometrics.

METHODS

About 670 mother-offspring pairs were analyzed in the longitudinal Healthy Start study. Maternal smoking data were collected during prenatal research visits. Offspring body composition and size were measured by air displacement plethysmography at delivery and postnatal follow-up (5 months) visits.

RESULTS

Comparing exposed and unexposed offspring, exposure to prenatal smoking was significantly associated with reduced neonatal FM (P = 0.007) and FFM (P = 0.02). In contrast, at 5 months, exposed offspring had comparable FM (P = 0.61) and FFM (P = 0.41). After subsequent adjustment for birth weight, offspring exposed to prenatal smoking had significantly greater FFM (154.7 g, 0.5, 309.0; P = 0.049) and sum of skinfolds (2.7 mm, 0.06, 5.3; P = 0.04). From delivery to follow-up, exposed offspring had significantly greater increases in FFM (156.4 g, 2.8, 310.1; P = 0.046) and sum of skinfolds (2.7 mm, 0.06, 5.3; P = 0.04), even after adjustment for respective delivery measures.

CONCLUSIONS

Exposure to prenatal smoking was significantly associated with rapid postnatal growth, which may increase the offspring's risk of metabolic diseases.

Quantity and timing of maternal prenatal smoking on neonatal body composition: the Healthy Start study

OBJECTIVE

To examine the dose-dependent and time-specific relationships of prenatal smoking with neonatal body mass, fat mass (FM), fat-free mass (FFM), and FM-to-FFM ratio, as measured by air-displacement plethysmography (PEA POD system).

STUDY DESIGN

We analyzed 916 mother-neonate pairs participating in the longitudinal prebirth cohort Healthy Start study. Maternal prenatal smoking information was collected in early, middle, and late pregnancy by self-report. Neonatal body composition was measured with the PEA POD system after delivery. Multiple general linear regression models were adjusted for maternal and neonatal characteristics.

RESULTS

Each additional pack of cigarettes smoked during pregnancy was associated with significant decreases in neonatal body mass (adjusted mean difference, -2.8 g; 95% CI, -3.9 to -1.8 g; P < .001), FM (-0.7 g; 95% CI, -1.1 to -0.3 g; P < .001), and FFM (-2.1 g; 95% CI, -2.9 to -1.3 g; P < .001). Neonates exposed to prenatal smoking throughout pregnancy had significantly lower body mass (P < .001), FM (P < .001), and FFM (P < .001) compared with those not exposed to smoking. However, neonates of mothers who smoked only before late pregnancy had no significant differences in body mass (P = .47), FM (P = .43), or FFM (P = .59) compared with unexposed offspring.

CONCLUSION

Exposure to prenatal smoking leads to systematic growth restriction. Smoking cessation before late pregnancy may reduce the consequences of exposure to prenatal smoking on body composition. Follow-up of this cohort is needed to determine the influence of catch-up growth on early-life body composition and the risk of childhood obesity.

Smoking patterns, depression, and sociodemographic variables among Flemish women during pregnancy and the postpartum period

BACKGROUND

Relationships among feelings of depression, smoking behavior, and educational level during pregnancy have been documented. Feelings of depression may contribute to persistent smoking during pregnancy. No longitudinal studies assessing feelings of depression in women with different antepartum and postpartum smoking patterns are available.

OBJECTIVES

The aim was to determine relationships between depressive symptoms, sociodemographic characteristics, and smoking pattern during and after pregnancy.

METHODS

An observational, prospective, noninterventional study was conducted. Data were collected during two stages of pregnancy (T0: <;16 weeks and T1: 32-34 weeks) and postpartum (T2: >6 weeks) in 523 Flemish women. Feelings of depression (measured using the Beck Depression Inventory [BDI]), smoking behavior, and sociodemographic variables were analyzed using a general linear mixed model implemented in SAS Proc MIXED.

RESULTS

Smokers and initial smokers reported significantly more depressive symptoms at all time points compared with recent ex-smokers, nonsmokers, and initial nonsmokers (p <; .001). The three-way interaction among time point, smoking pattern, and educational level was significant (p = .02). Evolution of mean BDI over time differed by educational level. Among participants with a secondary school certificate or less, differences were observed between smokers and nonsmokers, recent ex-smokers and initial nonsmokers, and nonsmokers and initial nonsmokers. Among participants with a college or university degree, no differences were observed.

