Social factors, psychopathology, and maternal smoking during pregnancy

Prenatal tobacco exposure associations with physical health and neurodevelopment in the ABCD cohort

OBJECTIVE

To investigate the strength and reproducibility of the teratogenic impact of prenatal tobacco exposure (PTE) on child physical health and neurodevelopmental outcomes, in the context of intersecting sociodemographic and other prenatal correlates, and test if early postnatal health mediates PTE associations with childhood outcomes.

METHOD

Among 9-10-year-olds (N = 8,803) in the Adolescent Brain Cognitive Development Study, linear mixed-effect models tested PTE associations with birth and childhood outcomes of physical health, cognitive performance, and brain structure, controlling for confounding sociodemographic and prenatal health correlates. Mediation analysis tested the extent to which health at birth explained the associations between PTE and childhood outcomes.

RESULTS

PTE was reported by 12% of mothers (8% [n = 738] pre-knowledge of pregnancy only, and 4% [n = 361] pre- and post-knowledge of pregnancy). PTE was highest for children with a risk for passive smoke exposure. Overall, children with any PTE had shorter breastfeeding durations than those without PTE, and PTE following knowledge of pregnancy was associated with being small for gestational age having lower birth weight, and obesity and lower cortical volume and surface area in childhood. Among children from high-parent education households, any PTE was related to lower cognitive performance, which was partially mediated by duration of breastfeeding.

CONCLUSIONS

PTE was linked to poorer health indicators at birth and neurodevelopmental outcomes at age 9-10 years in a large community cohort, independent of sociodemographic factors. Efficacious interventions for smoking-cessation during pregnancy are still needed and should incorporate support for breastfeeding to promote healthier development. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prenatal tobacco and alcohol exposures and the risk of anxiety symptoms in young adulthood: A population-based cohort study

BACKGROUND

Epidemiological studies have linked prenatal tobacco and alcohol exposures to internalizing behaviours in children and adolescents with inconsistent findings. Dearth of epidemiological studies have investigated the associations with the risk of experiencing symptoms of anxiety in young adulthood.

METHODS

Study participants (N = 1190) were from the Raine Study, a population-based prospective birth cohort based in Perth, Western Australia. Data on prenatal tobacco and alcohol exposures were available for the first and third trimesters of pregnancy. Experiencing symptoms of anxiety in young adulthood at age 20 years was measured by a short form of the Depression Anxiety Stress Scale (DASS 21). Relative risk (RR) of experiencing symptoms of anxiety in young adulthood for prenatal tobacco and alcohol exposures were estimated with log binomial regression.

RESULTS

After adjusting for potential confounders, we observed increased risks of experiencing symptoms of anxiety in young adults exposed to prenatal tobacco in the first trimester [RR = 1.52, 95% CI: 1.12-2.06, p-value < 0.01] and third trimester [RR = 1.53, 95% CI: 1.10-2.13, p-value  = 0.02]. However, we found insufficient statistical evidence for an association between first trimester [RR = 1.01, 95% CI: 0.76-1.22, p-value = 0.90] and third trimester [RR = 1.03, 95% CI: 0.80-1.34, p-value = 0.91] prenatal exposure to alcohol and the risk of experiencing symptoms of anxiety in young adults. There was a dose response association between prenatal tobacco exposure and increasing anxiety symptoms in offspring.

CONCLUSION

The findings of this study suggest that an association between prenatal tobacco exposure and risk of anxiety symptoms remains apparent into young adulthood.

Direction of association between Cardiovascular risk and depressive symptoms during the first 18 years of life: A prospective birth cohort study

BACKGROUND

Cardiovascular disease (CVD) and depression are bidirectionally associated in adults. However, the direction of association between CVD risk and depressive symptoms in young people and potential mechanisms are poorly understood.

METHODS

Using longitudinal birth cohort data, we created a CVD risk score age at 15 using age, ethnicity, physical activity, maternal social status, maternal smoking, own smoking, BMI, systolic blood pressure, LDL, HDL and triglycerides. We used regression analysis to test: (1) association between CVD risk score at age 15 and depressive symptoms at ages 12 and 18; (2) association of IL-6 and CRP at age 9 with depressive symptoms at age 12 and CVD risk score at age 15; and (3) mediating effects of CVD risk score on associations of IL-6/CRP at age 9 with depressive symptoms at age 18.

RESULTS

The risk set comprised 5007 participants. CVD risk score in mid-adolescence was associated with depressive symptoms in early-adulthood (adjusted beta=0.06; standard error (SE)=0.02; p<0.001). Depressive symptoms in childhood were not associated with CVD risk score in mid-adolescence (adjusted beta=0.03; SE=0.02; p=0.11). Childhood inflammatory markers were associated with CVD risk score in mid-adolescence. Adolescent CVD risk score mediated the associations between childhood inflammatory markers and depressive symptoms in early-adulthood.

LIMITATIONS

The cohort primarily comprises White individuals, limiting generalisability. Sample attrition required imputation for missing data.

CONCLUSIONS

Association between CVD risk and depression in childhood/adolescence is unidirectional, with higher CVD risk increasing the risk of depressive symptoms. Childhood inflammation may increase risk of depression by influencing adolescent CVD risk.

Family-Based Designs that Disentangle Inherited Factors from Pre- and Postnatal Environmental Exposures: In Vitro Fertilization, Discordant Sibling Pairs, Maternal versus Paternal Comparisons, and Adoption Designs

Identifying environmental risk and protective exposures that have causal effects on health is an important scientific goal. Many environmental exposures are nonrandomly allocated and influenced by dispositional factors including inherited ones. We review family-based designs that can separate the influence of environmental exposures from inherited influences shared between parent and offspring. We focus on prenatal exposures. We highlight that the family-based designs that can separate the prenatal environment from inherited confounds are different to those that are able to pull apart later-life environmental exposures from inherited confounds. We provide a brief review of the literature on maternal smoking during pregnancy and offspring attention-deficit/hyperactivity disorder (ADHD) and conduct problems; these inconsistencies in the literature make a review useful and this illustrates that results of family-based genetically informed studies are inconsistent with a causal interpretation for this exposure and these two offspring outcomes.

Predictive factors for nutritional behavior among pregnant women attending antenatal care clinic in 6th of October City

Background

Good maternal nutrition during pregnancy is important to ensure health for both the mother and the foetus. This study aimed to assess nutritional knowledge and behavior among a group of Egyptian pregnant women in addition to identify the factors influencing both their nutritional knowledge and behavior.

Methods

This comparative cross sectional study included 300 pregnant women attending the antenatal care clinics in 6^th of October University private hospital and El-Hussary primary health care (PHC) unit. The data was collected through a modified nutritional survey that was translated from Spanish to Arabic and revised by language experts for clarity.

Results

Almost all of the women attending the private hospital were university educated while about half of the women attending the PHC unit were graduated from technical education. In general, the level of knowledge about food requirements of both groups was satisfactory good; however, neither of them fulfilled the WHO recommendations of food intake during pregnancy or the optimum number of meals per day. The mean of random blood glucose was higher among the women attending the PHC unit; the BMI, mid arm circumference and subcutaneous fat were higher among the same group as well. In regard to fulfilling the WHO recommended servings per day, only starch and fat items were fulfilled by both groups, whereas the other three items (vegetables, fruits and dairy products) were merely included in the diets of both groups.

Conclusions

Healthy behavior among pregnant women in both group were influenced by their educational level, occupation as well as their pre-gestational BMI. Those were the only three significant predictive factors, where women with higher education showed an active lifestyle. In addition, women starting with normal BMI before pregnancy had better healthy behaviours including the choice of healthy diets.

