Nut allergy prevalence and differences between Asian-born children and Australian-born children of Asian descent: a state-wide survey of children at primary school entry in Victoria, Australia

BACKGROUND

Asian infants born in Australia are three times more likely to develop nut allergy than non-Asian infants, and rates of challenge-proven food allergy in infants have been found to be unexpectedly high in metropolitan Melbourne. To further investigate the risk factors for nut allergy, we assessed the whole-of-state prevalence distribution of parent-reported nut allergy in 5-year-old children entering school.

METHODS

Using the 2010 School Entrant Health Questionnaire administered to all 5-year-old children in Victoria, Australia, we assessed the prevalence of parent-reported nut allergy (tree nut and peanut) and whether this was altered by region of residence, socio-economic status, country of birth or history of migration. Prevalence was calculated as observed proportion with 95% confidence intervals (CI). Risk factors were evaluated using multivariable logistic regression and adjusted for appropriate confounders.

RESULTS

Parent-reported nut allergy prevalence was 3.1% (95% CI 2.9-3.2) amongst a cohort of nearly 60 000 children. It was more common amongst children of mothers with higher education and socio-economic index and less prevalent amongst children in regional Victoria than in Melbourne. While children born in Australia to Asian-born mothers (aOR 2.67, 95% CI 2.28-3.27) were more likely to have nut allergy than non-Asian children, children born in Asia who subsequently migrated to Australia were at decreased risk of nut allergy (aOR 0.1, 95% CI 0.03-0.31).

CONCLUSION

Migration from Asia after the early infant period appears protective for the development of nut allergy. Additionally, rural regions have lower rates of nut allergy than urban areas.

VITALITY trial: protocol for a randomised controlled trial to establish the role of postnatal vitamin D supplementation in infant immune health

INTRODUCTION

Postnatal vitamin D supplementation may be associated with a reduction in IgE-mediated food allergy, lower respiratory tract infections and improved bone health. Countries in the Northern hemisphere recommend universal infant vitamin D supplementation to optimise early vitamin D levels, despite the absence of large trials proving safety or efficacy for any disease outcome. With the aim of determining the clinical and cost-effectiveness of daily vitamin D supplementation in breastfed infants from age 6-8 weeks to 12 months of age, we have started a double-blind, randomised, placebo-controlled trial of daily 400 IU vitamin D supplementation during the first year of life, VITALITY.

METHODS ND ANALYSIS

Infants (n=3012) who are fully breastfed and not receiving vitamin D supplementation will be recruited at the time of their first immunisation, from council-led immunisation clinics throughout metropolitan Melbourne, Australia. The primary outcome is challenge-proven food allergy at 12 months of age. Secondary outcomes are food sensitisation (positive skin prick test), number of lower respiratory infections (through hospital linkage), moderately-severe and persistent eczema (by history and examination) and vitamin D deficiency (serum vitamin D <50 nmol/L) at age 12 months. The trial is underway and the first 130 participants have been recruited.

ETHICS AND DISSEMINATION

The VITALITY study is approved by the Royal Children's Hospital (RCH) Human Research Ethics Committee (#34168). Outcomes will be disseminated through publication and will be presented at scientific conferences.

TRIAL REGISTRATION NUMBERS

ANZCTR12614000334606 and NCT02112734; pre-results.

Polymorphisms affecting vitamin D-binding protein modify the relationship between serum vitamin D (25[OH]D3) and food allergy

BACKGROUND

There is evolving evidence that vitamin D insufficiency may contribute to food allergy, but findings vary between populations. Lower vitamin D-binding protein (DBP) levels increase the biological availability of serum vitamin D. Genetic polymorphisms explain almost 80% of the variation in binding protein levels.

OBJECTIVE

We sought to investigate whether polymorphisms that lower the DBP could compensate for adverse effects of low serum vitamin D on food allergy risk.

METHODS

From a population-based cohort study (n = 5276) we investigated the association between serum 25-hydroxyvitamin D3 (25[OH]D3) levels and food allergy at age 1 year (338 challenge-proven food-allergic and 269 control participants) and age 2 years (55 participants with persistent and 50 participants with resolved food allergy). 25(OH)D3 levels were measured using liquid chromatography-tandem mass spectrometry and adjusted for season of blood draw. Analyses were stratified by genotype at rs7041 as a proxy marker of DBP levels (low, the GT/TT genotype; high, the GG genotype).