DISCUSSION

A wide variety of smoking patterns were observed during pregnancy and early postpartum. Smoking patterns were associated with depression and showed complex interactions with educational level. Assessment and intervention for both smoking and depression are needed throughout the perinatal period to support the health of mothers, their infants, and families.

Using expired air carbon monoxide to determine smoking status during pregnancy: preliminary identification of an appropriately sensitive and specific cut-point

BACKGROUND

Measurement of carbon monoxide in expired air samples (ECO) is a non-invasive, cost-effective biochemical marker for smoking. Cut points of 6ppm-10ppm have been established, though appropriate cut-points for pregnant woman have been debated due to metabolic changes. This study assessed whether an ECO cut-point identifying at least 90% of pregnant smokers, and misidentifying fewer than 10% of non-smokers, could be established.

METHODS

Pregnant women (N=167) completed a validated self-report smoking assessment, a urine drug screen for cotinine (UDS), and provided an expired air sample twice during pregnancy.

RESULTS

Half of women reported non-smoking status early (51%) and late (53%) in pregnancy, confirmed by UDS. Using a traditional 8ppm+cut-point for the early pregnancy reading, only 1% of non-smokers were incorrectly identified as smokers, but only 56% of all smokers, and 67% who smoked 5+ cigarettes in the previous 24h, were identified. However, at 4ppm+, only 8% of non-smokers were misclassified as smokers, and 90% of all smokers and 96% who smoked 5+ cigarettes in the previous 24h were identified. False positives were explained by heavy second hand smoke exposure and marijuana use. Results were similar for late pregnancy ECO, with ROC analysis revealing an area under the curve of .95 for early pregnancy, and .94 for late pregnancy readings.

CONCLUSIONS

A lower 4ppm ECO cut-point may be necessary to identify pregnant smokers using expired air samples, and this cut-point appears valid throughout pregnancy. Work is ongoing to validate findings in larger samples, but it appears if an appropriate cut-point is used, ECO is a valid method for determining smoking status in pregnancy.

Correlates of smoking cessation at pregnancy onset among Hispanic women in Massachusetts

PURPOSE

To examine factors associated with smoking cessation at pregnancy onset in Hispanic women.

DESIGN

Cross-sectional analysis of baseline data from the prospective Latina Gestational Diabetes Mellitus Study.

SETTING

Public obstetrical practices of a medical center in Massachusetts, 2000-2004.

SUBJECTS

A total of 351 Hispanic (predominantly Puerto Rican) prenatal care patients who smoked in the year prior to pregnancy.

MEASURES

At enrollment, interviewers collected self-reported cigarette smoking prior to and during pregnancy and sociodemographic, health, and acculturation factors.

ANALYSIS

Logistic regression and backward elimination procedures were used to determine factors independently associated with quitting.

RESULTS

Forty-five percent of women reported quitting smoking at pregnancy onset. In multivariate analyses, women born outside the United States, women with a family history of diabetes, and non-Puerto Rican Hispanics were 32% to 54% more likely to quit smoking. Women with high stress, women with marijuana use, and parous women were 23% to 49% less likely to quit. Women who smoked 20+ cigarettes/d in prepregnancy were less likely to quit smoking (relative risk  =  .44; 95% confidence interval .27, .65) compared with light smokers. Age, income, body mass index, language preference, prepregnancy exercise, and alcohol consumption were not associated with quitting.

CONCLUSIONS

Non-U.S. birthplace, family history of diabetes, and non-Puerto Rican ethnicity were associated with quitting smoking at pregnancy onset in Hispanic women. Prepregnancy marijuana use and smoking, parity, and stress were associated with continued smoking.

Smoking during pregnancy and risk of abnormal glucose tolerance: a prospective cohort study

BACKGROUND

Disturbances in glucose metabolism during pregnancy are associated with negative sequalae for both mother and infant. The association between smoking and abnormal glucose tolerance (AGT) remains controversial. Therefore, the aim of this study was to examine the relationship between smoking prior to and during pregnancy and risk of AGT.