[Physiological and Psychological Data influencing Pregnant Women Smoking Behavior - CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

Nicotine is the main addictive substance in tobacco and its addictive effects mainly involve dopamine. Nicotine is mainly metabolized (C-oxidation) in the liver to cotinine by the cytochrome P450 enzyme system. Nicotine half-life is short being about 2hours. Nicotine metabolism appears to be increased during pregnancy, mainly due to an increased cytochrome activity and maternal cardiac output. Thus, the smoking behavior of the pregnant woman is subsequently modified with an increase in withdrawal syndromes and an increased desire to smoke. These pharmacological elements should be taken into account when prescribing nicotine replacement therapy. Regarding the markers of tobacco intoxication, there is a good correlation between the importance of smoking and the measurement of expired air carbon monoxide. Although there is no evidence of decreased obstetrical complications related to its use, it is simple and non-invasive and therefore may be useful in routine practice. It gives an instantaneous value of tobacco intoxication, and represents a starting point for dialogue and management and can help to highlight the reality of withdrawal. Regarding the evaluation of tobacco addiction, the most commonly used questionnaires are the Fagerström tests (FTCD, HSI…), which are well correlated with cotinine concentration. However, there is insufficient evidence of their usefulness in reducing tobacco consumption during pregnancy to recommend them in current practice. DSM-V diagnostic criteria for addiction should be known as they can also be used to characterize the intensity of this addiction.

Does early maternal responsiveness buffer prenatal tobacco exposure effects on young children's behavioral disinhibition?

Children with prenatal tobacco exposure (PTE) exhibit early self-regulatory impairments, reflecting a life-course persistent propensity toward behavioral disinhibition. Previously, we demonstrated the protective role of parental responsiveness for reducing the risk of exposure-related disruptive behavior in adolescence. Here, we expanded this line of inquiry, examining whether responsiveness moderates the relation of PTE to a broader set of behavioral disinhibition features in early childhood and testing alternative diathesis-stress versus differential susceptibility explanatory models. PTE was assessed prospectively using interviews and bioassays in the Midwestern Infant Development Study (MIDS). Mother-child dyads (N = 276) were re-assessed at approximately 5 years of age in a preschool follow-up. We quantified maternal responsiveness and child behavioral disinhibition using a combination of directly observed activities in the lab and developmentally sensitive questionnaires. Results supported a diathesis-stress pattern. Children with PTE and less responsive mothers showed increased disruptive behavior and lower effortful control compared with children without PTE. In contrast, exposed children with more responsive mothers had self-regulatory profiles similar to their non-exposed peers. We did not observe sex differences. Findings provide greater specification of the protective role of maternal responsiveness for self-regulation in children with PTE and help clarify mechanisms that may underscore trajectories of exposure-related behavioral disinhibition.

Associations between local government expenditures and low birth weight incidence: Evidence from national birth records

Local governments play an integral role in providing public services to their residents, yet the population health benefits are frequently overlooked, especially when services are outside the traditional health domain. With data from the U.S. Census of Governments and national birth records (spanning from 1992 to 2014), we examined whether local government expenditures on parks and recreation services (PRS) and housing and community development (HCD) predicted county low birth weight outcomes (population incidence and black-white disparities). Hypotheses were tested using bias-corrected county-by-period fixed effects models in a sample of 956 U.S. counties with a total of 3619 observations (observations were defined as three-year pooled estimates), representing 24 million births. Adjusting for prior county low birth weight incidence, levels of total operational, health, and hospital expenditures, and time-varying county sociodemographics, an increase in per capita county PRS expenditures of $50 was associated with 1.25 fewer low birth weight cases per 1000. Change in county HCD expenditures was not associated with low birth weight incidence, and, contrary to hypotheses, neither expenditure type was linked to county black-white disparities. Further examination of the benefits to birth outcomes from increasing parks and recreation services is warranted.

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Rising parks and recreation expenditures are linked to declining low birth weight.

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Housing and community expenditures are not associated with low birth weight.

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‘Health’ was the only expenditure type linked to black-white perinatal disparities.

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Benefits of parks and recreation services may include healthier birth outcomes.

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

Perinatal Navigator Approach to Smoking Cessation for Women With Prevalent Opioid Dependence

Women who smoke during pregnancy face psychosocial barriers to cessation, and women with opioid use disorder (OUD) face amplified barriers. We pilot tested a Perinatal Wellness Navigator (PWN) program for a group of high-risk perinatal women (N = 50; n = 42 with OUD) that consisted of (a) one-on-one tobacco treatment, (b) comprehensive assessment of cessation barriers, and (c) linkage to clinical/social services. Outcome measures were assessed at baseline and postintervention. Participants smoked 10 fewer cigarettes per day (p = .05) at postintervention and were less dependent on nicotine (p < .01). Mean postnatal depression scores (p = .03) and perceived stress (p = .03) decreased postintervention. Participants received at least one referral at baseline (n = 106 total), and 10 participants received an additional 18 referrals at postintervention to address cessation barriers. The PWN program was minimally effective in promoting total tobacco abstinence in a high-risk group of perinatal women, but participants experienced reductions in cigarettes smoked per day, nicotine dependence, stress, and depression.

Identifying the contribution of prenatal risk factors to offspring development and psychopathology: What designs to use and a critique of literature on maternal smoking and stress in pregnancy

Identifying prenatal environmental factors that have genuinely causal effects on psychopathology is an important research priority, but it is crucial to select an appropriate research design. In this review we explain why and what sorts of designs are preferable and focus on genetically informed/sensitive designs. In the field of developmental psychopathology, causal inferences about prenatal risks have not always been based on evidence generated from appropriate designs. We focus on reported links between maternal smoking during pregnancy and offspring attention-deficit/hyperactivity disorder or conduct problems. Undertaking a systematic review of findings from genetically informed designs and “triangulating” evidence from studies with different patterns of bias, we conclude that at present findings suggest it is unlikely that there is a substantial causal effect of maternal smoking in pregnancy on either attention-deficit/hyperactivity disorder or conduct problems. In contrast, for offspring birth weight (which serves as a positive control) findings strongly support a negative causal effect of maternal smoking in pregnancy. For maternal pregnancy stress, too few studies use genetically sensitive designs to draw firm conclusions, but continuity with postnatal stress seems important. We highlight the importance of moving beyond observational designs, for systematic evaluation of the breadth of available evidence and choosing innovative designs. We conclude that a broader set of prenatal risk factors should be examined, including those relevant in low- and middle-income contexts. Future directions include a greater use of molecular genetically informed designs such as Mendelian randomization to test causal hypotheses about prenatal exposure and offspring outcome.

A longitudinal examination of US teen childbearing and smoking risk

BACKGROUND

Teenage motherhood and smoking have important health implications for youth in the United States and globally, but the link between teen childbearing and subsequent smoking is inadequately understood. The selection of disadvantaged young women into early childbearing and smoking may explain higher smoking levels among teen mothers, but teen motherhood may also shape subsequent smoking through compromised maternal depression or socioeconomic status, and race/ethnicity may condition these processes.

OBJECTIVE

This study examines the relationship between US teen childbearing and subsequent daily smoking, accounting for prior smoking and selection processes related to social disadvantage. Analyses investigate whether socioeconomic status and depression in young adulthood explained any relationship between teen childbearing and daily smoking, as well as examining racial/ethnic heterogeneity in these processes.