RESULTS

Low serum 25(OH)D3 level (≤50 nM/L) at age 1 years was associated with food allergy, particularly among infants with the GG genotype (odds ratio [OR], 6.0; 95% CI, 0.9-38.9) but not in those with GT/TT genotypes (OR, 0.7; 95% CI, 0.2-2.0; P interaction = .014). Maternal antenatal vitamin D supplementation was associated with less food allergy, particularly in infants with the GT/TT genotype (OR, 0.10; 95% CI, 0.03-0.41). Persistent vitamin D insufficiency increased the likelihood of persistent food allergy (OR, 12.6; 95% CI, 1.5-106.6), particularly in those with the GG genotype.

CONCLUSIONS

Polymorphisms associated with lower DBP level attenuated the association between low serum 25(OH)D3 level and food allergy, consistent with greater vitamin D bioavailability in those with a lower DBP level. This increases the biological plausibility of a role for vitamin D in the development of food allergy.

Environmental and genetic determinants of vitamin D insufficiency in 12-month-old infants

We aimed to investigate the relationship between genetic and environmental exposure and vitamin D status at age one, stratified by ethnicity. This study included 563 12-month-old infants in the HealthNuts population-based study. DNA from participants' blood samples was genotyped using Sequenom MassARRAY MALDI-TOF system on 28 single nucleotide polymorphisms (SNPs) in six genes. Using logistic regression, we examined associations between environmental exposure and SNPs in vitamin D pathway and filaggrin genes and vitamin D insufficiency (VDI). VDI, defined as serum 25-hydroxyvitamin D3(25(OH)D3) level ≤50nmol/L, was measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Infants were stratified by ethnicity determined by parent's country of birth. Infants formula fed at 12 months were associated with reduced odds of VDI compared to infants with no current formula use at 12 months. This association differed by ethnicity (Pinteraction=0.01). The odds ratio (OR) of VDI was 0.29 for Caucasian infants (95% CI, 0.18-0.47) and 0.04 for Asian infants (95% CI, 0.006-0.23). Maternal vitamin D supplementation during pregnancy and/or breastfeeding were associated with increased odds of infants being VDI (OR, 2.39; 95% CI, 1.11-5.18 and OR, 2.5; 95% CI, 1.20-5.24 respectively). Presence of a minor allele for any GC SNP (rs17467825, rs1155563, rs2282679, rs3755967, rs4588, rs7041) was associated with increased odds of VDI. Caucasian infants homozygous (AA) for rs4588 had an OR of 2.49 of being associated with VDI (95% CI, 1.19-5.18). In a country without routine infant vitamin D supplementation or food chain fortification, formula use is strongly associated with a reduced risk of VDI regardless of ethnicity. There was borderline significance for an association between filaggrin mutations and VDI. However, polymorphisms in vitamin D pathway related genes were associated with increased likelihood of being VDI in infancy.

Sexual function, incontinence, and wellbeing in women after rectal cancer--a review of the evidence

INTRODUCTION

Colorectal cancer (CRC) is the second most common cancer. One-third of these cancers occur in the rectum. Treatment of rectal cancer involves surgery with/without radiotherapy and chemotherapy. Surgery is undertaken to prevent damage to the nerves controlling bladder, bowel, and sexual organs, whether this translates into preservation of urinary and fecal continence and sexual function and, ultimately, quality of life (QoL) is not known.

AIM

The aim of this review was to summarize the literature regarding the impact of treatment for rectal cancer on bladder and bowel continence, sexual function and QoL in women.

MAIN OUTCOME MEASURES

A comprehensive review of the current literature on sexual function, incontinence and wellbeing in women after treatment for rectal cancer highlighting prevalence rates, trial design, and patient population.

METHODS

We conducted a systematic search of the literature using A systematic search of the literature using Medline (Ovid, 1946-present) and PubMed (1966-2011) for English-language studies that included the following search terms: "colorectal cancer," or "rectal cancer," or "rectal neoplasm," and "sexual function," or "sexual dysfunction," or "wellbeing," or "QoL," or "urinary or fecal incontinence."

RESULTS

Although around 1/3 of women aged 50 to 70 years report lack of sexual desire, sexual function problems after treatment for rectal cancer are in the order of 60% among women. QoL improves with length of survival. Urinary and fecal incontinence are ongoing concerns for many women after treatment with rates up to 60%.