METHODS

We utilized data from a prospective cohort of 1,006 Hispanic (predominantly Puerto Rican) prenatal care patients in Western Massachusetts. Women reported pre- and early pregnancy smoking at recruitment (mean = 15 weeks) and mid pregnancy smoking at a second interview (mean = 28 weeks). AGT was defined as > 135 mg/dL on the routine 1-hour glucose tolerance test (1-hr OGTT). We used multivariable regression to assess the effect of pre, early, and mid-pregnancy smoking on risk of AGT and screening plasma glucose value from the 1-hr OGTT.

RESULTS

In age-adjusted models, women who smoked > 0-9 cigarettes/day in pre-pregnancy had an increased risk of AGT (OR = 1.90; 95% CI 1.02-3.55) compared to non-smokers; this was attenuated in multivariable models. Smoking in early (OR = 0.48; 95% CI 0.21-1.10) and mid pregnancy (OR = 0.38; 95% CI 0.13-1.11) were not associated with AGT in multivariable models. Smoking during early and mid pregnancy were independently associated with lower glucose screening values, while smoking in pre-pregnancy was not.

CONCLUSIONS

In this prospective cohort of Hispanic women, we did not observe an association between smoking prior to or during pregnancy and risk of AGT. Findings from this study, although based on small numbers of cases, extend prior research to the Hispanic population.

In utero smoke exposure and impaired response to inhaled corticosteroids in children with asthma

BACKGROUND

Few studies have examined the effects of in utero smoke exposure (IUS) on lung function in children with asthma, and there are no published data on the impact of IUS on treatment outcomes in children with asthma.

OBJECTIVES

To explore whether IUS exposure is associated with increased airway responsiveness among children with asthma and whether IUS modifies the response to treatment with inhaled corticosteroids (ICSs).

METHODS

To assess the impact of parent-reported IUS exposure on airway responsiveness in childhood asthma, we performed a repeated-measures analysis of methacholine PC(20) data from the Childhood Asthma Management Program, a 4-year, multicenter, randomized, double-masked, placebo-controlled trial of 1041 children age 5 to 12 years comparing the long-term efficacy of ICS with mast cell stabilizing agents or placebo.

RESULTS

Although improvement was seen in both groups, children with asthma and IUS exposure had on average 26% less of an improvement in airway responsiveness over time compared with unexposed children (P = .01). Moreover, while children who were not exposed to IUS who received budesonide experienced substantial improvement in PC(20) compared with untreated children (1.25-fold increase; 95% CI, 1.03-1.50; P = .02), the beneficial effects of budesonide were attenuated among children with a history of IUS exposure (1.04-fold increase, 95% CI, 0.65-1.68; P = .88).

CONCLUSION

In utero smoke exposure reduces age-related improvements in airway responsiveness among children with asthma. Moreover, IUS appears to blunt the beneficial effects of ICS use on airways responsiveness. These results emphasize the importance of preventing this exposure through smoking cessation counseling efforts with pregnant women.

Early exposure to secondhand tobacco smoke and the development of allergic diseases in 4 year old children in Malmö, Sweden

Background

Earlier studies have shown an association between secondhand tobacco smoke and allergy development in children. Furthermore, there is an increased risk of developing an allergy if the parents have an allergy. However, there are only few studies investigating the potential synergistic effect of secondhand tobacco smoke and allergic heredity on the development of an allergy.

Methods

The study was population-based cross-sectional with retrospective information on presence of secondhand tobacco smoke during early life. The study population consisted of children who visited the Child Health Care (CHC) centres in Malmö for their 4-year health checkup during 2006-2008 and whose parents answered a self-administered questionnaire (n = 4,278 children). The questionnaire was distributed to parents of children registered with the CHC and invited for the 4-year checkup during the study period.

Results

There was a two to four times increased odds of the child having an allergy or having sought medical care due to allergic symptoms if at least one parent had an allergy, while there were rather small increased odds related to presence of secondhand smoke during the child's first month in life or at the age of 8 months. However, children with heredity for allergies and with presence of secondhand tobacco smoke during their first year in life had highly increased odds of developing an allergy and having sought medical care due to allergic symptoms at 4 years of age. Thus, there was a synergistic effect enhancing the independent effects of heredity and exposure to secondhand tobacco smoke on allergy development.

Conclusions

Children with a family history of allergies and early exposure to secondhand tobacco smoke is a risk group that prevention and intervention should pay extra attention to. The tobacco smoke effect on children is an essential and urgent question considering it not being self chosen, possibly giving life lasting negative health effects and being possible to reduce.

