Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

Smoking cessation in pregnant women: A randomized controlled trial investigating the effectiveness of an eHealth intervention including heart rate variability-biofeedback training

BACKGROUND

Prenatal smoking and stress are associated with adverse health effects for women themselves and are risk factors for adverse outcomes of the child. Effective interventions are needed to support women with smoking cessation and reducing stress. The aims were (1) to test the effectiveness of an 8-week eHealth intervention targeting stress reduction and smoking cessation; (2) to examine whether stress reduction mediated the intervention effect on smoking behavior; (3) to test motivation to quit as a moderator; and (4) to investigate a dose-response effect of program usage.

METHODS

Pregnant women were included if they were >18 years of age, < 28 weeks pregnant at recruitment, and currently smoking. In total, 156 consenting participants were randomly assigned to the intervention or active control condition. Study outcomes on smoking (yes/no, frequency, and quantity) were collected via online questionnaires at pre-intervention (baseline; t0), post-intervention (8 weeks after t0; t1), and follow up at two weeks (t2) and three months (t3) after birth.

RESULTS

Smoking and stress reduced over the 8-week period in both conditions. The intervention effect on smoking was not mediated by stress reduction. Motivation to quit was found to moderate the intervention effect (smoking frequency and quantity) and a dose-response effect was found for program usage in the intervention for the reduction on smoking frequency and quantity.

CONCLUSION

Program usage and motivation to quit are important for smoking reduction in pregnant women. Further research is needed to examine how the intervention could be improved to increase treatment effectiveness.

Prevalence and descriptive epidemiology of choanal atresia and stenosis in Texas, 1999-2018

Choanal atresia and stenosis are common causes of congenital nasal obstruction, but their epidemiology is poorly understood. Compared to bilateral choanal atresia/stenosis, unilateral choanal atresia/stenosis is generally diagnosed later and might be under-ascertained in birth defect registries. Data from the population-based Texas Birth Defects Registry and Texas vital records, 1999-2018, were used to assess the prevalence of choanal atresia/stenosis. Poisson regression models were used to evaluate associations with infant and maternal characteristics in two analytic groups: isolated choanal atresia/stenosis (n = 286) and isolated, bilateral choanal atresia/stenosis (n = 105). The overall prevalence of choanal atresia/stenosis was 0.92/10,000, and the prevalence of isolated choanal atresia/stenosis was 0.37/10,000 livebirths. Variables associated with choanal atresia/stenosis in one or both analytic groups included infant sex, pregnancy plurality, maternal race/ethnicity, maternal age, and maternal residence on the Texas-Mexico border. In general, adjusted prevalence ratios estimated from the two analytic groups were in the same direction but tended to be stronger in the analyses restricted to isolated, bilateral defects. Epidemiologic studies of isolated choanal atresia/stenosis should consider focusing on cases with bilateral defects, and prioritizing analyses of environmental, social, and structural factors that could account for the association with maternal residence on the Texas-Mexico border.

A meta-analysis of the effects of vitamin C supplementation for pregnant smokers on the pulmonary function of their offspring

BACKGROUND

At present, the need for vitamin C supplementation for pregnant smokers has not been fully studied. This study is aimed at investigating whether vitamin C supplementation for pregnant smoking women can improve the pulmonary function of their offspring.

METHODS

Four databases were searched from inception to April 1, 2023 for studies on the effect of vitamin C supplementation to pregnant smokers on the pulmonary function of their offspring. Meanwhile, the reference lists of relevant studies were manually searched. The risk of bias in the included studies was assessed using the Cochrane Collaboration tool, and the data was analyzed using STATA/SE 17.0.

RESULTS

Four randomized controlled trials (RCTs), all of high quality, were enrolled in this meta-analysis, including 787 pregnant women. The offspring of pregnant smokers who received vitamin C supplementation exhibited improved Forced Expiratory Flow between 25 and 75% (FEF25-75), FEF50, FEF75, and Forced Vital Capacity (FVC) compared to those who did not receive vitamin C supplementation. However, there was no statistically significant difference in Forced Expiratory Volume at 0.5 s (FEV0.5) and the ratio of FEV0.5 to FVC between the offspring of pregnant smokers who received vitamin C and the control group.

CONCLUSION

Vitamin C supplementation for smoking pregnant women may enhance the pulmonary function of their offspring, particularly in FEF25-75, FEF50, FEF75, and FVC. Nevertheless, there are no significant differences in FEV0.5 and the FEV0.5/FVC ratio. These findings suggest that vitamin C supplementation has potential benefits for specific pulmonary function. Further studies are needed to comprehensively assess the effects of vitamin C on pulmonary function in the context of maternal smoking during pregnancy.

Prenatal tobacco smoke exposure and risk for cognitive delays in infants born very premature

Prenatal tobacco smoke exposure (TSE) and prematurity are independent risk factors for abnormal neurodevelopment. The objectives were to compare differences in Bayley-III cognitive, language, and motor scores at 2 years corrected age (CA) in 395 infants born very preterm (≤ 32 weeks gestation) with and without prenatal TSE. We performed multivariable linear regression analyses to examine associations between prenatal TSE and neurodevelopmental outcomes and a mediation analysis to estimate direct effects of prenatal TSE on outcomes and indirect effects through preterm birth. In total, 50 (12.6%) infants had prenatal TSE. Infants with prenatal TSE had lower mean [95% CI] Cognitive score (82.8 [78.6, 87.1]) vs. nonexposed infants (91.7 [90.1, 93.4]). In children with and without prenatal TSE, there were significant differences in mean [95% CI] Language scores (81.7 [76.0, 87.4] vs. 92.4 [90.2, 94.6], respectively) and mean [95% CI] Motor scores (86.5 [82.2, 90.7] vs. 93.4 [91.8, 95.0], respectively); scores remained significant after controlling for confounders. Preterm birth indirectly mediated 9.0% of the total effect of prenatal TSE on Cognitive score (P = NS). However, 91% of the remaining total effect was significant and attributable to TSE's direct harmful effects on cognitive development (β = - 5.17 [95% CI - 9.97, - 0.38]). The significant association is largely due to TSE's direct effect on cognitive development and not primarily due to TSE's indirect effect on preterm birth.

The Gene Expression Profiles Associated with Maternal Nicotine Exposure in the Liver of Offspring Mice

This study aims to investigate the effect of maternal nicotine exposure on the gene expression profiles in the liver of offspring mice. Pregnant mice were subcutaneously injected with either saline vehicle or nicotine twice a day on gestational days 11-21. Total RNA from the liver samples which collected from the offspring mice of postnatal day 7 and 21 was subjected to RNA sequencing. Gene Ontology (GO) functional enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) signaling pathway enrichment analysis were conducted to identify the functions of differentially expressed genes (DEGs). Four genes were selected for further validation by quantitative reverse transcription polymerase chain reaction (qRT-PCR). A total of 448 DEGs and 186 DEGs were identified on postnatal day 7 and 21, respectively. GO analysis revealed that the DEGs on postnatal day 7 mainly participated in the biological functions of cell growth and proliferation, and the DEGs on postnatal day 21 mainly participated in ion transport/activity. KEGG enrichment analysis showed that the DEGs on postnatal day 7 were mainly enriched in the cell cycle, cytokine-cytokine receptor interactions, hypertrophic cardiomyopathy, and the p53 signaling pathway, while the DEGs on postnatal day 21 were mainly enriched in neuroactive ligand-receptor interactions, the calcium signaling pathway, retinol metabolism, and axon guidance. The qRT-PCR results were consistent with the RNA sequencing data. The DEGs may affect the growth of liver in early postnatal period while may affect ion transport/activity in late postnatal period.

Prepubescent Electronic Cigarette Exposure Affects Sexual Motivation and Puberty in Female But Not Male Long-Evans Rats

INTRODUCTION

A method for delivering vaporized nicotine to animals has been developed using e-cigarette devices. The present experiment was designed to measure the effects of e-cigarette nicotine on pubertal onset and development of reproductive behavior in female and male Long-Evans rats.