CONCLUSION

There is a gap in our knowledge of the effects of rectal cancer and its treatment on urinary and fecal continence, sexual function and QoL in women. There is a need for studies of sufficient size and duration to gain a better understanding of the disease and its management and the long-term effects on these parameters. This information is needed to develop preventative health care plans for women treated for rectal cancer that target those most at risk for these adverse outcomes.

Cosmetic surgery prior to diagnosis of breast cancer

BACKGROUND

Cosmetic breast surgery is amongst the top five most commonly performed cosmetic surgical procedures. With breast cancer being the most common non-skin malignancy in women, the likelihood that a woman undergoing cosmetic breast surgery may have an occult breast cancer needs to be considered. Most of the available data pertaining to breast cancer diagnosis in the setting of cosmetic surgery are from studies of cosmetic breast surgery populations. We report on the prevalence of breast cancer as an incidental finding during cosmetic breast surgery in the context of women subsequently diagnosed with invasive breast cancer.

METHODS

The Bupa Health Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1684 women recruited within 12 months of their first diagnosis with invasive breast cancer. Participants completed an enrolment questionnaire and annual follow-up questionnaires for 5 years.

RESULTS

At the second follow-up, 1.5% of women reported having undergone cosmetic breast surgery prior to being diagnosed with breast cancer, 16 had undergone breast reduction and seven had augmentations. Invasive breast cancer was diagnosed at the time of a cosmetic breast procedure in two women, in both an augmentation and a reduction procedure, which is 8.7% (95% confidence interval 23.5% to +20.9%) of the women in our study reporting a cosmetic breast procedure prior to diagnosis.

CONCLUSIONS

Although prior cosmetic breast surgery was reported by few women, breast cancer was diagnosed in two women during the procedure. Surgeons performing elective breast surgery need to understand and apply consistent, reliable breast cancer screening practices.

Vaginal DHEA to treat menopause related atrophy: a review of the evidence

Vaginal atrophy is a common symptom of postmenopausal estrogen deficiency and can present as dryness, irritation, infection and dyspareunia and can affect sexual function and quality of life. Currently vaginal atrophy is treated with the intravaginal application of preparations containing estradiol or estriol, which are both effective and safe. It has been proposed that intravaginally administered dehydroepiandrosterone (DHEA) can be used to treat vaginal atrophy. DHEA and its sulphate DHEAS are the most abundant circulating sex steroid hormones in women, and provide a large precursor reservoir for the intracellular production of androgens and estrogens in non-reproductive tissues. Levels of DHEA and DHEAS decline with age. Although there is some evidence to support the use of intravaginal DHEA for postmenopausal women with symptoms of vaginal atrophy, independent studies are required to confirm this. In addition studies regarding the effects of vaginal DHEA on sexual function in women without vaginal atrophy are needed. Given that the efficacy and long term safety of low dose vaginal estradiol and estriol therapy is well established and that vaginal estrogen requires application of 2-3 times a week, rather than daily dosing; the benefit of daily vaginal DHEA over estrogen also needs to be considered as women may find it unpalatable to adhere to daily dosing with a cream preparation.

Clinical review: DHEA replacement for postmenopausal women

CONTEXT

It has been proposed that because dehydroepiandrosterone (DHEA) and its sulfate, DHEAS, are important precursors for estrogen and androgen production, treatment with DHEA is a physiologically based strategy for the alleviation of hormone deficiency symptoms in postmenopausal women. We have summarized the physiology of DHEA in women and reviewed the findings from randomized controlled trials (RCT) of the effects of DHEA therapy in postmenopausal women with normal adrenal function.

EVIDENCE ACQUISITION

We reviewed the medical literature for key papers investigating DHEA physiology and RCT of the use of DHEA in postmenopausal women through November 2010. The focus was on sexual function, well-being, metabolic parameters, and cognition as study endpoints.

EVIDENCE SYNTHESIS

Although cross-sectional studies have indicated a link between low DHEA levels and impaired sexual function, well-being, and cognitive performance in postmenopausal women, placebo-controlled RCT do not show benefits of oral DHEA for any of these outcomes or favorable effects on lipids and carbohydrate metabolism.

CONCLUSIONS

Taken together, findings from this review of the published literature of studies do not support the use of DHEA in postmenopausal women at this time.

Breast cancer survivors' beliefs about the causes of breast cancer

OBJECTIVE

To explore the beliefs held by breast cancer (BC) survivors about the factors that contribute to the development of their BC.  