Paternal alcoholism and offspring ADHD problems: a children of twins design

OBJECTIVE

A recent Children-of-Female-Twin design suggests that the association between maternal alcohol use disorder and offspring ADHD is due to a combination of genetic and environmental factors, such as prenatal nicotine exposure. We present here a complementary analysis using a Children-of-Male-Twin design examining the association between paternal alcoholism and offspring attention deficit hyperactivity problems (ADHP).

METHODS

Children-of-twins design: offspring were classified into 4 groups of varying genetic and environmental risk based on father and co-twin's alcohol dependence status.

RESULTS

Univariate results are suggestive of a genetic association between paternal alcohol dependence and broadly defined offspring ADHP. Specifically, offspring of male twins with a history of DSM-III-R alcohol dependence, as well as offspring of non-alcohol dependent monozygotic twins whose co-twin was alcohol dependent, were significantly more likely to exhibit ADHP than control offspring. However, multivariate models show maternal variables independently predicting increased risk for offspring ADHP and significantly decreased support for a genetic mechanism of parent-to-child transmission.

CONCLUSIONS

In support of earlier work, maternal variables (i.e., maternal ADHD and prenatal exposure) were strongly associated with child ADHP; however, the role of paternal alcohol dependence influences was not definitive. While genetic transmission may be important, the association between paternal alcohol dependence and child ADHP is more likely to be indirect and a result of several pathways.

Genetic and environmental influences on externalizing behavior and alcohol problems in adolescence: a female twin study

Genetic and environmental contributions to the observed correlations among DSM-IV ADHD problems [inattentive (INATT) and hyperactive/impulsive (HYP/IMP) behaviors], conduct problems (CDP) and alcohol problems (AlcProb) were examined by fitting multivariate structural equation models to data from the Missouri Adolescent Female Twin Study [N=2892 twins (831 monozygotic pairs, 615 dizygotic pairs)]. Based on results of preliminary regression models, we modified the structural model to jointly estimate (i) the regression of each phenotype on significant familial/prenatal predictors, and (ii) genetic and environmental contributions to the residual variance and covariance. Results suggested that (i) parental risk factors, such as parental alcohol dependence and regular smoking, increase risk for externalizing behavior; (ii) prenatal exposures predicted increased symptomatology for HYP/IMP (smoking during pregnancy), INATT and CDP (prenatal alcohol exposure); (iii) after adjusting for measured familial/prenatal risk factors, genetic influences were significant for HYP/IMP, INATT, and CDP; however, similar to earlier reports, genetic effects on alcohol dependence symptoms were negligible; and (iv) in adolescence, correlated liabilities for conduct and alcohol problems are found in environmental factors common to both phenotypes, while covariation among impulsivity, inattention, and conduct problems is primarily due to genetic influences common to these three behaviors. Thus, while a variety of adolescent problem behaviors are significantly correlated, the structure of that association may differ as a function of phenotype (e.g., comorbid HYP/IMP and CDP vs. comorbid CDP and AlcProb), a finding that could inform different approaches to treatment and prevention.

Heart rate and blood pressure control in infants exposed to maternal cigarette smoking

AIM

Exposure to maternal cigarette smoking is a major risk factor for sudden infant death syndrome (SIDS). Foetal and postnatal smoke-exposure may alter cardiovascular control in infants. We studied heart rate (HR) and blood pressure (BP) responses in smoke-exposed infants.

METHODS

Eleven infants exposed to maternal cigarette smoking were studied at the age of 12 +/- 2.1 (range 10-16) weeks. Twenty healthy, age-matched infants from non-smoking families served as controls. During confirmed slow-wave sleep (NREM3), 3-5 sec side motion and 45 sec 45 degrees head-up tilt tests were performed.

RESULTS

Control infants showed consistent biphasic HR and BP responses to side motion, with an initial 2-5% increase followed by a 2% decrease (p < 0.0001). In smoke-exposed infants, the initial HR (p = 0.009) and BP responses (p < 0.0001) were markedly reduced, and the subsequent decrease in BP was more prominent (systolic blood pressure, SBP, p = 0.005; diastolic blood pressure, DBP, p = 0.03). No differences were observed between the groups in tilt test results, HR variability or HR responses to spontaneous arousals.