AIM AND METHODS

Rats received daily 10-min sessions of electronic-cigarette vaporized nicotine (5% Virginia Tobacco JUUL Pods) or room air in a whole-body exposure chamber (postnatal day 28-31). Pubertal onset was monitored daily (ie, vaginal opening in females, preputial separation in males). Two weeks later, rats were tested for sexual motivation using the partner-preference paradigm, whereby subjects were given the opportunity to approach either a sexual partner or a same-sex social partner. Four weeks later, partner preference was assessed again, 10 min after rats were re-exposed to their same prepubertal treatment.

RESULTS

We found that prepubescent electronic-cigarette vaporized nicotine disrupted puberty and sexual motivation in female but not male rats. In vaped females, vaginal opening was delayed and less time was spent with the male stimulus compared to room-air controls. In contrast, no effect of e-cigarette vapor was observed on pubertal onset or on any measures of sexual behavior in male rats. No effects were observed in either female or male rats on the second partner-preference test.

CONCLUSIONS

Prepubescent vaporized nicotine affected the development of reproductive physiology and behavior in female rats but not in male rats, whereas an additional acute exposure to nicotine vapor had no effect in either female or male adult rats.

IMPLICATIONS

Given the prevalence of increasingly younger users, more animal research is needed to explore the effects of e-cigarette smoking on multiple developmental systems including reproductive physiology and behavior. This model could be useful in exploring multiple behavioral and physiological endpoints in both sexes. Adjustments to the duration of exposure and control conditions will be necessary for future experiments to best model human use.

The Effects of Maternal Smoking on Thyroid Function: Findings from Routine First-Trimester Sonographic Anomaly Screening

AIM

This study aimed to assess the effect of tobacco exposure on maternal thyroid function and investigate its relationship to subclinical hypothyroidism in pregnant women during the first trimester.

SUBJECTS AND METHOD

A comparison of maternal thyroid function was made on 45 smokers, who composed the study group, and 72 non-smokers, pregnant women, who constituted the control group. After determining smokers by questionnaire, carbon monoxide (CO) levels in the expiratory air of the participants in both groups were measured and recorded, and the smokers' exposure was objectively confirmed.

RESULTS

Smoking and non-smoking pregnant women were similar regarding body mass index (BMI). While the TSH and fT4 levels were respectively 1.48 mlU/L and 11.43 pmol/L in pregnant women who smoked, that ratio changed to 1.72 mlU/L and 11.17 pmol/L in the non-smokers' group. But the differences between the groups were not statistically significant (p=0.239, p=0.179). Even though the rate of subclinical hypothyroidism was 8.9% in the smoking group, it was approximately 19.4% in the non-smoker group; the difference was not statistically significant (p=0.187).

CONCLUSION

This study proved that there is no statistically significant difference between maternal serum TSH and fT4 levels and the rate of subclinical hypothyroidism in smokers during pregnancy in the first trimester.

Pyroptosis is involved in maternal nicotine exposure-induced metabolic associated fatty liver disease progression in offspring mice

We have investigated whether inflammasomes and pyroptosis are activated in maternal nicotine exposure (MNE) offspring mice and whether they are involved in MNE-promoted metabolic associated fatty liver disease (MAFLD) in adult offspring. We injected pregnant mice subcutaneously with saline vehicle or nicotine twice a day on gestational days 11-21. Offspring mice from both groups were fed with a normal diet (ND) or a high-fat diet (HFD) for 6 months at postnatal day 21 to develop the MAFLD model. Serum biochemical indices were analyzed, and liver histology was performed. The expression levels of inflammasome and pyroptosis proteins were detected by western blot. We found MNE significantly aggravated the injury of MAFLD in adult offspring mice. MNE activated inflammasomes and pyroptosis in both infant and adult offspring mice. HFD treatment activated inflammasomes but not pyroptosis at 3 months, while it showed no effect at 6 months. However, pyroptosis was more severe in MNE-HFD mice than in MNE-ND mice at 6 months. Taken together, our data suggest MNE promotes MAFLD progression in adult offspring mice. MNE also induces NLRP3 and NLRP6 inflammasome activation and pyroptosis in both infant and adult offspring mice, which may be involved in MNE-promoted progression of MAFLD.

Why women continue to smoke during pregnancy: a qualitative study among smoking pregnant women

Smoking during pregnancy is a serious public health concern due to its adverse consequences on fetal development and pregnant women's health. For the success of smoking cessation interventions, it is essential to determine why pregnant women continue smoking. The objective of this study is to determine the beliefs, attitudes, and barriers to quitting smoking during pregnancy. We adopted a qualitative research design. The participants consisted of 22 pregnant women who smoke, selected by purposive sampling. We collected data through semi-structured interviews and analyzed it using thematic analysis. We identified six themes namely "Reasons for starting to smoke: family and social environment," "Intention to quit smoking and related factors," "Smoking and emotional well-being," "Smoking and stressful life experiences," "Protective thoughts: reducing smoking to safeguard their babies," and "Belief in a healthy pregnancy and inadequate risk perception." Women expressed the desire to protect their fetus from the harm of smoking. However, they continued to smoke due to a lack of knowledge, inadequate risk perception, psychological difficulties, and lack of motivation. Health professionals should be aware of the difficulties experienced by pregnant women who smoke and should support them in quitting smoking.

Contingency management interventions for abstinence from cigarette smoking in pregnancy and postpartum: A systematic review and meta-analysis

Contingency management is one of the most effective treatments for substance use disorders in not-pregnant people. The most recent quantitative review of its efficacy among pregnant and postpartum women who smoke cigarettes concluded with moderate certainty that those receiving contingent financial incentives were twice as likely to be abstinent compared with controls. We aimed to update and extend previous reviews. Five databases were systematically searched for randomized controlled trials (RCTs) published before December 2022 that assessed the effectiveness of incentives for abstinence from substance use. Data from trials of smoking abstinence were pooled using a random-effects meta-analysis model (restricted maximum likelihood). Results are reported as risk-ratios (RRs) with 95% confidence intervals (CIs). This study is registered with PROSPERO, CRD42022372291. Twelve RCTs (3136) pregnant women) were included. There was high certainty evidence that women receiving incentives were more likely to be abstinent than controls at the last antepartum assessment (12 RCTs; RR = 2.43, 95% CI 2.04-2.91, n = 2941, I2 = 0.0%) and moderate certainty evidence at the longest postpartum assessment while incentives were still available (five RCTs; RR = 2.72, 1.47-5.02, n = 659, I2 = 44.5%), and at the longest postpartum follow-up after incentives were discontinued (six RCTs; RR = 1.93, 1.08-3.46, n = 1753, I2 = 51.8%). Pregnant women receiving incentives are twice as likely to achieve smoking abstinence during pregnancy suggesting this intervention should be standard care for pregnant women who smoke. The results also demonstrate that abstinence continues into the postpartum period, including after incentives are discontinued, but more trials measuring outcomes in the postpartum period are needed to strengthen this conclusion.