METHODS

Multivariate binary logistic regression analyses employ the National Longitudinal Study of Adolescent to Adult Health (Add Health; N = 7,529).

RESULTS

The highest daily smoking prevalence occurred among non-Hispanic White teen mothers, with lower prevalence among Hispanic and non-Hispanic Black teen mothers. Compared to other women, teenage mothers are 2.5 times as likely to smoke daily in young adulthood. Their greater likelihood of daily smoking is due in part to selection and is also mediated by socioeconomic status in ways that differ by race/ethnicity.

CONCLUSIONS

The findings suggest that preventing teen pregnancy or ameliorating its socioeconomic consequences may decrease daily smoking in this vulnerable population. Reducing teen smoking, especially during pregnancy, could improve teen, maternal, and infant health and thereby increase US health and longevity.

CONTRIBUTION

This study provides new, nationally representative information about selection, mediation, and heterogeneity processes in the relationship between teen childbearing and subsequent smoking.

Determinants of low risk of asthma exacerbation during pregnancy

BACKGROUND

Assessment of asthma control every 4-6 weeks during pregnancy is recommended to reduce risk of exacerbation, and by that improve outcome.

OBJECTIVE

To identify determinants of pregnancies with low risk of asthma exacerbation.

METHODS

All pregnant women enrolled into the Management of Asthma during Pregnancy (MAP) programme at Hvidovre Hospital since 2007. Assessment of asthma control, adjustment of treatment, spirometry and measurement of exhaled nitric oxide (F_E NO) were performed, and baseline characteristics and exacerbation history were collected at enrolment. Determinants of low-exacerbation risk pregnancies were identified by logistic regression analysis (stepwise backward elimination).

RESULTS

In 1283 pregnancies, 107 exacerbations were observed. Multiple regression analysis revealed that no history of pre-pregnancy exacerbations (P < .001), no prescribed controller medication (P < .001), and clinically stable asthma at enrolment (P = .002) were significantly associated with low risk of exacerbation during pregnancy; with these combined characteristics, only two of 385 pregnancies were complicated by an exacerbation (OR 0.04, 95% CI 0.01-0.18, P < .001).

CONCLUSION AND CLINICAL RELEVANCE

Clinically stable asthma at enrolment, together with no history of previous exacerbations and no prescribed controller medication, is a determinant of low risk of an asthma exacerbation during pregnancy, which may guide clinicians in individualizing surveillance of asthma during pregnancy.

The Role of Maternal Adverse Childhood Experiences and Race in Intergenerational High-Risk Smoking Behaviors

INTRODUCTION

A history of adversity in childhood is associated with cigarette smoking in adulthood, but there is less evidence for prenatal and next-generation offspring smoking. We investigated the association between maternal history of childhood adversity, pregnancy smoking, and early initiation of smoking in offspring, overall and by maternal race/ethnicity.

METHODS

Data on maternal childhood exposure to physical abuse, household alcohol abuse, and household mental illness, prenatal smoking behaviors, and offspring age of smoking initiation were analyzed from the US National Longitudinal Survey of Youth 1979 (NLSY79, n = 2999 mothers) and the NLSY79 Children and Young Adults Survey (NLSYCYA, n = 6596 children). Adjusted risk ratios were estimated using log-linear regression models. We assessed multiplicative interaction by race/ethnicity for all associations and a three-way interaction by maternal exposure to adversity and race/ethnicity for the association between prenatal and child smoking.

RESULTS

Maternal exposure to childhood physical abuse was significantly associated with 39% and 20% increased risks of prenatal smoking and child smoking, respectively. Household alcohol abuse was associated with significantly increased risks of 20% for prenatal smoking and 17% for child smoking. The prenatal smoking-child smoking relationship was modified by maternal exposure to household alcohol abuse and race. There were increased risks for Hispanic and white/other mothers as compared to the lowest risk group: black mothers who did not experience childhood household alcohol abuse.

CONCLUSIONS

Mothers in this national sample who experienced adversity in childhood are more likely to smoke during pregnancy and their offspring are more likely to initiate smoking before age 18. Findings varied by type of adversity and race/ethnicity.

IMPLICATIONS

These findings support the importance of a life-course approach to understanding prenatal and intergenerational smoking, and suggest that maternal early-life history is a potentially important risk factor that could be targeted with screening and interventions to reduce smoking in pregnant women and their children.

Smoking Cessation for Pregnant Smokers: Development and Pilot Test of an Emotion Regulation Treatment Supplement to Standard Smoking Cessation for Negative Affect Smokers

INTRODUCTION

Negative affect has been identified as a factor influencing continued smoking during pregnancy. In this study, a multi-component emotion regulation intervention was developed to address negative emotional smoking triggers and pilot-tested among low-income pregnant smokers. Treatment feasibility and acceptability, cotinine-verified rates of smoking cessation, and self-report of mean cigarettes smoked were assessed.

METHODS

Pregnant smokers who self-reported smoking in response to negative affect (N = 70) were randomly assigned to receive one of two 8-session interventions: (1) emotion regulation treatment combined with standard cognitive-behavioral smoking cessation (ERT + CBT) or (2) a health and lifestyle plus standard smoking cessation active control (HLS + CBT). Outcomes for the 4-month period following the quit date are reported.

RESULTS

Treatment attendance and subjective ratings provide evidence for the feasibility and acceptability of the ERT + CBT intervention. Compared with the HLS + CBT control condition, the ERT + CBT condition demonstrated higher abstinence rates at 2 months (ERT + CBT = 23% vs. HLS + CBT = 0%, OR = 13.51; 95% CI = 0.70-261.59) and 4 months (ERT = 18% vs. HLS = 5%; OR = 2.98; 95% CI = 0.39-22.72) post-quit. Mean number of cigarettes per day was significantly lower in ERT + CBT at 2 months (ERT + CBT = 2.73 (3.35) vs. HLS + CBT = 5.84 (6.24); p = .05) but not at 4 months (ERT + CBT = 2.15 (3.17) vs. HLS + CBT = 5.18 (2.88); p = .06) post-quit.

CONCLUSIONS

The development and initial test of the ERT + CBT intervention supports its feasibility and acceptability in this difficult-to-treat population. Further development and testing in a Stage II randomized clinical trial are warranted.

IMPLICATIONS

Negative affect has been identified as a motivator for continued smoking during pregnancy. To date, smoking cessation interventions for pregnant smokers have not specifically addressed the role of negative affect as a smoking trigger. This treatment development pilot study provides support for the feasibility and acceptability of a multi-component ERT + CBT for low-income pregnant smokers who self-report smoking in response to negative affect. Study findings support further testing in a fully-powered Stage II efficacy trial powered to assess mediators and moderators of treatment effects.

Prevalence and correlates of alcohol and tobacco use among pregnant women in the United States: Evidence from the NSDUH 2005-2014

Alcohol and tobacco use during pregnancy are among the strongest and most preventable risk factors for adverse neonatal health outcomes, but few developmentally sensitive, population-based studies of this phenomenon have been conducted. To address this gap, the present study examined the prevalence and correlates of alcohol and tobacco use among pregnant adolescents (aged 12-17) and adults (aged 18-44) in the United States. Data were derived from the population-based National Survey of Drug Use and Health (80,498 adolescent and 152,043 adult women) between 2005 and 2014. Findings show disconcerting levels of past-month use among pregnant women with 11.5% of adolescent and 8.7% of adult women using alcohol, and 23.0% of adolescent and 14.9% of adult women using tobacco. Compared to their non-pregnant counterparts, pregnant adolescents were less likely to report past 30-day alcohol use (AOR=0.52, 95% CI=0.36-0.76), but more likely to report past 30-day tobacco use (AOR=2.20, 95% CI=1.53-3.18). Compared to their non-pregnant adult counterparts, pregnant adults were less likely to report using alcohol (AOR=0.06, 95% CI=0.05-0.07) and tobacco (AOR=0.47, 95% CI=0.43-0.52). Compared to pregnant abstainers, pregnant women reporting alcohol/tobacco use were more likely to have had a major depressive episode in the past 12months, report criminal justice system involvement, and endorse comorbid alcohol/tobacco use. Given alcohol and tobacco's deleterious consequences during pregnancy, increased attention to reducing use is critical. Findings suggest that tobacco use is especially problematic for both adolescents and adults and is strongly linked with depression and criminal justice involvement, especially among adults.