CONCLUSION

Maternal cigarette smoking may alter vestibulo-mediated cardiovascular control in early infancy. This may contribute to increased SIDS risk.

Exposure to cigarette smoke in utero: comparison of reports from mother and daughter

BACKGROUND

Smoking during pregnancy has been associated with asthma, obesity, and decreased cognitive functioning in the offspring. To study the role of in utero smoking exposure in offsprings' adult health outcomes, it may be necessary to rely upon reports by the offspring themselves.

METHODS

We studied 34,949 mother-daughter pairs participating in the Nurses' Health Study II for whom data on the daughter's early passive cigarette smoke exposure had been obtained from both mother and daughter. We calculated sensitivity and specificity of daughter's early exposure to smoke (using mother's report as the gold standard), as well as kappa statistics. Mother and daughter reports were also analyzed as risk factors for asthma and birthweight to demonstrate face validity.

RESULTS

Sensitivity of daughters' reported prenatal exposure ranged from 74% to 85%, while specificity was between 90% and 95% (kappa = 0.72-0.81). Daughter's reported childhood exposure as a proxy for mother's report of smoking during pregnancy had a sensitivity of 89% and specificity of 88%. Results were similar for daughter's report of father's smoking during her childhood. Maternal smoking during pregnancy is consistently associated with reductions in offspring birthweight, and with asthma risk in offspring. The daughter's risk of being very low (<1500 g) or low birthweight (<2500 g) or of having asthma were similar when exposure was defined according to mother's report, daughter's report of fetal smoke exposure, and daughter's report of mother's smoking during childhood.

CONCLUSIONS

Daughter's report of mother's smoking prenatally and in childhood are good proxy measures for mother's own report of smoking during pregnancy.

Smoking and risk of preterm birth among predominantly Puerto Rican women

PURPOSE

Studies of smoking during pregnancy and preterm birth among Hispanic women are sparse. Our goal was to evaluate the effect of cigarette smoking during pre-pregnancy, early pregnancy, and mid pregnancy on preterm birth among Hispanic women, the fastest growing ethnic group in the United States.

METHODS

We evaluated data from a prospective cohort study of 1,041 Hispanic (predominantly Puerto Rican) women recruited between 2000 and 2004 in Springfield, Massachusetts. At recruitment (mean = 15 weeks), women reported their smoking since pregnancy awareness (early pregnancy) and in the year prior to pregnancy (pre-pregnancy). Mid pregnancy smoking was collected at a second interview (mean = 28 weeks).

RESULTS

Smoking in pre-pregnancy was not associated with preterm birth. After adjustment for age, parity, education, and illicit drug use, women who smoked in early pregnancy had 1.6 times the risk of preterm birth (95% confidence interval [CI], 1.0-2.7) compared with nonsmokers. Women who smoked in mid pregnancy had 2.1 times the risk of preterm birth (95% CI, 1.0-4.2) compared with nonsmokers with a trend of increased risk of preterm birth with increasing levels of smoking (p trend, 0.03).

CONCLUSIONS

Smoking in early or mid pregnancy increased the risk of spontaneous preterm birth in a Hispanic population.

Dietary behaviors, physical activity, and cigarette smoking among pregnant Puerto Rican women

BACKGROUND

Few studies have examined predictors of meeting health guidelines in pregnancy among Latina women.

OBJECTIVE

We assessed dietary behaviors, physical activity, and cigarette smoking in the Latina Gestational Diabetes Mellitus Study, a prospective cohort of 1231 prenatal care patients.

DESIGN

Self-reported information on lifestyle factors, demographics, medical history, and physical activity was collected by bilingual interviewers during pregnancy. Fruit/vegetable intake was determined by summing the reported consumption of specific fruit and vegetables on a food-frequency questionnaire designed for this population and then adjusted for reported total daily servings.