Impact of in-utero electronic cigarette exposure on neonatal neuroinflammation, oxidative stress and mitochondrial function

Introduction: Despite the prevalence of the perception that electronic cigarettes (e-cig) are a safer alternative to tobacco smoke, growing concern about their potential toxic impact warrants adequate investigation focusing on special populations like maternal and pediatric groups. This study evaluated the consequences of maternal e-cig use on neonatal neuroinflammation, oxidative stress, and mitochondrial function in primary cultured neurons and postnatal day (PD) 7 and 90 brain. Methodology: Pregnant CD1 mice were exposed to e-cig vapor (2.4% nicotine) from gestational day 5 (E5) till PD7, and the primary neurons were isolated from pups at E16/17. Cellular total reactive oxygen species (ROS) and mitochondrial superoxide were measured in primary neurons using CM-H2DCFDA and Mitosox red, respectively. Mitochondrial function was assessed by Seahorse XF Cell Mitostress analysis. The level of pro-inflammatory cytokines was measured in primary neurons and PD7 and PD90 brains by RT-PCR and immunobead assay. Western blot analysis evaluated the expression of antioxidative markers (SOD-2, HO-1, NRF2, NQO1) and that of the proinflammatory modulator NF-κB. Results: Significantly higher level of total cellular ROS (p < 0.05) and mitochondrial superoxide (p < 0.01) was observed in prenatally e-cig-exposed primary neurons. We also observed significantly reduced antioxidative marker expression and increased proinflammatory modulator and cytokines expression in primary neurons and PD7 (p < 0.05) but not in PD90 postnatal brain. Conclusion: Our findings suggest that prenatal e-cig exposure induces postnatal neuroinflammation by promoting oxidative stress (OS), increasing cytokines' levels, and disrupting mitochondrial function. These damaging events can alter the fetal brain's immune functions, making such offspring more vulnerable to brain insults.

Prenatal exposure to long-term heat stress and stillbirth in Ghana: A within-space time-series analysis

INTRODUCTION

Few studies examined the association between prenatal long-term ambient temperature exposure and stillbirth and fewer still from developing countries. Rather than ambient temperature, we used a human thermophysiological index, Universal Thermal Climate Index (UTCI) to investigate the role of long-term heat stress exposure on stillbirth in Ghana.

METHODS

District-level monthly UTCI was linked with 90,532 stillbirths of 5,961,328 births across all 260 local districts between 1^st January 2012 and 31^st December 2020. A within-space time-series design was applied with distributed lag nonlinear models and conditional quasi-Poisson regression.

RESULTS

The mean (28.5 ± 2.1 °C) and median UTCI (28.8 °C) indicated moderate heat stress. The Relative Risks (RRs) and 95% Confidence Intervals (CIs) for exposure to lower-moderate heat (1st to 25th percentiles of UTCI) and strong heat (99th percentile) stresses showed lower risks, relative to the median UTCI. The higher-moderate heat stress exposures (75th and 90th percentiles) showed greater risks which increased with the duration of heat stress exposures and were stronger in the 90th percentile. The risk ranged from 2% (RR = 1.02, 95% CI 0.99, 1.05) to 18% (RR = 1.18, 95% CI 1.02, 1.36) for the 90th percentile, relative to the median UTCI. Assuming causality, 19 (95% CI 3, 37) and 27 (95% CI 3, 54) excess stillbirths per 10,000 births were attributable to long-term exposure to the 90th percentile relative to median UTCI for the past six and nine months, respectively. Districts with low population density, low gross domestic product, and low air pollution which collectively defined rural districts were at higher risk as compared to those in the high level (urban districts).

DISCUSSION

Maternal exposure to long-term heat stress was associated with a greater risk of stillbirth. Climate change-resilient interventional measures to reduce maternal exposure to heat stress, particularly in rural areas may help lower the risk of stillbirth.

Electronic Cigarette Use during Pregnancy: Is It Harmful?

Although combustible cigarette smoking rates have declined in recent years, alternative tobacco product use, particularly electronic cigarette use ("vaping"), has increased among young adults. Recent studies indicate that vaping during pregnancy is on the rise, possibly due to the perception that it is a safer alternative to combustible cigarette smoking. However, e-cigarette aerosols may contain several newer, potentially toxic compounds, including some known developmental toxicants that may adversely impact both the mother and the fetus. However, there is paucity of studies that have examined the effects of vaping during pregnancy. While the adverse perinatal outcomes of cigarette smoking during pregnancy are well established, the specific risks associated with inhaling vaping aerosols during pregnancy requires more research. In this article, we discuss the existing evidence and knowledge gaps on the risks of vaping during pregnancy. Studies that investigate vaping-associated systemic exposure and its effects (i.e., biomarker analyses) and maternal and neonatal clinical health outcomes are needed to reach more robust conclusions. We particularly emphasize the need to go beyond comparative studies with cigarettes, and advocate for research that objectively evaluates the safety of e-cigarettes and other alternative tobacco products.

Maternal e-cigarette use can disrupt postnatal blood-brain barrier (BBB) integrity and deteriorates motor, learning and memory function: influence of sex and age

Electronic nicotine delivery systems (ENDS), also commonly known as electronic cigarettes (e-cigs) are considered in most cases as a safer alternative to tobacco smoking and therefore have become extremely popular among all age groups and sex. It is estimated that up to 15% of pregnant women are now using e-cigs in the US which keeps increasing at an alarming rate. Harmful effects of tobacco smoking during pregnancy are well documented for both pregnancy and postnatal health, however limited preclinical and clinical studies exist to evaluate the long-term effects of prenatal e-cig exposure on postnatal health. Therefore, the aim of our study is to evaluate the effect of maternal e-cig use on postnatal blood-brain barrier (BBB) integrity and behavioral outcomes of mice of varying age and sex. In this study, pregnant CD1 mice (E5) were exposed to e-Cig vapor (2.4% nicotine) until postnatal day (PD) 7. Weight of the offspring was measured at PD0, PD7, PD15, PD30, PD45, PD60 and PD90. The expression of structural elements of the BBB, tight junction proteins (ZO-1, claudin-5, occludin), astrocytes (GFAP), pericytes (PDGFRβ) and the basement membrane (laminin α1, laminin α4), neuron specific marker (NeuN), water channel protein (AQP4) and glucose transporter (GLUT1) were analyzed in both male and female offspring using western blot and immunofluorescence. Estrous cycle was recorded by vaginal cytology method. Long-term motor and cognitive functions were evaluated using open field test (OFT), novel object recognition test (NORT) and morris water maze test (MWMT) at adolescence (PD 40-45) and adult (PD 90-95) age. In our study, significantly reduced expression of tight junction proteins and astrocyte marker were observed in male and female offspring until PD 90 (P < 0.05). Additionally, prenatally e-cig exposed adolescent and adult offspring showed impaired locomotor, learning, and memory function compared to control offspring (P < 0.05). Our findings suggest that prenatal e-cig exposure induces long-term neurovascular changes of neonates by disrupting postnatal BBB integrity and worsening behavioral outcomes.

Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners

Policy Points Local health departments with direct maternal and child health service provisions exhibit greater social service collaboration, thereby enhancing community capacity to improve health care access and social determinant support. These findings may prioritize collaboration as a community-based effort to reduce disparities in maternal and child health and chronic disease.

CONTEXT

Improving maternal and child health (MCH) care in the United States requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations, impacting local service delivery capacity. We measured MCH service provision among LHDs and examined its association with patterns of social service collaboration among community partners.

METHODS

We analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure the LHD provision of MCH services and the types of social services involved in the implementation of essential public health activities. We compared the extensive and intensive margins of social service collaboration among LHDs with any versus no MCH service provision. We then used latent class analysis (LCA) to classify collaboration and logistic regression to estimate community correlates of collaboration.

FINDINGS

Of 620 LHDs, 527 (85%) provided at least one of seven observed MCH services. The most common service was Special Supplemental Nutrition Program for Women, Infants, and Children (71%), and the least common was obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. LCA identified two classes of LHDs: high (n = 257; 49%) and low (n = 270; 51%) collaborators. Between 74% and 96% of high collaborators were engaged with social service organizations that provided basic needs services, compared with 31%-60% of low collaborators. Rurality and very high maternal vulnerability were significantly correlated with low collaboration among MCH service-providing LHDs.

CONCLUSIONS

LHDs with direct MCH service provision exhibited greater social service collaboration. Collaboration was lowest in rural communities and communities with very high maternal vulnerability. Over half of MCH service-providing LHDs were classified as low collaborators, suggesting unrealized opportunities for social service engagement in these communities.