Environmental PAH exposure and male idiopathic infertility: a review on early life exposures and adult diagnosis

The male reproductive system is acutely and uniquely sensitive to a variety of toxicities, including those induced by environmental pollutants throughout the lifespan. Early life hormonal and morphological development results in several especially sensitive critical windows of toxicity risk associated with lifelong decreased reproductive health and fitness. Male factor infertility can account for over 40% of infertility in couples seeking treatment, and 44% of infertile men are diagnosed with idiopathic male infertility. Human environmental exposures are poorly understood due to limited available data. The latency between maternal and in utero exposure and a diagnosis in adulthood complicates the correlation between environmental exposures and infertility. The results from this review include recommendations for more and region specific monitoring of polycyclic aromatic hydrocarbon (PAH) exposure, longitudinal and clinical cohort considerations of exposure normalization, gene-environment interactions, in utero exposure studies, and controlled mechanistic animal experiments. Additionally, it is recommended that detailed semen analysis and male fertility data be included as endpoints in environmental exposure cohort studies due to the sensitivity of the male reproductive system to environmental pollutants, including PAHs.

The Modified Reasons for Smoking Scale: factorial structure, validity and reliability in pregnant smokers

RATIONALE, AIMS AND OBJECTIVES

Smoking during pregnancy can cause several maternal and neonatal health risks, yet a considerable number of pregnant women continue to smoke. The objectives of this study were to test the factorial structure, validity and reliability of the Dutch version of the Modified Reasons for Smoking Scale (MRSS) in a sample of smoking pregnant women and to understand reasons for continued smoking during pregnancy.

METHODS

A longitudinal design was performed. Data of 97 pregnant smokers were collected during prenatal consultation. Structural equation modelling was performed to assess the construct validity of the MRSS: an exploratory factor analysis was conducted, followed by a confirmatory factor analysis.Test-retest reliability (<16 weeks and 32-34 weeks pregnancy) and internal consistency were assessed using the intraclass correlation coefficient and the Cronbach's alpha, respectively. To verify concurrent validity, Mann-Whitney U-tests were performed examining associations between the MRSS subscales and nicotine dependence, daily consumption, depressive symptoms and intention to quit.

RESULTS

We found a factorial structure for the MRSS of 11 items within five subscales in order of importance: tension reduction, addiction, pleasure, habit and social function. Results for internal consistency and test-retest reliability were good to acceptable. There were significant associations of nicotine dependence with tension reduction and addiction and of daily consumption with addiction and habit.

CONCLUSIONS

Validity and reliability of the MRSS were shown in a sample of pregnant smokers. Tension reduction was the most important reason for continued smoking, followed by pleasure and addiction. Although the score for nicotine dependence was low, addiction was an important reason for continued smoking during pregnancy; therefore, nicotine replacement therapy could be considered. Half of the respondents experienced depressive symptoms. Hence, it is important to identify those women who need more specialized care, which can include not only smoking cessation counselling but also treatment for depression.

Factors Associated with Smoking Cessation in Pregnancy

Objective The objective of this study was to quantify the influence of various patient characteristics on early smoking cessation to better identify target populations for focused counseling and interventions. Study Design This study was a population-based retrospective cohort study of 1,003,532 Ohio live births more than 7 years (2006-2012). Women who quit smoking in the first trimester were compared with those who smoked throughout pregnancy. Logistic regression estimated the strength of association between patient factors and smoking cessation. Results The factors most strongly associated with early smoking cessation were non-white race and Hispanic ethnicity, at least some college education, early prenatal care, marriage, and breastfeeding. Numerous factors commonly associated with adverse perinatal outcomes were found to have a negative association with smoking cessation: low educational attainment, limited or late prenatal care, prior preterm birth, age < 20 years, age ≥ 35 years, and indicators of low SES. In addition, the heaviest smokers (≥ 20 cigarette/day) were least likely to quit (adjusted relative risk [RR], 0.35; 95% confidence interval 0.34, 0.36). Conclusion Early prenatal care and initiation of breastfeeding before discharge from the hospital are associated with increased RR of quitting early in pregnancy by 52 and 99%, respectively. Public health initiatives and interventions should focus on the importance of early access to prenatal care and education regarding smoking cessation for these particularly vulnerable groups of women who are at inherently high risk of pregnancy complications.

Heart Disease, Hypertension, Gestational Diabetes Mellitus, and Preeclampsia/Eclampsia in Mothers With Juvenile Arthritis: A Nested Case-Control Study

OBJECTIVE

To determine whether women with a history of juvenile arthritis are at higher risk for heart disease and hypertension and for developing adverse maternal outcomes: gestational diabetes mellitus, maternal hypertension, and preeclampsia/eclampsia.

METHODS

We designed a nested case-control study from a cohort of first-time mothers with prior physician billing codes suggesting juvenile arthritis, and a matched comparison group without juvenile arthritis. For the nested case-control design, we selected 3 controls for each case for the outcomes of heart disease (n = 403), prepregnancy hypertension (n = 66), gestational diabetes mellitus (n = 285), maternal hypertension (n = 561), and preeclampsia/eclampsia (n = 236). We used conditional logistic regression, adjusting for maternal age and education.

RESULTS

Having juvenile arthritis was associated with heart disease (odds ratio [OR] 2.44 [95% confidence interval (95% CI) 1.15-5.15]) but not with gestational hypertension, diabetes mellitus, or preeclampsia/eclampsia. All 66 cases of prepregnancy hypertension had juvenile arthritis. Having prepregnancy hypertension was strongly associated with preeclampsia/eclampsia (OR 8.05 [95% CI 2.69-24.07]).

CONCLUSION

Women with a history of juvenile arthritis had a higher risk of heart disease. This risk signals the potential importance of cardiac prevention strategies in juvenile arthritis. As this was a retrospective study, it was not possible to correct for some relevant potential confounders. Further studies should assess the impact of medications, disease severity, and other factors (e.g., obesity) on cardiac outcomes in juvenile arthritis.

Geographic Variation in Maternal Smoking during Pregnancy in the Missouri Adolescent Female Twin Study (MOAFTS)

Objective

Despite well-known adverse health effects of maternal smoking during pregnancy (MSP), it is still unclear if MSP varies geographically and if neighborhood socioeconomic deprivation (SED) plays an important role in MSP. This study aims to investigate small-area geographic variation in MSP and examine the association of SED with MSP.

Methods

The Missouri Adolescent Female Twin Study (MOAFTS) is a cohort study of female like-sex twins born in Missouri to Missouri-resident parents during 1975–1985. Biological mothers completed a baseline interview in 1995–1998 and reported MSP with the twins. Residential address of the mother at birth was geocoded. We developed a census tract-level SED index using a common factor approach based on 21 area-level socioeconomic variables from the 1980 Census data. Multilevel logistic regressions estimated geographic heterogeneity (random effect) in MSP and the odds ratios (ORs, fixed effects) of neighborhood SED associated with MSP.