RESULTS

Approximately 13% of women met physical activity guidelines [>or=10 metabolic equivalents (MET)-h/wk], 19% met fruit/vegetable guidelines (7 servings/d), 21% of women smoked, and 1.4% consumed alcohol during pregnancy. In multivariate analyses, Spanish-language preference, an indicator of less acculturation, was associated with an approximately 40% less likelihood of both smoking [odds ratio (OR): 0.6; 95% CI: 0.4, 0.8] and meeting physical activity guidelines (OR: 0.6; 95% CI: 0.3, 1.0). College education was associated with a 2-fold greater likelihood of meeting fruit/vegetable guidelines (OR: 2.2; 95% CI: 1.1, 4.3) and a lower likelihood of smoking (OR: 0.2; 95% CI: 0.1, 0.4). A history of adverse pregnancy outcome was associated with a >4-fold greater likelihood of meeting physical activity guidelines. Smoking in pregnancy was associated with a decreased likelihood of meeting the fruit/vegetable guidelines (RR: 0.5; 95% CI: 0.3, 0.9).

CONCLUSION

Factors related to engagement in prenatal health behaviors should be addressed in the design of targeted intervention strategies in this underserved and rapidly growing population.

A longitudinal study of environmental tobacco smoke exposure in children: parental self reports versus age dependent biomarkers

Background

Awareness of the negative effects of smoking on children's health prompted a decrease in the self-reporting of parental tobacco use in periodic surveys from most industrialized countries. Our aim is to assess changes between ETS exposure at the end of pregnancy and at 4 years of age determined by the parents' self-report and measurement of cotinine in age related biological matrices.

Methods

The prospective birth cohort included 487 infants from Barcelona city (Spain). Mothers were asked about maternal and household smoking habit. Cord serum and children's urinary cotinine were analyzed in duplicate using a double antibody radioimmunoassay.

Results

At 4 years of age, the median urinary cotinine level in children increased 1.4 or 3.5 times when father or mother smoked, respectively. Cotinine levels in children's urine statistically differentiated children from smoking mothers (Geometric Mean (GM) 19.7 ng/ml; 95% CI 16.83–23.01) and exposed homes (GM 7.1 ng/ml; 95% CI 5.61–8.99) compared with non-exposed homes (GM 4.5 ng/ml; 95% CI 3.71–5.48). Maternal self-reported ETS exposure in homes declined in the four year span between the two time periods from 42.2% to 31.0% (p < 0.01). Nevertheless, most of the children considered non-exposed by their mothers had detectable levels of cotinine above 1 ng/mL in their urine.

Conclusion

We concluded that cotinine levels determined in cord blood and urine, respectively, were useful for categorizing the children exposed to smoking and showed that a certain increase in ETS exposure during the 4-year follow-up period occurred.

Acculturation and cigarette smoking among pregnant Hispanic women residing in the United States

OBJECTIVES

We explored whether higher levels of acculturation were associated with higher rates of cigarette smoking among pregnant Hispanic women residing in the United States.

METHODS

We evaluated data from the Latina Gestational Diabetes Mellitus Study, a prospective study of 1231 Hispanic prenatal care patients conducted from 2000 to 2004 in Massachusetts. Self-reported data on acculturation, cigarette smoking, and covariates were collected by bilingual interviewers using a questionnaire. We conducted logistic regression multivariate analyses to examine the impact of acculturation level on the odds of smoking.

RESULTS

Overall, 21% of women reported smoking during pregnancy. Acculturation was associated with elevated smoking rates in pregnant Hispanic women. US-born Hispanic women who preferred English had more than twice the odds of smoking compared with Puerto Rican or foreign-born Hispanic women who preferred Spanish (odds ratio [OR]=2.76, 95% confidence interval [CI] 1.36, 5.63).

CONCLUSIONS

Our findings suggest that higher-acculturated Hispanic women living in the United States are more likely to smoke cigarettes during pregnancy than are less-acculturated Hispanic women. These results will inform interventions aimed at reducing cigarette smoking during pregnancy among US Hispanic women.

Maternal Smoking and Environmental Tobacco Smoke Exposure and the Risk of Orofacial Clefts

BACKGROUND

Smoking during pregnancy has been associated with orofacial clefts in numerous studies. However, most previous studies have not been able to assess the relation between maternal smoking and specific phenotypes (eg, bilateral clefts).

METHODS

We examined the association between periconceptional maternal smoking, environmental tobacco smoke (ETS) exposure, and cleft lip with or without cleft palate (CLP) (n = 933) and cleft palate only (CPO) (n = 528) compared with infants with no major birth defects (n = 3390). Infants were born between 1 October 1997 and 31 December 2001, and exposures were ascertained from maternal telephone interviews for the National Birth Defects Prevention Study. We excluded infants who had a first-degree relative with an orofacial cleft. Effect estimates were adjusted for folic acid use, study site, prepregnancy obesity, alcohol use, gravidity, and maternal age, education, and race/ethnicity.