Epigenetics and the Exposome: DNA Methylation as a Proxy for Health Impacts of Prenatal Environmental Exposures

The accumulation of every day exposures can impact health across the life course, but our understanding of such exposures is impeded by our ability to delineate the relationship between an individual's early life exposome and later life health effects. Measuring the exposome is challenging. Exposure assessed at a given time point captures a snapshot of the exposome but does not represent the full spectrum of exposures across the life course. In addition, the assessment of early life exposures and their effects is often further challenged by lack of relevant samples and the time gap between exposures and related health outcomes in later life. Epigenetics, specifically DNA methylation, has the potential to overcome these barriers as environmental epigenetic perturbances can be retained through time. In this review, we describe how DNA methylation can be framed in the world of the exposome. We offer three compelling examples of common environmental exposures, including cigarette smoke, the endocrine active compound bisphenol A (BPA), and the metal lead (Pb), to illustrate the application of DNA methylation as a proxy to measure the exposome. We discuss areas for future explorations and current limitations of this approach. Epigenetic profiling is a promising and rapidly developing tool and field of study, offering us a unique and powerful way to assess the early life exposome and its effects across different life stages.

Effects of Pollution on Pregnancy and Infants

The fetus is particularly susceptible to environmental contaminants as it is developing at the time of pregnancy and is, therefore, more susceptible to their effects. Pregnancy loss, which includes stillbirth and spontaneous abortion (miscarriage), preterm labor and delivery, and neonatal death, is the worst pregnancy outcome. Stunting and its related health and developmental effects are particularly common in populations living in underdeveloped countries or those exposed to high levels of particle pollution. Several environmental toxins can affect an embryo, fetus, or infant as they are developing. This study explores the following questions: What part do pesticides, heavy metals, dioxin derivatives, and polychlorinated diphenyl compounds play as macroenvironmental pollutants in mutagenesis and teratogenesis? What effects do substances that exposed persons have considerable control over, such as alcohol, narcotics, and tobacco smoke, have on the microenvironment? What consequences should practitioners be aware of these toxins in terms of ethics and the law? This study seeks to assess pertinent primary scientific studies on how pollution affects the health of the fetus and newborn during pregnancy.

Economic analysis of financial incentives for smoking cessation during pregnancy and postpartum

Higgins and colleagues' recently-completed randomized controlled trial and pooled data with 4 related trials of smoking cessation in pregnant women in Vermont (USA) showed that abstinence-contingent financial incentives (FI) increased abstinence over control conditions from early pregnancy through 24-weeks postpartum. Control conditions were best practices (BP) alone in the recent trial and payments provided independent of smoking status (noncontingently) in the others. This paper reports economic analyses of abstinence-contingent FI. Merging trial results with maternal and infant healthcare costs from all Vermont Medicaid deliveries in 2019, we computed incremental cost-effectiveness ratios (ICERs) for quality-adjusted life years (QALYs) and compared them to established thresholds. The healthcare sector cost (±standard error) of adding FI to BP averaged $634.76 ± $531.61 per participant. Based on this trial, the increased probability per BP + FI participant of smoking abstinence at 24-weeks postpartum was 3.17%, the cost per additional abstinent woman was $20,043, the incremental health gain was 0.0270 ± 0.0412 QALYs, the ICER was $23,511/QALY gained, and the probabilities that BP + FI was very cost-effective (ICER≤$65,910) and cost-effective (ICER≤$100,000) were 67.9% and 71.0%, respectively. Based on the pooled trials, the corresponding values were even more favorable-8.89%, $7138, 0.0758 ± 0.0178 QALYs, $8371/QALY, 98.6% and 99.3%, respectively. Each dollar invested in abstinence-contingent FI over control smoking-cessation programs yielded $4.20 in economic benefits in the recent trial and $11.90 in the pooled trials (very favorable benefit-cost ratios). Medicaid and commercial insurers may wish to consider covering financial incentives for smoking abstinence as a cost-effective service for pregnant beneficiaries who smoke. Trial Registration: ClinicalTrials.gov identifier: NCT02210832.

Randomized Controlled Trial Examining the Efficacy of Adding Financial Incentives to Best practices for Smoking Cessation Among pregnant and Newly postpartum Women

We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ2 [2] = 9.01, P = .01), with percent SGA deliveries (+SEM) greatest in BP, intermediate in BP + FI, and lowest in NS (17.65 + 4.13, 10.81 + 3.61, and 2.53 + 1.77, respectively). Reliability analyses supported the efficacy of financial incentives for increasing abstinence antepartum and postpartum and decreasing SGA deliveries; external-validity analyses supported relationships between antepartum cessation and SGA risk. Adding financial incentives to Best Practice increases smoking cessation among antepartum and postpartum women and improves other maternal-infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210832.

Maternal acute thermophysiological stress and stillbirth in Western Australia, 2000-2015: A space-time-stratified case-crossover analysis

BACKGROUND

The extreme thermal environment driven by climate change disrupts thermoregulation in pregnant women and may threaten the survival of the developing fetus.

OBJECTIVES

To investigate the acute effect of maternal exposure to thermophysiological stress (measured with Universal Thermal Climate Index, UTCI) on the risk of stillbirth and modification of this effect by sociodemographic disparities.

METHODS

We conducted a space-time-stratified case-crossover analysis of daily UTCI and 2835 singleton stillbirths between 1st January 2000 and 31st December 2015 across multiple small areas in Western Australia. Distributed lag non-linear models were combined with conditional quasi-Poisson regression to investigate the effects of the UTCI exposure from the preceding 6 days to the day of stillbirth. We also explored effect modification by fetal and maternal sociodemographic factors.

RESULTS

The median UTCI was 13.9 °C (representing no thermal stress) while the 1st and 99th percentiles were 0.7 °C (slight cold stress) and 31.7 °C (moderate heat stress), respectively. Relative to median UTCI, we found positive associations between acute maternal cold and heat stresses and higher risks of stillbirth, increasing with the intensity and duration of the thermal stress episodes. The cumulative risk from the preceding 6 days to the day of stillbirth was stronger in the 99th percentile (RR = 1.19, 95% CI: 1.17, 1.21) than the 1st percentile (RR = 1.14, 95% CI: 1.12, 1.15), relative to the median UTCI. The risks were disproportionately higher in term and male stillborn fetuses, smoking, unmarried, ≤19 years old, non-Caucasian, and low socioeconomic status mothers.

DISCUSSION

Acute maternal exposure to both cold and heat stresses may contribute to the risk of stillbirth and be exacerbated by sociodemographic disparities. The findings suggest public health attention, especially for the identified higher-risk groups. Future studies should consider the use of a human thermophysiological index, rather than surrogates such as ambient temperature.

Quitting Smoking before and after Pregnancy: Study Methods and Baseline Data from a Prospective Cohort Study

Smoking during pregnancy and postpartum remains an important public health problem. No known prior study has prospectively examined mutual changes in risk factors and women's smoking trajectory across pregnancy and postpartum. The objective of this study was to report methods used to implement a prospective cohort (Msgs4Moms), present participant baseline characteristics, and compare our sample characteristics to pregnant women from national birth record data. The cohort study was designed to investigate smoking patterns, variables related to tobacco use and abstinence, and tobacco treatment quality across pregnancy through 1-year postpartum. Current smokers or recent quitters were recruited from obstetrics clinics. Analyses included Chi-square and independent sample t-tests using Cohen's d. A total of 62 participants (41 smokers and 21 quitters) were enrolled. Participants were Black (45.2%), White (35.5%), and multiracial (19.3%); 46.8% had post-secondary education; and most were Medicaid-insured (64.5%). Compared with quitters, fewer smokers were employed (65.9 vs 90.5%, Cohen's d = 0.88) and more reported financial strain (61.1% vs 28.6%; Cohen's d = 0.75). Women who continue to smoke during pregnancy cope with multiple social determinants of health. Longitudinal data from this cohort provide intensive data to identify treatment gaps, critical time points, and potential psychosocial variables warranting intervention.