Results

Of 1658 MOAFTS mothers, 35.2% reported any MSP and 21.9% reported MSP beyond the first trimester. Neighborhood SED was associated with any MSP (the highest vs. the lowest quartile: OR = 1.90, 95% confidence interval [CI] = 1.40–2.57, P_trend<0.001) and MSP beyond the first trimester (OR = 1.98, 95% CI = 1.38–2.85, P_trend = 0.002) in unadjusted analyses. After adjusting for individual covariates (demographics, socioeconomic conditions, alcohol use, and parents’ cohabitation), neighborhood SED was not associated with MSP, but geographic variation still persisted in MSP (variance = 0.41, P = 0.003) and in MSP beyond the first trimester (variance = 0.82, P<0.001).

Conclusions

Neighborhood SED was associated with MSP in unadjusted analyses but this association could be explained by individual socioeconomic conditions. Nonetheless, significant geographic variation in MSP persisted and was not accounted for by differences in neighborhood SED. To develop effective interventions to reduce MSP, further studies are necessary to explore underlying reasons for its geographic variation.

Social Integration and Maternal Smoking: A Longitudinal Analysis of a National Birth Cohort

Objectives Social support and engagement are related to smoking behavior in general populations, but it is unknown whether these measures of social integration as experienced by recent mothers are related to longitudinal maternal smoking patterns. The purpose of this study is, first, to describe longitudinal patterns of maternal smoking before, during, and after pregnancy through the early childhood parenting years, as well as variation in these patterns; and second, to examine these patterns in relation to social integration, emotional, behavioral, and sociodemographic factors. Methods Among 9050 mothers of the Early Childhood Longitudinal Study-Birth Cohort (a nationally representative probability sample of children born in 2001), we estimated trajectories of maternal smoking with a general growth mixture model and examined how baseline predictors are associated with these patterns over a 5-6 year period beginning 3 months prior to pregnancy. Results A 5-class solution identified trajectories of nonsmokers (70.5 %), temporary quitters (9.4 %), pregnancy-inspired quitters (3.3 %), delayed initiators (5.1 %), and persistent smokers (11.7 %). Modifiable risk factors included postpartum alcohol consumption and behavioral cues from co-resident smokers, while breastfeeding beyond 6 months and social engagement through religious service attendance were protective characteristics. Conclusions for Practice Prevention of and treatment for maternal perinatal and postpartum smoking is best informed by mothers' emotional, behavioral and sociodemographic characteristics. Religious service attendance, but not measures of social support or social engagement, was a protective factor for maternal smoking trajectories.

Nicotine Dependence Measures for Perinatal Women

This integrative review provides an overview of nicotine dependence measures used with perinatal women and an evaluation of their psychometric properties. Fifty-five articles that met inclusion and exclusion criteria were identified from five different databases. Most of the studies used the Fagerström Test for Nicotine Dependence (FTND). Other approaches included diagnostic tests, the Wisconsin Inventory of Smoking Dependence Motives (WISDM), the Tobacco Dependence Screener, and single-item measures. This review indicated that the FTND may not be the best option for measuring nicotine dependence in this population. The WISDM is a newer instrument that has excellent psychometric properties and captures nonnicotinic dimensions of nicotine dependence relevant to women. Future research is needed to assess its reliability in the perinatal population. Other recommendations from this review include the use of biomarker validation, thorough psychometric reporting on nicotine dependence instruments, and the use of multiple instruments to maximize comparability between nicotine dependence instruments.

Birth Outcomes in Women with a History of Juvenile Idiopathic Arthritis

OBJECTIVE

To determine whether children born to women who had juvenile idiopathic arthritis (JIA) had more adverse birth outcomes than children born to mothers who never had JIA.

METHODS

Our cohort study used data from physician billing and hospitalizations covering the province of Quebec, Canada. We identified all women with JIA with a first-time birth between January 1, 1983, and December 31, 2010, and assembled a control cohort of first-time mothers without JIA from the same administrative data, matching 4:1 for date of first birth, maternal age, and area of residence. We compared outcomes (stillbirth, prematurity, small for gestational age, and major congenital anomalies) in the JIA versus non-JIA groups using logistic regression.

RESULTS

Mean age at delivery was 24.7 years in the JIA group (n = 1681) and 25.0 years for the non-JIA group (n = 6724). Women who had JIA were at higher risk for a premature baby [adjusted relative risk (RR) 1.20, 95% CI 1.01-1.42], a baby small for gestational age (adjusted RR 1.19, 95% CI 1.04-1.37), and a child with a congenital malformation (adjusted RR 6.51, 95% CI 5.05-8.39). Neural tube defects were higher in the JIA offspring: 1.61% (95% CI 1.11-2.33) versus 0.03% (95% CI 0.01-0.11) in the non-JIA group, as were congenital heart defects: 1.07% (95% CI 0.68-1.69) versus 0.58% (95% CI 0.42-0.79).

CONCLUSION

Most women with JIA will deliver a normal baby, even though they are at higher risk for having a child with adverse birth outcomes. Research is needed to understand pathophysiologic mechanisms and to investigate the effects of medications during childhood and youth on future birth outcomes.

Effects of prenatal alcohol and cigarette exposure on offspring substance use in multiplex, alcohol-dependent families

BACKGROUND

Prenatal exposures to alcohol, cigarettes, and other drugs of abuse are associated with numerous adverse consequences for affected offspring, including increased risk for substance use and abuse. However, maternal substance use during pregnancy appears to occur more often in those with a family history of alcohol dependence. Utilizing a sample that is enriched for familial alcohol dependence and includes controls selected for virtual absence of familial alcohol dependence could provide important information on the relative contribution of familial risk and prenatal exposures to offspring substance use.

METHODS

A sample of multigenerational families specifically ascertained to be at either high or low risk for developing alcohol dependence (AD) provided biological offspring for a longitudinal prospective study. High-risk families were selected based on the presence of 2 alcohol-dependent sisters. Low-risk families were selected on the basis of minimal first and second-degree relatives with AD. High-risk (HR = 99) and Low-risk offspring (LR = 110) were assessed annually during childhood and biennially in young adulthood regarding their alcohol, drug, and cigarette use. At the first childhood visit, mothers were interviewed concerning their prenatal use of substances.

RESULTS

High-risk mothers were more likely to use alcohol, cigarettes, and other drugs during pregnancy than low-risk control mothers, and to consume these substances in greater quantities. Across the sample, prenatal exposure to alcohol was associated with increased risk for both offspring cigarette use and substance use disorders (SUD), and prenatal cigarette exposure was associated with increased risk for offspring cigarette use. Controlling for risk status by examining patterns within the HR sample, prenatal cigarette exposure remained a specific predictor of offspring cigarette use, and prenatal alcohol exposure was specifically associated with increased risk for offspring SUD.

CONCLUSIONS

Women with a family history of SUD are at increased risk for substance use during pregnancy. Both familial loading for alcohol dependence and prenatal exposure to alcohol or cigarettes are important risk factors in the development of offspring substance use. An inadequate assessment of family history may obscure important interactions between familial risk and prenatal exposures on offspring outcomes.