METHODS

The BUPA Health Foundation Health and Well-being after Breast Cancer Study is a prospective cohort study of 1684 women recruited within 12 months of their first diagnosis with invasive BC. Participants completed an enrollment questionnaire (EQ), first follow-up questionnaire (FQ1) and a second follow-up questionnaire (FQ2), 12 months and 24 months post-EQ, respectively. In the FQ2, women were asked whether they believed anything contributed to the development of their BC and whether they had made lifestyle changes since the FQ1. Well-being was assessed at the FQ2 using the psychological general well-being index (PGWB).  

RESULTS

In total, 1496/1684 women completed the FQ2 and 43.5% reported belief in a factor that may have contributed to their developing BC. These women were more likely to be younger (p<0.0001) and educated beyond high school (p<0.0001). Stress (58.1%) was the most common reason given, followed by previous use of hormone therapy (17.0%) and a family history of any cancer (9.8%). Women who believed stress contributed to their BC had lower PGWB scores than other study participants (70.9 ± 16.1, n = 361 versus 77.3 ± 14.9, n = 1071, mean difference = 6.4, 95% CI: 4.6-8.2 p<0.0001) and were more likely to have made lifestyle changes since their BC diagnosis.  

CONCLUSIONS

Many women with BC believe that stress has contributed to their condition. Women who held this belief were more likely to adopt strategies to reduce stress than those who did not.

Sexual function after breast cancer

INTRODUCTION

Breast cancer (BC) remains the most common non-skin cancer in women and an increasing number are living as BC survivors.

AIM

The aim of this article is to evaluate the impact of the first diagnosis of invasive BC and its treatment, menopausal symptoms, and body image on sexual function.

METHODS

The BUPA Foundation Health and Wellbeing after Breast Cancer Study is a prospective cohort study of 1,684 women recruited within 12 months of their first diagnosis with invasive BC. Each participant completed an enrollment questionnaire (EQ) and first follow-up questionnaire (FQ1) 12 months post-EQ.

MAIN OUTCOME MEASURE

Sexual function was evaluated by the Menopause-Specific Quality of Life Questionnaire embedded within the FQ1.

RESULTS

Of the 1,011 women in the analyses, 70% experienced sexual function problems and 77% reported vasomotor symptoms. Women experiencing sexual function problems were postmenopausal (P = 0.02), experienced vasomotor symptoms (P < 0.01), and used aromatase inhibitors (P = 0.03). Women with vasomotor symptoms were twice as likely to experience sexual function problems (odds ratio [OR] 1.93, 95% confidence interval [CI] 141, 2.63; P < 0.001). This association was more extreme for women on aromatase inhibitors (OR 3.49, 95% CI 1.72, 7.09; P = 0.001) but did not persist in women not using endocrine therapies (OR 1.41, 95% CI 0.84, 2.36; P = 0.19). Women on aromatase inhibitors were more likely to report sexual function problems (OR 1.50, 95% CI 1.0, 2.2, P = 0.04) and women with body image issues were 2.5 times more likely to report sexual function problems (OR 2.5 95% CI 1.6, 3.7, P < 0.001). Women using tamoxifen were not more likely to experience sexual function problems (OR 1.1, 95% CI 0.8, 1.5, P = 0.6); however, women with body image issues were twice as likely to experience sexual function problems (OR 2.1, 95% CI 1.5, 3.0, P < 0.001).

CONCLUSION

Seventy percent of partnered BC survivors less than 70 experienced sexual function problems. Sexual problems are related to the use of aromatase inhibitors which can exacerbate menopausal symptoms.

Methodology and challenges to recruitment to a randomized, double-blind, placebo-controlled trial of oral DHEA in postmenopausal women

OBJECTIVE

To report on the issues encountered in the recruitment of healthy naturally menopausal women in the community to a randomized placebo-controlled trial of dehydroepiandrosterone (DHEA) therapy for treatment of loss of sexual desire.

METHODS

Recruitment of women was achieved by advertising and media publicity. We have reported on the method by which women initially contacted us and the reasons for nonparticipation.

RESULTS

Nine hundred and eighteen women contacted us about participating in the study; 706 of these were telephoned screened, and 93 of these (10%) women were randomized to therapy. The main determinants for nonparticipation included ineligibility on phone screening (58%), withdrawal of interest either before or after screening (55%), and preexisting pathology after attending for screening (8%).