RESULTS

Periconceptional smoking was associated with CLP (odds ratio = 1.3; 95% confidence interval = 1.0-1.6), and more strongly associated with bilateral CLP (1.7; 1.2-2.6), with a weaker association observed for CPO. Heavy maternal smoking (25+ cigarettes/day) was associated with CLP (1.8; 1.0-3.2), bilateral CLP (4.2; 1.7-10.3), and CPO with Pierre Robin sequence (2.5; 0.9-7.0). ETS exposure was not associated with CLP or CPO.

CONCLUSIONS

This study confirmed the modest association between smoking and orofacial clefts that has been consistently reported, and identified specific phenotypes most strongly affected.

Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population

OBJECTIVES

The goal of this investigation was to examine the prevalence of different types of intimate partner violence (IPV) during pregnancy, as well as the association between both physical and psychological IPV and negative health behaviors, including smoking, other substance use, inadequate prenatal care utilization, and nutrition, in a rural sample.

METHODS

104 southern Appalachian women, primarily Caucasian and lower SES, completed a pregnancy interview focused on IPV (CTS2) and health behaviors. Medical records were also reviewed.

RESULTS

81% of participants reported some type of IPV during the current pregnancy, with 28% reporting physical IPV, and 20% reporting sexual violence. More than half were current smokers. Physical IPV during pregnancy was associated with significantly increased rates of pregnancy smoking (including decreased rates of quitting and reducing), increased rates of alcohol, marijuana, and harder illicit drug use around the time of conception, and later entry into prenatal care. The experience of psychological IPV during pregnancy was associated with a significantly decreased likelihood of quitting or reducing smoking during pregnancy, an increased rate of alcohol use around the time of conception, and an increased rate of pre-pregnancy obesity.

CONCLUSIONS

In this sample, pregnancy IPV and smoking occurred at rates well above national averages. Additionally, while physical IPV during pregnancy was associated with several negative pregnancy health behaviors, the experience of psychological IPV, even in the absence of physical IPV, also placed women at increased risk for negative health behaviors, all of which have been linked to poor pregnancy and newborn outcomes.

Risk factors for isolated biliary atresia, National Birth Defects Prevention Study, 1997–2002

Biliary atresia is a rare birth defect that affects 1 in 12,000 to 1 in 19,500 live births. We used data from the National Birth Defects Prevention Study, a multistate case-control study, to identify potential risk factors for isolated biliary atresia (no additional unrelated major birth defects diagnosed). Infants were identified from eight states from 1997 to 2002, with clinical information abstracted from medical records. Potential risk factors assessed include: demographic factors, seasonality, preterm birth, maternal smoking, maternal alcohol use, maternal illicit drug use, maternal health, maternal medication use, maternal vitamin use, and maternal nutrition. Infants of non-Hispanic black mothers were more likely to have biliary atresia than infants of non-Hispanic white mothers (adjusted odds ratio (aOR) = 2.29, 95% confidence interval (CI) 1.07-4.93) and infants conceived during the spring season were more likely to have biliary atresia than infants conceived in winter (aOR = 2.33, 95%CI 1.05-5.16). Low intakes of vitamin E, copper, phosphorus, and beta tocopherol were associated with the occurrence of isolated biliary atresia (borderline significance). Low iron intake had a borderline inverse association with biliary atresia. While this analysis provides support for previous reports of a possible association between seasonal variation and the occurrence of biliary atresia, more data are needed to evaluate whether the seasonal variation is related to infectious agents. The role of nutrients in the development of biliary atresia remains unclear. Further studies of genetic, infectious, and nutrient exposures and the association of biliary atresia are warranted.