Month-wise estimates of tobacco smoking during pregnancy for the United States, 2002-2009

The timing of prenatal exposure to tobacco cigarette smoking can be crucial for the developing fetus. Pushing the field beyond prior pregnancy trimester-focused smoking estimates, we estimated month-specific prevalence proportions for tobacco cigarette smoking among pregnant and non-pregnant women of the United States, with consideration of tobacco dependence (TD) as well. In advance, we posited that pregnancy onset might prompt smoking cessation in early months, before the end of the 1st trimester, and that TD might account for sustained smoking in later months, especially months 8-9, when there are added reasons to quit. Estimates are from the 2002-2009 National Surveys on Drug Use and Health Restricted-Data Analysis System (R-DAS), with large nationally representative samples of US civilians, including 12-44 year old women (n ~ 70,000) stratified by pregnancy status and month of pregnancy, with multi-item assessment of TD as well as recently active smoking. Age was held constant via the Breslow-Day indirect standardization approach, a methodological detail of potential interest to other research teams conducting online R-DAS analyses. Among 12-44 year old women in Month 1 of pregnancy, as well as non-pregnant women, just over one in four was a recently active smoker (26-27 %), and approximately one-half of these smokers qualified as a TD case (52 %). Corresponding estimates for women in Month 3 were 17.6 % and two-thirds, respectively, lending some support for our advance hypotheses. Nonetheless, our a priori TD hypothesis about Months 8-9 seems to be contradicted: an increased concentration of TD among smokers surfaced early in pregnancy. Evidence of a possible ameliorative pregnancy effect on smoking prevalence as well as TD's effect on smoking persistence might be seen quite early in pregnancy. Substitution of a month-specific view for the traditional trimester view sheds new light on how pregnancy might shape smoking behavior before the end of trimester 1, with TD seeming to thwart a public health goal of 100 % cessation, early in pregnancy.

Growth Models of Maternal Smoking Behavior: Individual and Contextual Factors

BACKGROUND

Persistent maternal smoking during pregnancy, reduction or cessation during pregnancy, and smoking initiation or resumption postpartum impel further research to understand these behavioral patterns and opportunities for intervention.

OBJECTIVES

We investigated heterogenous longitudinal patterns of smoking quantity to determine if these patterns vary across three maternal age groups, and whether the influence of individual and contextual risk factors varies by maternal age.

METHODS

Separate general growth mixture models were estimated for mothers ages 15-25, 26-35, and 36+, allowing different empirical patterns of an ordinal measure of smoking behavior at six time points, from preconception through child entry to kindergarten.

RESULTS

We identify five classes for mothers ages 15-25, four classes for ages 26-35, and three classes for ages 36+. Each age group presents classes of nonsmokers and persistent heavy smokers. Intermediate to these ends of the spectrum, each age group exhibited its own smoking classes characterized by the extent of pregnancy smoking reductions and postpartum behavior. In all three age groups, class membership can be distinguished by individual sociodemographic and behavioral characteristics. Co-resident smokers predicted nearly all smoking classifications across age groups, and selected neighborhood characteristics predicted classification of younger (15-25) and older (36+) mothers.

CONCLUSIONS

The design, timing, and delivery of smoking prevention and cessation services, for women seeking to become pregnant and for women presenting for prenatal or pediatric care, are best guided by individual characteristics, particularly maternal age, preconception alcohol consumption, and postpartum depression, but neighborhood characteristics merit further attention for mothers at different ages.

Examination of the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68) Factor Structure in a Sample of Pregnant Smokers

INTRODUCTION

Smoking during pregnancy poses known risks to fetal and infant development. Women who continue to smoke during pregnancy exhibit higher levels of nicotine dependence than women who quit. Increased understanding of the construct of nicotine dependence in pregnant smokers may aid in the development of effective treatments. Research has suggested that nicotine dependence is a multifaceted construct, driven not only by withdrawal and tolerance processes, but also by reinforcement, sensory, and contextual processes. The Wisconsin inventory of smoking dependence motives (WISDM-68) assesses 13 varied smoking motives in order to assess processes that may lead to nicotine dependence.

METHODS

The factor structure of the WISDM-68 was explored using an ethnically diverse sample of 294 pregnant women who had been screened and/or enrolled in a smoking cessation treatment study. Confirmatory analyses were conducted with previously published models. An exploratory factor analysis and exploratory structural equation modeling (ESEM) were conducted to develop and validate a measurement model for the WISDM-68 in this sample.

RESULTS

Previously established models were not a good fit for the present data. Using ESEM, a 9-factor model exhibiting both predictive and concurrent validity emerged. Two factors predicted abstinence 6 months posttreatment. Several factors were associated with smoking heaviness, the Fagerström test for cigarette dependence and time to first cigarette.

CONCLUSIONS

In contrast to previously published studies, a 9-factor model best characterizes the WISDM in the present sample. These findings may reflect smoking motivations unique to young, pregnant women who continue to smoke during pregnancy.

Women’s longitudinal smoking patterns from preconception through child’s kindergarten entry: profiles of biological mothers of a 2001 US birth cohort

To identify longitudinal patterns of women’s smoking during the pre-conception, perinatal, and early parenting period and describe risk factors distinguishing the different profiles. We conducted longitudinal latent class analysis of maternal smoking status over a 6–7 year period in a sample of 8,650 biological mothers of the Early Childhood Longitudinal Study-Birth Cohort, nationally representative of US births in 2001. Five latent classes were identified: pregnancy-inspired quitters (4.3 %), delayed initiators (5.1 %), persistent smokers (8.5 %), temporary quitters (10.4 %), and nonsmokers (71.7 %). These classes were distinguished by age, race/ethnicity, education, poverty status, marital status, parity, drinking behavior, and depression. For example, when compared to those with college degrees, those with less than a high school degree were at least five times as likely to be in the delayed initiator, temporary quitter, or persistent smoker classes (vs. the nonsmoker class). Heterogeneous longitudinal smoking patterns indicate the need for both prevention messages and cessation treatment continuing past parturition, tailored to fit individual profiles in order to achieve better health outcomes for both mothers and children.

Ethnic differences in tobacco use during pregnancy: findings from a primary care sample in São Paulo, Brazil

OBJECTIVES

Tobacco use during pregnancy is a global health concern. To date the majority of research originates in developed countries, thus we have a need to better understand factors related to maternal health in developing countries. We examine the prevalence and correlates of smoking by ethnicity in a sample of pregnant primary care patients in São Paulo, Brazil.

DESIGN

Data were obtained from completed surveys during perinatal care visits in primary care clinics. We examine a sample of 811 pregnant women surveyed during 20-30 weeks of pregnancy. Multiple logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

We found significant ethnic differences in smoking during pregnancy. Compared to White women, Black women were more likely to use tobacco during pregnancy (OR: 1.95; 95% CI: 1.16-3.27). In the fully adjusted model, when accounting for common mental disorders, differences in smoking during pregnancy by ethnicity remained (OR: 1.96; 95% CI: 1.14-3.36).

CONCLUSIONS

There are ethnic differences in tobacco use during pregnancy. Clinical implications including universal screening for tobacco use during pregnancy and culturally relevant approaches to smoking cessation are suggested.