CONCLUSIONS

Despite ongoing interest by women to participate in research for therapies to treat low libido, concerns about the use of any hormonal treatment and the time poverty experienced by many women at midlife present new barriers to recruitment and need to be considered in assessing the feasibility of studies in this field.

DHEA therapy for women: effect on sexual function and wellbeing

DHEA is increasingly available commercially as a supplement aimed at improving libido and wellbeing in postmenopausal women. However there is scant evidence to support the use of DHEA for this purpose, and safety data for DHEA therapy are lacking. Dehydroepiandrosterone (DHEA) and its sulphate DHEAS are the most abundant circulating sex steroid hormones in women, providing a large precursor reservoir for the intracellular production of androgens and oestrogens in non-reproductive tissues. Levels of DHEA and DHEAS decline with age. It has been proposed that restoring the circulating levels of these steroids to those found in young people may have anti-ageing effects and improve wellbeing and sexual function. However this is not supported by the published literature. We have reviewed the physiology of DHEA and DHEAS in women and the published literature pertaining to the use of DHEA therapy for libido and wellbeing in postmenopausal women. The literature was searched using Medline (Ovid) and Pub-Med for original studies. Overall, the interpretation of data from randomised controlled trials conducted in well women is limited by inadequate sample size and short treatment durations with inconsistent results for the outcomes of libido and wellbeing. Studies of DHEA in women with adrenal insufficiency, although indicating potential improvements in mood and libido, are also limited by their short treatment phase durations. In addition safety data for DHEA therapy are lacking. The potential value of DHEA therapy for women still requires exploration in adequately powered well-designed randomised placebo-controlled trials. The studies of DHEA therapy in women with adrenal insufficiency suggest that this group is the most likely to derive health benefits from DHEA supplementation.

Follow-up difficulty: correlates and relationship with outcome in heroin dependence treatment in the NEPOD study

Data collected from 317 heroin users who participated in four studies that were included in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence were analysed to examine predictors of follow-up difficulty and whether follow-up difficulty was related to heroin use outcomes. Participants who were no longer receiving treatment were more difficult to contact and more likely to be lost to follow-up. Participants treated in general practice settings were also more difficult to contact and more likely to be lost to follow-up than participants treated at specialist clinics. Contact difficulty among followed-up participants (either in or out of treatment) was unrelated to heroin use outcomes. The 21% of participants who were followed-up with just one contact attempt reported 20.0 heroin-free days in the previous month, increasing only slightly to 20.9 based on the 70% of participants eventually contacted after up to 20 attempts. The study examined three methods for imputing missing heroin use outcome data and concluded that imputation of missing outcome data by inserting corresponding baseline data may be too conservative.

Implementing Buprenorphine Treatment in Community Settings in Australia: Experiences from the Buprenorphine Implementation Trial

Buprenorphine was registered in Australia as a maintenance and detoxification agent for the management of opioid dependence in November, 2000, and became widely available in August, 2001. This paper provides an overview of key developments in the introduction of buprenorphine treatment in Australia, with an emphasis upon the delivery of services in community-based (primary care) settings. A central study in this work was the Buprenorphine Implementation Trial (BIT), a randomized, controlled trial comparing buprenorphine and methadone maintenance treatment delivered under naturalistic conditions by specialist and community-based service providers (general practitioners and community pharmacists) in 139 subjects across nineteen treatment sites. In addition to conventional patient outcome measures (treatment retention, drug use, psychosocial functioning, and cost effectiveness), the BIT study also involved the development and evaluation of clinical guidelines, training programs for clinicians, and client literature, which are described here. Integration of treatment systems (methadone with buprenorphine, specialist and primary-care programs) and factors thought to be important in the uptake of buprenorphine treatment in Australia since registration are discussed.

A randomized trial comparing levo-alpha acetylmethadol with methadone maintenance for patients in primary care settings in Australia

AIMS

The present study aimed to compare the efficacy of levo-alpha-acetylmethadol (LAAM) and methadone, as measured by retention in treatment and heroin use, in a randomized trial conducted under naturalistic conditions.

SETTING

This study is the first randomized trial comparing LAAM with methadone in the primary care setting. Participants were recruited through 29 medical practitioners working in specialist and generalist settings in Australia.

PARTICIPANTS

Existing methadone maintenance patients, aged 18 years and over and able to give informed consent, were randomized to receive either LAAM or methadone. A total of 93 patients participated.