Prenatal exposure to ambient air pollution and adverse birth outcomes: An umbrella review of 36 systematic reviews and meta-analyses

Multiple systematic reviews and meta-analyses linked prenatal exposure to ambient air pollutants to adverse birth outcomes with mixed findings, including results indicating positive, negative, and null associations across the pregnancy periods. The objective of this study was to systematically summarise systematic reviews and meta-analyses on air pollutants and birth outcomes to assess the overall epidemiological evidence. Systematic reviews with/without meta-analyses on the association between air pollutants (NO₂, CO, O₃, SO₂, PM_2.5, and PM₁₀) and birth outcomes (preterm birth; stillbirth; spontaneous abortion; birth weight; low birth weight, LBW; small-for-gestational-age) up to March 30, 2022 were included. We searched PubMed, CINAHL, Scopus, Medline, Embase, and the Web of Science Core Collection, systematic reviews repositories, grey literature databases, internet search engines, and references of included studies. The consistency in the directions of the effect estimates was classified as more consistent positive or negative, less consistent positive or negative, unclear, and consistently null. Next, the confidence in the direction was rated as either convincing, probable, limited-suggestive, or limited non-conclusive evidence. Final synthesis included 36 systematic reviews (21 with and 15 without meta-analyses) that contained 295 distinct primary studies. PM_2.5 showed more consistent positive associations than other pollutants. The positive exposure-outcome associations based on the entire pregnancy period were more consistent than trimester-specific exposure averages. For whole pregnancy exposure, a more consistent positive association was found for PM_2.5 and birth weight reductions, particulate matter and spontaneous abortion, and SO₂ and LBW. Other exposure-outcome associations mostly showed less consistent positive associations and few unclear directions of associations. Almost all associations showed probable evidence. The available evidence indicates plausible causal effects of criteria air pollutants on birth outcomes. To strengthen the evidence, more high-quality studies are required, particularly from understudied settings, such as low-and-middle-income countries. However, the current evidence may warrant the adoption of the precautionary principle.

SISTAQUIT: training health care providers to help pregnant Aboriginal and Torres Strait Islander women quit smoking. A cluster randomised controlled trial

BACKGROUND

About 44% of Indigenous Australian women smoke during pregnancy, compared with 12% of pregnant non-Indigenous women. Health care providers can assist smoking cessation, but they are not typically trained in culturally appropriate methods.

OBJECTIVES

To determine whether a health care worker training intervention increases smoking cessation rates among Indigenous pregnant smokers compared with usual care.

METHODS AND ANALYSIS

Supporting Indigenous Smokers to Assist Quitting (SISTAQUIT) study is a multicentre, hybrid type 1, pragmatic, cluster randomised controlled trial that compares the effects of an intervention for improving smoking cessation by pregnant Indigenous women (16 years or older, 32 weeks' gestation or less) with usual care. Twenty-one health services caring for Indigenous people in five Australian jurisdictions were randomised to the intervention (ten sites) or control groups (eleven sites). Health care providers at intervention sites received smoking cessation care training based on the ABCD (ask/assess; brief advice; cessation; discuss psychosocial context) approach to smoking cessation for Indigenous women, an educational resource package, free oral nicotine replacement therapy for participating women, implementation support, and trial implementation training. Health care providers in control group services provided usual care.

PRIMARY OUTCOME

abstinence from smoking (self-reported abstinence via survey, validated by carbon monoxide breath testing when possible) four weeks after enrolment in the study.

SECONDARY OUTCOMES

health service process evaluations; knowledge, attitudes, and practices of health care providers; and longer term abstinence, perinatal outcomes, and respiratory outcomes for babies (to six months). Ethics approval: The human research ethics committees of the University of Newcastle (H-2015-0438) and the Aboriginal Health and Medical Research Council of NSW (1140/15) provided the primary ethics approval. Dissemination of results: Findings will be disseminated in peer-reviewed publications, at local and overseas conferences, and via public and social media, and to participating health services in art-based formats and reports. Policy briefs will be communicated to relevant government organisations.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry, ACTRN12618000972224 (prospective).

Implementation and Outcomes of a Maternal Smoking Cessation Program for a Multi-ethnic Cohort in California, USA, 2012-2019

Smoking during pregnancy remains one of the most significant risk factors for poor birth outcomes. During 2012-2019, the Loma Linda University Health Comprehensive Tobacco Treatment Program (CTTP) used a multicomponent behavioral intervention for tobacco cessation for 1402 pregnant smokers with components of known efficacy (i.e., incentives, biomarker testing, feedback, and motivational interviewing). The CTTP cohort includes a multi-ethnic sample of pregnant women with a mean age of 27 years referred by collaborating community-based healthcare providers in San Bernardino county. Evaluation of program outcomes from 7 years of follow-up (2012-2019) creates a rich cohort dataset for implementation science research to examine the real-world effectiveness of the program. In this report, we provide a cohort profile, and 8-week prolonged abstinence (8-week PA) and relapse findings from the first year of follow-up (n = 233). We found: (1) 28.4% achieved 8-week PA, (2) At a median of 6.2 months of follow-up after achieving 8-week PA, 23.2% of enrolled subjects reported tobacco cessation, and (3) a high rate of loss to follow-up (44%). In addition, our modeling indicated that the odds of relapse/smoking after enrollment was significantly higher in young mothers, non-Hispanic mothers (White, Black/African-American), mothers in the first and third trimester, and rural mothers. Formative quantitative and qualitative research on the CTTP cohort will consider the effects of a range of implementation science (number of intervention sessions, addition of a mHealth component, distance to care) and individual (partner/household smoking, birth outcomes, NICU) outcome measures for the purpose of scaling up the CTTP model.

Climate changes, air pollution and allergic diseases in childhood and adolescence

OBJECTIVE

To analyze the impacts of climate change on the development of immature respiratory and immune systems in children.

SOURCE OF DATA

The authors of the present study performed a non-systematic review of English, Spanish, and Portuguese articles published in the last five years in databases such as PubMed, EMBASE, and SciELO. The terms used were air pollution OR climate changes OR smoke, AND children OR health.

SYNTHESIS OF DATA

The increase in the prevalence of some diseases, such as allergic ones, is attributed to the interactions between genetic potential and the environment. However, disordered growth combined with inadequate waste management has caused problems for the planet, such as heatwaves, droughts, forest fires, increased storms and floods, interference in food crops and their nutritional values, changes in the infectious disease pattern, and air pollution resulting from the continuous use of fossil fuels. Children, beings still in the development stage with immature respiratory and immune systems, are the primary victims of the climate crisis.

CONCLUSIONS

The authors documented that prenatal and postnatal exposure to ambient air pollutants will accelerate or worsen the morbidity and mortality of many health conditions, including allergic diseases. Ambient air pollutants change the microbiota, interfere with the immune response, and take direct action on the skin and respiratory epithelium, which facilitates the penetration of allergens. Understanding how the children and adolescent health and well-being are affected by climate change is an urgent matter.

Maternal factors associated with smoking during gestation and consequences in newborns: Results of an 18-year study

BACKGROUND

Tobacco use is one of the most important causes of obstetric and perinatal pathologies. Its frequency during pregnancy is high and could be related to various socioeconomic and cultural characteristics of the mothers.

AIM

The aim of this study is to determine the trend and prevalence of smoking in pregnant mothers in our area over the years and the socio-cultural or obstetric factors associated with smoking as well as the repercussions on the newborns related to its consumption.

METHODS

Retrospective study of 18,959 mothers of healthy newborns in the maternity ward of the regional hospital during the years 2002-2019. The variable under study was maternal smoking during pregnancy compared with various maternal, obstetric, and perinatal factors.