Least explored factors associated with prenatal smoking

Poor pregnancy and birth outcomes are major problems in the United States, and maternal smoking during pregnancy has been identified as one of the most preventable risk factors associated with these outcomes. This study examines less explored risk factors of smoking among underserved African American pregnant women. A cross-sectional survey was conducted at an outpatient obstetrics-gynecology clinic of an inner-city university hospital in Virginia from March 2009 through January 2011 in which pregnant women (N = 902) were interviewed at their first prenatal care visit. Survey questions included items related to women's sociodemographic characteristics as well as their pregnancy history; criminal history; receipt of social services; child protective services involvement; insurance status; and history of substance abuse, domestic violence, and depression. Multiple logistic regression was conducted to calculate odds ratios and 95 % confidence intervals depicting the relationship between these factors and smoking during pregnancy. The analysis reported that maternal age [OR = 1.08, 95 % CI = 1.05-1.12], less than high school education [OR = 4.30, 95 % CI = 2.27-8.14], unemployed [OR = 2.33, 95 % CI = 1.35-4.04], criminal history [OR = 1.66, 95 % CI = 1.05-2.63], receipt of social services [OR = 2.26, 95 % CI = 1.35-3.79] alcohol use [OR = 2.73, 95 % CI = 1.65-4.51] and illicit drug use [OR = 1.97, 95 % CI = 1.04-3.74] during pregnancy were statistically significant risk factors associated with smoking during pregnancy. In addition to the well known risk factors, public health professionals should be aware that criminal history and receipt of social services are important factors associated with smoking during pregnancy. Social service providers such as WIC and prisons and jails may offer a unique opportunity for education and cessation interventions during the preconception or interconception period.

A sibling-comparison study of smoking during pregnancy and childhood psychological traits

Prenatal exposure to substances of abuse is associated with numerous psychological problems in offspring, but quasi-experimental studies controlling for co-occurring risk factors suggest that familial factors (e.g., genetic and environmental effects shared among siblings) confound many associations with maternal smoking during pregnancy (SDP). Few of the quasi-experimental studies in this area have explored normative psychological traits in early childhood or developmental changes across the lifespan, however. The current study used multilevel growth curve models with a large, nationally-representative sample in the United States to investigate for potential effects of SDP on the developmental trajectories of cognitive functioning, temperament/personality, and disruptive behavior across childhood, while accounting for shared familial confounds by comparing differentially exposed siblings and statistically controlling for offspring-specific covariates. Maternal SDP predicted the intercept (but not change over time) for all cognitive and externalizing outcomes. Accounting for familial confounds, however, attenuated the association between SDP exposure and all outcomes, except the intercept (age 5) for reading recognition. These findings, which are commensurate with previous quasi-experimental research on more severe indices of adolescent and adult problems, suggest that the associations between SDP and developmental traits in childhood are due primarily to confounding factors and not a causal association.

White matter microstructure, alcohol exposure, and familial risk for alcohol dependence

Offspring from families with alcohol dependence (AD) have been shown to exhibit brain morphological alterations that appear to be related to their familial/genetic risk for AD. Greater susceptibility for developing AD may be related to structural underpinnings of behavioral traits that predispose to AD. We examined white matter (WM) integrity in 81 individuals with either a high density of AD in their families (N=44) or without a family history for either alcohol or drug dependence (N=37). Magnetic resonance images were acquired on a Siemens 3 T scanner with fractional anistropy (FA) and the apparent diffusion coefficient (ADC), along with radial diffusivity (RD) and longitudinal (axial) diffusivity calculated for major white matter tracts in both hemispheres. Extensive personal histories of alcohol and drug use were available from longitudinal collection of data allowing for reliable estimates of alcohol and drug exposure. We found that the interaction of personal exposure to alcohol and familial risk for AD predicts reduction in WM integrity for the inferior longitudinal fasciculus (ILF) and the superior longitudinal fasciculus (SLF) in the left hemisphere and the forceps major tract. Only one tract showed a significant difference for exposure alone, the anterior thalamic radiation.

Long-term maintenance of smoking cessation in pregnancy: an analysis of the birth cohort generation XXI

INTRODUCTION

Pregnancy affords opportunities for health promotion and disease prevention. We worked with a population-based cohort of women who gave birth in Portugal to quantify the proportion of women who quit smoking during pregnancy, the proportion of these women who continued to abstain 4 years after delivery, and the determinants of these outcomes.

METHODS

A birth cohort was assembled in public maternity units of Porto, Portugal, in 2005-2006, and all women were reevaluated at an average of 4 years after delivery. A total of 5,420 mothers were included in the analysis. Smoking status at baseline and at follow-up was ascertained by interview. Adjusted prevalence ratios and 95% CIs were computed using robust Poisson regression.

RESULTS

Overall, 47.4% of women who smoked ceased smoking and 41.7% reduced cigarette consumption during pregnancy. Four years after delivery, 32.1% of those who stopped smoking during pregnancy continued to abstain. Older women, first-time mothers, light smokers, those who were living with a partner at the time of follow-up, those who became pregnant again after the index pregnancy, those who breast fed for more than 52 weeks, and those with a child diagnosed with asthma and/or rhinitis were more likely to abstain from smoking.

CONCLUSIONS

Approximately half of all women stopped smoking during pregnancy and, among these, approximately one third continued to abstain 4 years after delivery. The high proportion of relapse may be attributable to poor awareness or skepticism regarding the adverse effects of secondhand smoke on children or physiological and psychological dependence on nicotine.

Validation of the alcohol use module from a multidimensional prenatal psychosocial risk screening instrument

The purpose of the study was to validate the Prenatal Risk Overview (PRO) Alcohol use domain against a structured diagnostic interview. The PRO was developed to screen for 13 psychosocial risk factors associated with poor birth outcomes. After clinic staff administered the PRO to prenatal patients, they asked for consent to administration of selected modules of the structured clinical interview for DSM-IV (SCID) by a research assistant. To assess the criterion validity of the PRO, low and moderate/high risk classifications from the alcohol use domain were cross-tabulated with SCID Alcohol Use Disorder variables. The study sample included 744 women. Based on PRO responses, 48.7% reported alcohol use during the 12 months before they learned they were pregnant; 5.4% reported use post pregnancy awareness. The typical quantity consumed pre-pregnancy was four or more drinks per occasion. Based on the SCID, 7.4% met DSM-IV criteria for either Alcohol Abuse or Dependence. Sensitivity and specificity of the PRO for Alcohol Use Disorders were 83.6 and 80.3%, respectively. Negative predictive value was 98.4% and positive predictive value was 25.3%. The results indicate the PRO effectively identified pregnant women with Alcohol Use Disorders. However, prenatal screening must also detect consumption patterns that do not meet diagnostic thresholds but may endanger fetal development. The PRO also identified women who continued to drink after they knew they were pregnant, as well as those whose previous drinking habits put them at risk for resumption of hazardous use.

Disentangling the relationships between maternal smoking during pregnancy and co-occurring risk factors

BACKGROUND

Maternal smoking during pregnancy (SDP) has been studied extensively as a risk factor for adverse offspring outcomes and is known to co-occur with other familial risk factors. Accounting for general familial risk factors has attenuated associations between SDP and adverse offspring outcomes, and identifying these confounds will be crucial to elucidating the relationship between SDP and its psychological correlates.

METHOD

The current study aimed to disentangle the relationship between maternal SDP and co-occurring risk factors (maternal criminal activity, drug problems, teen pregnancy, educational attainment, and cohabitation at childbirth) using a population-based sample of full- (n=206 313) and half-sister pairs (n=19 363) from Sweden. Logistic regression models estimated the strength of association between SDP and co-occurring risk factors. Bivariate behavioral genetic models estimated the degree to which associations between SDP and co-occurring risk factors are attributable to genetic and environmental factors.

RESULTS

Maternal SDP was associated with an increase in all co-occurring risk factors. Of the variance associated with SDP, 45% was attributed to genetic factors and 53% was attributed to unshared environmental factors. In bivariate models, genetic factors accounted for 21% (non-drug-, non-violence-related crimes) to 35% (drug-related crimes) of the covariance between SDP and co-occurring risk factors. Unshared environmental factors accounted for the remaining covariance.