Biomarkers to assess the utility of potential reduced exposure tobacco products

To date, we have no valid biomarkers that serve as proxies for tobacco-related disease to test potential reduced exposure products. This paper represents the deliberations of four workgroups that focused on four tobacco-related heath outcomes: Cancer, nonmalignant pulmonary disease, cardiovascular disease, and fetal toxicity. The goal of these workgroups was to identify biomarkers that offer some promise as measures of exposure or toxicity and ultimately may serve as indicators for future disease risk. Recommendations were based on the relationship of the biomarker to what is known about mechanisms of tobacco-related pathogenesis, the extent to which the biomarker differs among smokers and nonsmokers, and the sensitivity of the biomarker to changes in smoking status. Other promising biomarkers were discussed. No existing biomarkers have been demonstrated to be predictive of tobacco-related disease, which highlights the importance and urgency of conducting research in this area.

Prognostic factors in the treatment of generalized aggressive periodontitis: II. Effects of smoking on initial outcome

AIMS

The aim of this study was to investigate the effects of smoking on the response to non-surgical treatment for aggressive periodontitis.

METHODS

Seventy-nine patients with generalized aggressive periodontitis were included in the study; 20 were smokers. All patients received a course of non-surgical periodontal therapy and outcomes assessed 10 weeks post-operatively. Non-responding patients were designated if they had 30% or more non-responding deep sites.

RESULTS

At baseline, bleeding scores were lower in smokers. There was no difference in baseline plaque, pocket depth (PD), recession or clinical attachment levels (CALs); when sites were selected by equal levels of CAL, increased recession was seen in smokers. Outcomes were poorer in smokers (mean PD change 1.75+/-0.56 versus 2.23+/-0.87 mm). The odds ratio for 30% of sites not responding in smokers was 2.9; for 40% non-responding it was 5.9. Smoking altered the distribution of site-specific responses to increase specifically the number of non-responding sites. There was no significant difference in responses between ex-smokers and never-smokers.

CONCLUSIONS

The results demonstrate that smoking is a major risk factor for poor response to initial treatment and emphasize the importance of smoking cessation in periodontal therapy.

Biomarkers to assess the utility of potential reduced exposure tobacco products

To date, we have no valid biomarkers that serve as proxies for tobacco-related disease to test potential reduced exposure products. This paper represents the deliberations of four workgroups that focused on four tobacco-related heath outcomes: Cancer, nonmalignant pulmonary disease, cardiovascular disease, and fetal toxicity. The goal of these workgroups was to identify biomarkers that offer some promise as measures of exposure or toxicity and ultimately may serve as indicators for future disease risk. Recommendations were based on the relationship of the biomarker to what is known about mechanisms of tobacco-related pathogenesis, the extent to which the biomarker differs among smokers and nonsmokers, and the sensitivity of the biomarker to changes in smoking status. Other promising biomarkers were discussed. No existing biomarkers have been demonstrated to be predictive of tobacco-related disease, which highlights the importance and urgency of conducting research in this area.

Self-Reported and Serum Cotinine-Validated Smoking in Pregnant Women in Estonia

OBJECTIVES

Although widely used in epidemiological studies, self-report has been shown to underestimate the prevalence of smoking among pregnant women. Objectives of this study were to examine the discrepancy between self-reported and cotinine-validated smoking status, and the sociodemographic characteristics associated with the misclassification of real smoking status among pregnant women in Tallinn, the capital of Estonia.

METHODS

Serum cotinine assays were performed on a subsample (n = 1360) of the pregnant women, who had participated in a recent study of human papillomavirus type 16 (HPV-16) seroprevalence in Estonia. In the present study, serum concentrations > or = 15 ng/ml were used to distinguish current smokers from nonsmokers. The serum-validated smoking level was compared with the self-reported level in the records of the Estonian Medical Birth Registry. For the group of self-reported non-smokers, the differences between the cotinine-validated smokers and the cotinine-validated nonsmokers, with respect to their sociodemographic characteristics (age, ethnicity, educational level, employment status, marital status, parity), were estimated by logistic regression.

RESULTS

Of 1239 women who reported being nonsmokers, 259 (20.9%) had serum cotinine levels > or = 15 ng/ml, and can be regarded as current smokers. Among self-reported nonsmokers, nondisclosure of current smoking was significantly more frequent in non-Estonian, less educated, socially inactive, cohabiting and multiparous women.

CONCLUSIONS

Self-reported data on smoking in pregnant women underestimates the real smoking prevalence in Estonia. Maternal unwillingness to declare smoking during pregnancy needs to be taken into account in the practice of maternal and child health to better target prenatal smoking cessation interventions.