RESULTS

A mean percentage of 20.4% of the mothers smoked, with significantly decreasing percentages over the years. There was a significant association between smoking and mothers' age, origin, level of education, the occurrence of previous abortions, parity, type of breastfeeding at discharge, type of delivery, low birth weight, and need for neonatal resuscitation.

CONCLUSIONS

This defines a profile of pregnant smokers on whom it is important to act: young, Spanish, with a low level of education, multiparous, and with previous miscarriages. Its repercussions are also evident with a lower birth weight in newborns. Knowledge of these factors will make it possible to design more effective intervention strategies to reduce smoking during pregnancy.

RELEVANCE FOR PATIENTS

Any effort that reduces smoking habits can improve the health status of mothers and newborns and the first step is to know who are risk pregnants.

Tobacco consumption from the 1st trimester of pregnancy to 7 months postpartum: Effects of previous tobacco consumption, and depression and anxiety symptoms

OBJECTIVE

Previous tobacco consumption, and depression and anxiety symptoms are major predictors of women's tobacco consumption during pregnancy and the postpartum period. However, the joint effect of these predictors is still unexplored. This study aimed to analyse the effects of previous tobacco consumption, and depression and anxiety symptoms on women's tobacco consumption status and quantity from the 1st trimester of pregnancy to 7 months postpartum.

METHOD

A sample of 803 Spanish women was assessed at the 1st and the 3rd trimester of pregnancy, and at 2 and 7 months postpartum. Previous tobacco consumption, and depression and anxiety symptoms were self-reported. Pregnancy and postpartum tobacco consumption were confirmed with biochemical tests.

RESULTS

Women with more previous tobacco consumption or more anxiety symptoms presented a steeper decrease in the number of cigarettes smoked per week from the 1st trimester of pregnancy to the childbirth, although smoking more cigarettes than women with less previous tobacco consumption or less anxiety symptoms. Women with more depression symptoms showed a higher tendency to relapse smoking during the first 2 months postpartum.

CONCLUSIONS

Previous tobacco consumption and anxiety symptoms were associated with higher smoking quantity during pregnancy, while depression symptoms were associated with consumption relapse during postpartum period.

The Impact of Oxidative Stress of Environmental Origin on the Onset of Placental Diseases

Oxidative stress (OS) plays a pivotal role in placental development; however, abnormal loads in oxidative stress molecules may overwhelm the placental defense mechanisms and cause pathological situations. The environment in which the mother evolves triggers an exposure of the placental tissue to chemical, physical, and biological agents of OS, with potential pathological consequences. Here we shortly review the physiological and developmental functions of OS in the placenta, and present a series of environmental pollutants inducing placental oxidative stress, for which some insights regarding the underlying mechanisms have been proposed, leading to a recapitulation of the noxious effects of OS of environmental origin upon the human placenta.

Media use in gynecological and obstetric care and women’s perceived level of education received of lifestyle-related risks: A cross-sectional study

Objective:

The application of media on lifestyle-related risk factors (LRRFs) by healthcare providers to educate women may improve women’s adherence, health literacy, and awareness of LRRFs, as well as offspring’s health outcomes. This study investigated whether exposure to media-based education in gynecological and obstetric care is associated with LRRFs perceived levels of education received during pregnancy and lactation.

Methods:

We conducted a cross-sectional, observational study across 14 randomly generated sample points in the 12 most populated cities in Baden-Württemberg, southwest Germany. Women were recruited from gynecological and obstetric institutions. Participants were 219 women who met our inclusion criteria and completed the quantitative questionnaire. We applied ordinal logistic regression analyses to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of women’s perceived level of education received related to healthcare providers’ exposure to media-based education.

Results:

Media-based education on LRRFs during pregnancy through gynecologists and/or midwives were significantly associated with women’s perceived level of education received (gynecologists: OR = 4.26 (95% CI: 2.04, 8.90; p < .001); midwives: OR = 3.86 (95% CI: 1.66, 8.98; p = .002)). Similar results were found for media-based education through gynecologists and/or midwives on LRRFs during lactation and its association with women’s self-assessed level of perceived level of education received (gynecologists: OR = 4.76 (95% CI: 2.15, 10.56; p < .001); midwives: OR = 7.61 (95% CI: 3.13, 18.53; p < .001)).

Conclusions:

This study suggests that the exposure to media-based education in gynecological and obstetric care increases women’s perceived level of education received of LRRFs during pregnancy and lactation. Therefore, it is recommendable to apply media in gynecological and obstetric care settings.

Cotinine as an indicator of fetal exposure to active and passive smoking in pregnant women

Introduction

Within 5 years, the number of pregnant smokers in Poland decreased by 5%. Still, 6% of pregnant women are active and 18% are passive smokers, and 5% smoke and drink alcohol. The study examined the levels of cotinine concentration in the blood of pregnant women and in the umbilical cord blood of their children in relation to the number of cigarettes smoked; the places and persons conducive to exposure of pregnant women to tobacco smoke were determined.

Materials and Methods

The study included 123 women who have entered medical facilities for childbirth during physiological pregnancy, who filled out a questionnaire about their lifestyle. Moreover, venous and umbilical blood was collected from them and their newborns for cotinine evaluation. The nicotine marker was determined by the UPLC/MS/MS analytical method.

Results

When examining the frequency of smoking and exposure to smoke, it was found that 38% of the respondents concealed their smoking status by giving false answers, as shown by the biochemical analysis of the presence of cotinine in the blood. A significant correlation was found between the cotinine levels of exposed and smoking mothers and their babies. Pregnant smokers were in the presence of smokers more often (p = 0.019). Moreover, it was found that the presence of women in the company of smokers who smoked more than 20 cigarettes/day resulted in a significant (p = 0.011) increase of cotinine in the umbilical blood in 31.5% of newborns, higher than the concentration in mothers.

Conclusions

Protecting women from passive smoking requires extensive educational measures. The inclusion of cotinine level assessment in pregnant women in the program of the standard of perinatal examinations should be considered in order to protect children from diseases resulting from the effects of nicotine in the embryonic period.

Tobacco Smoking and Liver Cancer Risk: Potential Avenues for Carcinogenesis

Smoking a cigarette generates over 4000 chemicals that have a deleterious impact on each part of the human body. It produces three main severe effects on the liver organ: oncogenic, immunological, and indirect or direct toxic effects. It results in the production of cytotoxic substances, which raises fibrosis and necro-inflammation. Additionally, it also directs the production of pro-inflammatory cytokines tumour necrosis factor alfa (TNF-α) and interleukins (IL-1β, IL-6) that will be responsible for the chronic liver injury. Furthermore, it gives rise to secondary polycythemia and successively raises the turnover and mass of red cells, which might be a common factor responsible for the development of oxidative stress in the liver due to iron overload. It also produces chemicals that are having oncogenic properties and raises the risk of liver cancer especially in sufferers of chronic hepatitis C. Smoking modulates both humoral and cell-mediated responses by restricting the proliferation of lymphocytes and inducing their apoptosis and ultimately decreasing the surveillance of cancer cells. Moreover, it has been determined that heavy smoking impacts the response of hepatitis C patients to interferon (IFN) therapy through different mechanisms, which can be improved by phlebotomy. Efforts are being made in different nations in decreasing the prevalence of smoking to improve premature death and ill effects of their nation's individuals.