CONCLUSIONS

The genetic factors that influence a woman's criminal behavior, substance abuse and her offspring's rearing environment all influence SDP. Therefore, the intergenerational transmission of genes conferring risk for antisocial behavior and substance misuse may influence the associations between maternal SDP and adverse offspring outcomes.

Simultaneous quantitative determination of bupropion and its three major metabolites in human umbilical cord plasma and placental tissue using high-performance liquid chromatography-tandem mass spectrometry

A liquid chromatography in tandem with electro-spray ionization mass spectrometry method has been developed and validated for the quantitative determination of bupropion and its major metabolites (hydroxybupropion, threo- and erythrohydrobupropion) in human umbilical cord plasma and placental tissue. The samples were acidified with trichloroacetic acid, and protein precipitated by adding acetonitrile. Chromatographic separation of drug and metabolites was achieved by using a Waters Symmetry C(18) column, with an isocratic elution of 31% methanol and 69% formic acid (0.04%, v/v) aqueous solution at a flow rate of 1.0 mL/min. Detection was carried out by mass spectrometry using positive electro-spray ionization mode, and the compounds were monitored using multiple reactions monitoring method. Deuterium-labeled isotopes of the compounds were used as internal standards. Calibration curves were linear (r(2)>0.99) in the tested ranges. The lower limit of quantification of analytes in umbilical cord plasma samples is <0.72 ng/mL and 0.92 ng/g in placental tissue samples. The relative deviation of this method was <15% for intra- and inter-day assays, and the accuracy ranged between 88% and 105%. The extraction recovery of the four analytes ranged between 89% and 96% in umbilical cord plasma, and 64% and 80% in placental tissue. No significant matrix effect was observed in the presented method.

Risk factors associated with nicotine dependence in a sample of Romanian pregnant smokers

OBJECTIVES

To fill the gap in assessing nicotine dependence during pregnancy in an unexplored population in Central and Eastern Europe and to analyze the associations of maternal characteristics and prenatal risk factors with moderate-heavy nicotine dependence among pregnant smokers.

STUDY DESIGN

A questionnaire was applied to pregnant smokers in Romania to assess nicotine dependence and other related risks poorly documented in Central and Eastern Europe. The response rate was >80% and the valid sample included 137 pregnant smokers. Descriptive statistics and logistic regressions were used to assess nicotine dependence and to analyze the associations of maternal characteristic and prenatal risk factors with moderate-heavy nicotine dependence.

RESULTS

Approximately 43% of the pregnant smokers in our sample (59 of 137) had moderate to heavy nicotine dependence. Depressive symptoms were associated with moderate-heavy nicotine dependence among pregnant smokers (OR=3.07, p<0.05). Women carrying an unwanted pregnancy had higher odds of moderate-heavy nicotine dependence (OR=2.59, p<0.05) compared to other pregnant women. High stress, lack of social support, and socioeconomic status were not associated with nicotine dependence.

CONCLUSIONS

A large proportion of women had moderate-heavy nicotine dependence in a sample of Romanian pregnant smokers. The more dependent pregnant smokers were more likely to have depressive symptoms. Prenatal care should include brief nicotine dependence assessments and mental health screening and referrals for pregnant women who smoke. Special and intensive efforts, including psychosocial components, may be needed for the nicotine dependent pregnant smokers.

Relationships between self-reported smoking, household environmental tobacco smoke exposure and depressive symptoms in a pregnant minority population

This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking.

RESULTS

Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.

Cerebellum volume in high-risk offspring from multiplex alcohol dependence families: association with allelic variation in GABRA2 and BDNF

Offspring from families with multiple cases of alcohol dependence have a greater likelihood of developing alcohol dependence (AD) and related substance use disorders. Greater susceptibility for developing these disorders may be related to structural differences in brain circuits that influence the salience of rewards or modify the efficiency of information processing and AD susceptibility. We examined the cerebellum of 71 adolescent/young adult high-risk (HR) offspring from families with multiple cases of alcohol dependence (multiplex families), and 60 low-risk (LR) controls with no family history of alcohol or drug dependence who were matched for age, gender, socioeconomic status and IQ, with attention given to possible effects of personal use of substances and maternal use during pregnancy. Magnetic resonance images were acquired on a General Electric 1.5-Tesla scanner and manually traced (BRAINS2) blind to clinical information. GABRA2 and BDNF variation were tested for their association with cerebellar volumes. High-risk offspring from multiplex AD families showed greater total volume of the cerebellum and total gray matter (GM), in comparison with LR controls. An interaction between allelic variation in GABRA2 and BDNF genes was associated with GM volumes, suggesting that inherited variation in these genes may promote early developmental differences in neuronal proliferation of the cerebellum.

Maternal smoking during pregnancy among Aboriginal women in New South Wales is linked to social gradient

OBJECTIVE

Social gradients in Aboriginal health are seldom explored. This study describes social gradients and trends in smoking during pregnancy among Aboriginal mothers in NSW.

METHODS

This was a secondary analysis of the NSW Midwives Data Collection (MDC) 1994-2007, covering all births in NSW. Analyses examined associations between socio-demographic characteristics and smoking during pregnancy.

RESULTS

Data from 1,214,206 pregnant women showed that 17.4% smoked during pregnancy. The rate of smoking during pregnancy among all NSW women declined from 22.3% in 1994 to 12.8% in 2007; the rate among Aboriginal women remained high, declining from 61.4% in 1994 to 50.2% in 2007. Smoking was substantially higher among Aboriginal mothers compared to non-Aboriginal mothers. Socio-economic analyses showed that the smoking rate among low SES Aboriginal mothers was approximately two and a half times that of high SES Aboriginal women, a similar gradient to non-Aboriginal women.

CONCLUSIONS

Indicators of socio-economic position are a consistent, independent correlate of smoking during pregnancy for Aboriginal and non-Aboriginal women.

IMPLICATIONS

There is a need for a social inequalities approach to smoking during pregnancy, specifically targeting more disadvantaged Aboriginal mothers and all teenage mothers for smoking prevention. Strategies to access more disadvantaged mothers should not be missed through broadly focused Aboriginal tobacco control strategies.

The relationship of childhood trauma to nicotine dependence in pregnant smokers

Pregnant women with high levels of nicotine dependence are the least likely to quit smoking spontaneously during pregnancy or to benefit from smoking cessation interventions. In the general population, there is increasing evidence of a relationship between smoking, nicotine dependence, and exposure to childhood trauma. We examined the relationship of childhood trauma to several measures of nicotine dependence and evaluated whether this relationship was mediated by major depressive disorder or depressive symptom severity in pregnant smokers. Moderate to extreme levels of childhood trauma were significantly related to smoking within 5 minutes or less of waking, and to the Behavioral Choice-Melioration, Negative Reinforcement, and Tolerance subscales of the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68) scale. The relationships between childhood emotional abuse and the WISDM-68 Total and Negative Reinforcement subscale were partially mediated by depressive symptoms. Results suggest that childhood trauma may be a risk factor underlying nicotine dependence in pregnant smokers. Increased understanding of the relationship of affect regulation to smoking in individuals with childhood trauma histories may aid in the development of more effective treatments of nicotine dependence for this population of smokers.

Psychiatric disorders and treatment in low-income pregnant women

AIMS

This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment.

METHOD

To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there.

RESULTS

The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects.

CONCLUSIONS

With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.