Risk Assessment of Passive Smoking Based on Analysis of Hair Nicotine and Cotinine as Exposure Biomarkers by In-Tube Solid-Phase Microextraction Coupled On-Line to LC-MS/MS

Passive smoking due to environmental tobacco smoke is a serious public health concern because it increases the risk of lung cancer and cardiovascular disease. However, the current status and effect of passive smoking in various lifestyles are not fully understood. In this study, we measured hair nicotine and cotinine levels as exposure biomarkers in non-smokers and assessed the risk from the actual situation of passive smoking in different lifestyle environments. Nicotine and cotinine contents in hair samples of 110 non-smoker subjects were measured by in-tube solid-phase microextraction with on-line coupling to liquid chromatography-tandem mass spectrometry, and self-reported lifestyle questionnaires were completed by the subjects. Nicotine and cotinine were detected at concentrations of 1.38 ng mg⁻¹ and 12.8 pg mg⁻¹ respectively in the hair of non-smokers, with levels significantly higher in subjects who reported being sensitive to tobacco smoke exposure. These levels were also affected by type of food intake and cooking method. Nicotine and cotinine in hair are useful biomarkers for assessing the effects of passive smoking on long-term exposure to environmental tobacco smoke, and our analytical methods can measure these exposure levels in people who are unaware of passive smoking. The results of this study suggest that the environment and places of tobacco smoke exposure and the lifestyle behaviors therein are important for the health effects of passive smoking.

Precision treatment with nicotine in autosomal dominant sleep-related hypermotor epilepsy (ADSHE): An observational study of clinical outcome and serum cotinine levels in 17 patients

PURPOSE

To report the clinical outcome of nicotine exposure in patients with autosomal dominant sleep-related hypermotor epilepsy (ADSHE), along with serum concentrations of the major nicotine metabolite cotinine.

METHODS

We recruited 17 ADSHE patients with CHRNA4 mutations (12 with p.S280F and 5 with p.L291 dup). Clinical characteristics were collected from hospital records. A telephone interview was performed on the use and seizure-reducing effect of nicotine applying a six-point rating scale from "none" to very good". Serum concentrations of cotinine were measured in 14 nicotine users.

RESULTS

All patients but one had ever used nicotine. Nine had used snuff; seven were current users. Eleven had used transdermal nicotine; nine were current users. Seven reported long-lasting seizure control, all used nicotine, four transdermal nicotine and three snuff. In 78% of patients using continuous transdermal nicotine, the effect was rated as good or very good. Cotinine concentrations were 453 ± 196 (mean ± SD) nmol/l in seven patients using transdermal nicotine only vs. 1241 ± 494 nmol/l in seven using other forms of nicotine. No correlation with seizure control was found. Three patients experienced improvement with transdermal delivery compared to snuff.

CONCLUSION

This is the hitherto largest observational study supporting a favorable effect of nicotine in this specific seizure disorder. Better seizure control from transdermal nicotine compared to only day-time consumption suggests benefit from exposure throughout the night. According to current clinical experience, patients with uncontrolled ADSHE harboring relevant mutations should be offered precision treatment with transdermal nicotine.

Cumulative disadvantage as a framework for understanding rural tobacco use disparities

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural-nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The association of in utero tobacco smoke exposure, quantified by serum cotinine, and Autism Spectrum Disorder

Previous studies on in utero exposure to maternal environmental tobacco smoke (ETS) or maternal active smoking and Autism Spectrum Disorder (ASD) have not been entirely consistent, and no studies have examined in utero cotinine concentrations as an exposure classification method. We measured cotinine in stored second trimester maternal serum for 498 ASD cases and 499 controls born in California in 2011-2012. We also obtained self-reported maternal cigarette smoking during and immediately prior to pregnancy, as well as covariate data, from birth records. Using unconditional logistic regression, we found no association between log10 cotinine concentrations and odds for developing ASD among children of non-smokers (aOR: 0.93 [95% CI: 0.69, 1.25] per ng/ml), which represents exposure to ETS, though there may be a possible interaction with race. We found no association between cotinine-defined smoking (≥3.08 ng/ml vs. <3.08 ng/ml) (adjusted odds ratio [aOR]: 0.73 (95% confidence interval [95% CI]: 0.35, 1.54)) or self-reported smoking (aOR: 1.64 [95% CI: 0.65, 4.16]) and ASD. In one of the few studies of ETS and the first with measured cotinine, our results indicate no overall relationship between in utero exposure to tobacco smoke from maternal ETS exposure or active smoking, and development of ASD. LAY SUMMARY: This study found that women who smoke or are exposed to tobacco smoke during pregnancy are not more likely to have children with Autism Spectrum Disorder (ASD). This is the first ASD study to measure a chemical in the mother's blood during pregnancy to identify exposure to tobacco smoke.

The Comparative Effectiveness of Varenicline and Nicotine Patches for Smoking Abstinence During Pregnancy: Evidence From a Population-based Cohort Study

INTRODUCTION

In the general population, varenicline is consistently shown to be more efficacious for smoking cessation than nicotine replacement therapy (NRT). Current clinical guidelines for the management of smoking during pregnancy recommend against the use of varenicline, whilst supporting the use of NRT. However, little is known about the comparative effectiveness of these smoking cessation therapies among pregnant women.

AIMS AND METHODS

Routinely-collected records of all births in two Australian States during 2011 and 2012 were used to create a population-based cohort of women who smoked during the first half of pregnancy. Pharmaceutical dispensing data were used to identify varenicline and nicotine patch dispensings in the first half of pregnancy. Propensity score matching was used to account for the potentially different distribution of confounding factors between the treatment groups. The outcome was defined as smoking abstinence during the second half of pregnancy.

RESULTS

After propensity score-matching, our cohort comprised 60 women who used varenicline and 60 who used nicotine patches during the first half of pregnancy. More varenicline users (33.3%, 95% CI: 21.7%-46.7%) quit smoking than nicotine patch users (13.3%, 95% CI: 5.9%-24.6%). The adjusted rate difference was 24.2% (95% CI: 10.2%-38.2%) and the adjusted relative risk was 2.8 (95% CI: 1.4-5.7).

CONCLUSIONS

Varenicline was almost three times more effective than nicotine patches in assisting pregnant women to quit smoking. Further studies are needed to corroborate our results. Together with data on the safety of varenicline during pregnancy, evidence regarding the relative benefit of varenicline and NRT during pregnancy important for informing clinical decisions for pregnant smokers.

IMPLICATIONS

This study is the first to measure the comparative effectiveness of varenicline and nicotine patches during pregnancy - women using varenicline were almost three times as likely to quit smoking than those using nicotine patches. This study addressed a clinically important question using an observational study, noting that there is an absence of evidence from randomized controlled trials because of the ethical issues associated with including pregnant women in clinical trials of medicines of unknown safety.

Maternal Exposure and Neonatal Effects of Drugs of Abuse

The public health crisis of pregnant women being exposed to drugs of abuse and of its impact on their unborn children continues to grow at an alarming rate globally. The state of pregnancy is unique, with physiological changes that can lead to changes in the way drugs are handled by the body in both pharmacokinetics and response. These changes place the pregnant woman, fetus, and newborn infant at risk, as many of these drugs can cross the placenta and into breast milk. The substances most commonly linked to harmful effects include alcohol, tobacco, cannabis, stimulants, and opioids. The pharmacological and toxicological changes caused by in utero exposure or breastfeeding exposure are difficult to study, and the full extent of the mechanisms involved are not fully understood. However, these changes can significantly affect the risks of substance abuse and influence optimal treatment of pregnant women with a substance use disorder. In addition, newborns who were exposed to drugs of abuse in utero can experience withdrawal syndromes. Pharmacological management in infants is used to guide and treat withdrawal symptoms, with the goal being to improve the infant's sleep, eating, and comfort. Several barriers may prevent pregnant women from seeking help for substance use, including stigma and interactions with the legal system. Understanding changes in pharmacology, including pharmacokinetic changes that happen during pregnancy, is essential for anticipating the extent of maternal exposure and neonatal adverse effects.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Pregnant Women Who Smoke May Be at Greater Risk of Adverse Effects from Bushfires

Bushfires substantially increase the environmental health risks for people living in affected areas, especially the disadvantaged (e.g., those experiencing health inequities due to their socio-economic status, racial/ethnic backgrounds, geographic location and/or sexual orientation) and those with pre-existing health conditions. Pregnant women exposed to bushfire smoke are at a greater risk of adverse pregnancy and foetal outcomes, especially if they smoke tobacco, which may compound the toxic impacts. Bushfires may also exacerbate mental stress, leading to an increase in smoking. There are gaps in the evidence and more research is required on the combined effect of bushfire smoke and tobacco smoke on pregnant populations.

Addressing Smoking Cessation among Women in Substance Use Treatment: A Qualitative Approach to Guiding Tailored Interventions

Intersecting socially marginalized identities and unique biopsychosocial factors place women with substance use disorders (SUDs) experiencing myriad disadvantages at higher risk for smoking and stigmatization. Here, based on our work with women receiving care for SUDs in four participating treatment/women-serving centers (N = 6 individual clinics), we: (1) describe the functions of smoking for women with SUDs; and (2) explore participants’ experiences of a comprehensive tobacco-free workplace (TFW) program, Taking Texas Tobacco-Free (TTTF), that was implemented during their SUD treatment. Ultimately, information gleaned was intended to inform the development of women-tailored tobacco interventions. Data collection occurred pre- and post-TTTF implementation and entailed conducting client (7) and clinician (5) focus groups. Using thematic analysis, we identified four main themes: “the social context of smoking,” “challenges to finding support and better coping methods,” “addressing underlying conditions: building inner and outer supportive environments,” and “sustaining support: TFW program experiences.” Women reported that: smoking served as a “coping mechanism” for stress and facilitated socialization; stigmatization hindered quitting; non-stigmatizing counseling cessation support provided alternative coping strategies; and, with clinicians, the cessation opportunities TTTF presented are valuable. Clinicians reported organizational support, or lack thereof, and tobacco-related misconceptions as the main facilitator/barriers to treating tobacco addiction. Effective tobacco cessation interventions for women with SUDs should be informed by, and tailored to, their gendered experiences, needs, and recommendations. Participants recommended replacing smoking with healthy stress alleviating strategies; the importance of adopting non-judgmental, supportive, cessation interventions; and the support of TFW programs and nicotine replacement therapy to aid in quitting.

Epigenetic Alterations of Maternal Tobacco Smoking during Pregnancy: A Narrative Review

In utero exposure to maternal tobacco smoking is the leading cause of birth complications in addition to being associated with later impairment in child’s development. Epigenetic alterations, such as DNA methylation (DNAm), miRNAs expression, and histone modifications, belong to possible underlying mechanisms linking maternal tobacco smoking during pregnancy and adverse birth outcomes and later child’s development. The aims of this review were to provide an update on (1) the main results of epidemiological studies on the impact of in utero exposure to maternal tobacco smoking on epigenetic mechanisms, and (2) the technical issues and methods used in such studies. In contrast with miRNA and histone modifications, DNAm has been the most extensively studied epigenetic mechanism with regard to in utero exposure to maternal tobacco smoking. Most studies relied on cord blood and children’s blood, but placenta is increasingly recognized as a powerful tool, especially for markers of pregnancy exposures. Some recent studies suggest reversibility in DNAm in certain genomic regions as well as memory of smoking exposure in DNAm in other regions, upon smoking cessation before or during pregnancy. Furthermore, reversibility could be more pronounced in miRNA expression compared to DNAm. Increasing evidence based on longitudinal data shows that maternal smoking-associated DNAm changes persist during childhood. In this review, we also discuss some issues related to cell heterogeneity as well as downstream statistical analyses used to relate maternal tobacco smoking during pregnancy and epigenetics. The epigenetic effects of maternal smoking during pregnancy have been among the most widely investigated in the epigenetic epidemiology field. However, there are still huge gaps to fill in, including on the impact on miRNA expression and histone modifications to get a better view of the whole epigenetic machinery. The consistency of maternal tobacco smoking effects across epigenetic marks and across tissues will also provide crucial information for future studies. Advancement in bioinformatic and biostatistics approaches is key to develop a comprehensive analysis of these biological systems.

Prenatal Exposure to Cigarette Smoke and Anogenital Distance at 4 Years in the INMA-Asturias Cohort

Smoking by women is associated with adverse pregnancy outcomes such as spontaneous abortion, preterm delivery, low birth weight, infertility, and prolonged time to pregnancy. Anogenital distance (AGD) is a sensitive biomarker of prenatal androgen and antiandrogen exposure. We investigated the effect of smoking and passive smoke exposure during pregnancy on anogenital distance in offspring at 4 years in the INMA-Asturias cohort (Spain). Women were interviewed during pregnancy to collect information on tobacco consumption, and anogenital distance was measured in 381 children: Anoscrotal distance in boys and anofourchetal distance in girls. We also measured maternal urinary cotinine levels at 32 weeks of pregnancy. We constructed linear regression models to analyze the association between prenatal smoke exposure and anogenital distance and adjusted the models by relevant covariates. Reported prenatal smoke exposure was associated with statistically significant increased anogenital index (AGI), both at week 12 of pregnancy (β = 0.31, 95% confidence interval: 0.00, 0.63) and at week 32 of pregnancy (β = 0.31, 95% confidence interval: 0.00, 0.63) in male children, suggesting altered androgenic signaling.

Weight gain during pregnancy in women with HIV receiving different antiretroviral regimens

BACKGROUND

No published studies have evaluated in pregnant women with HIV weight gain with different antiretroviral drug classes.

METHODS

Data from a national cohort study were used. We compared absolute weight gain and occurrence of excessive weight gain in women with HIV who received during pregnancy integrase inhibitors (INSTI), protease inhibitors (PI), or non-nucleoside reverse transcriptase inhibitors (NNRTI). Excessive weight gain was defined according to the Institute of Medicine recommendations. Possible predictors of weight gain were assessed using univariate and multivariate analyses.

RESULTS

Among 273 cases (PI: 191, NNRTI: 43, INSTI: 39), the mean weight increase was 11.3 kg, and 25.4% of the mothers had an excessive weight increase. No significant differences were found among the three treatment groups for absolute weight increase, occurrence of excessive weight gain, infant birthweight, and other pregnancy and laboratory outcomes. The comparisons of individual drugs, although based on a limited number of cases, suggested no major differences. A significant positive correlation was found between weight gain and CD4⁺ T-cell increase during pregnancy. In multivariate analyses, drug class and nucleoside backbone were not associated with absolute or excessive weight increase. Excessive weight increase was significantly associated with week of delivery (adjusted odds ratio: 1.74, 95% CI 1.15, 2.63), obesity (5.21, 95% CI 1.85, 14.64), overweight (7.95, 95% CI 3.26, 19.39), recent substance use (5.96, 95% CI 1.13, 31.40) and fasting 2nd trimester hyperglycaemia (3.94, 95% CI 1.14, 13.65).

CONCLUSIONS

No significant differences in absolute weight change or occurrence of excessive weight gain were found among women with HIV who received during pregnancy different classes of antiretroviral drugs.

Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter?

Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.

Factors Associated with Prenatal Smoking Cessation Interventions among Public Health Nurses in Japan

This study aimed to identify the factors associated with prenatal smoking cessation interventions based on the 5As model among public health nurses (PHNs) in Japan. A nationwide cross-sectional study was conducted from December 2019 to February 2020 via a self-administered questionnaire. The study subjects were 1988 PHNs working in 431 health centers of municipalities and special wards across the country. Of the 1988 questionnaires mailed, 521 responses (26.2%) were included in the analysis. Of the 521 responses, most of the respondents were female (98.1%) and the mean age was 37.5 years. There were statistically significant differences on age, work regions, experience years working as a PHN and smoking cessation training after becoming a PHN in implementing the 5As. Self-efficacy, professional development competency, research utilization competency, age and experience years working as a PHN were positively associated with the 5As. Social nicotine dependence was negatively associated with the 5As. Furthermore, self-efficacy mediated the relationship between the 5As and professional development competency, research utilization competency, social nicotine dependence, age and experience years working as a PHN. In the future, smoking cessation intervention training should be widely implemented to improve self-efficacy and prenatal smoking cessation interventions among Japanese PHNs.