INTERVENTION

After being trained in the use of LAAM, existing methadone prescribers were then able to determine an individually tailored treatment regimen for each patient. The trial was an open-label study. Methadone and LAAM dosing was supervised through local community pharmacies. Participation in ancillary services (e.g. counselling) was optional for all patients. The treatment period for the trial was 12 months.

MEASUREMENTS

Baseline, 3-, 6- and 12-month interviews were conducted. Outcome measures were retention in treatment, self-reported heroin use and serious adverse events.

FINDINGS

There were no significant differences between LAAM and methadone on retention in treatment, nor heroin use. There was a trend for LAAM patients to have lower heroin use than methadone patients. Of the seven serious adverse events in the LAAM group, three were not drug-related. There were two dosing errors.

CONCLUSIONS

This study demonstrates (a) the efficacy of LAAM as a treatment for heroin dependence, and (b) the capacity for LAAM to be effectively delivered in primary care settings by trained general practitioners and pharmacists. The next challenge is to resolve outstanding safety concerns with LAAM.

A RACOG sponsored pilot study of a quality assurance program regarding management of labour by provincial Fellows. Royal Australian College of Obstetricians and Gynaecologists

OBJECTIVE

To develop an effective and practical self-administered obstetric audit program for use by clinicians within their own practice.

SETTING

The private and public practices of specialists in provincial practice.

SAMPLE

Two periods of 3 months in each Fellow's practice, separated by a period of 3 months to allow for data review, resulting in the review of management of 6708 singleton births.

METHODS

All provincial Fellows in active practice in Australia in early 1998 were invited to take part in a voluntary 'quality cycle' obstetric practice audit. The data from the first 3 month period was fed back to participating Fellows for review before a second 3-month audit period was undertaken.

RESULTS

One hundred and twenty provincial Fellows were invited to take part; 62 registered for the study, 58 commenced the project, and 52 completed the entire cycle. 60.1% of the 6708 women studied laboured spontaneously, 25.8% had labour induced, and 14.1% had elective Caesarean sections. 87.8% of the 5759 women who laboured gave birth vaginally. There was little change in the incidence of intervention in labour between the first and second study periods.

CONCLUSIONS

It is possible to design a worthwhile self-administered clinical audit in obstetric practice with which specialists in full-time practice can cope and which provides useful personalised feedback for the specialist.

A randomized controlled trial of a smoking cessation intervention during pregnancy

This study was a randomized controlled trial of a smoking cessation intervention for pregnant smokers. Women who reported smoking at their first antenatal visit and satisfied the inclusion criteria were asked to participate in the trial. Analysis was restricted to 393 evaluable women in the control group (received usual antenatal care) and 339 women to the study group (received usual antenatal care plus the intervention). The primary hypotheses were that the intervention would result in a higher proportion of quitters and that the mean birth-weight of babies born to women receiving the intervention would be greater than that of babies born to women in the control group. The outcome measures were smoking status based on self-report combined with a urinary cotinine level of <115 ng/mL, and birth-weight. There was no significant difference in quit rate between women receiving the intervention and women in the control group (11.9% versus 9.8% p=0.41). Babies born to women receiving the intervention were on average 84 g heavier than babies born to controls (p=0.04). The factors that contribute to the lack of a significant increase in smoking cessation in the intervention group and the possible explanation for the changes in birth-weight are discussed.

"A survey of antenatal clinic staff: some perceived barriers to the promotion of smoking cessation in pregnancy"

Antenatal clinic staff were surveyed for their attitudes to smoking in pregnancy in 1993 and again in 1996 to monitor the effect of a randomised controlled trial of a smoking intervention conducted in the clinic over the period. Descriptive analysis showed that staff believe smoking in pregnancy is an important health risk for both mother and baby, quitting smoking is difficult, counselling is only moderately successful, they lack the skill to counsel smokers and there is little time to do so. The lack of structural support within clinic administration, the lack of a comprehensive hospital policy on smoking and unclear public health messages, were also identified as barriers to reducing the prevalence of smoking.

Women who spontaneously quit smoking in early pregnancy

Spontaneous quitters are prepregnancy smokers who quit by the time of their first antenatal visit. We recruited 192 self-declared spontaneous quitters and 407 smokers at their first visit to the antenatal clinic at the Royal Women's Hospital during April, 1994-May, 1995. Spontaneous quitters made up 23% of prepregnancy smokers. Information about self-declared quitters and smokers was collected by self-completed questionnaires. Urine samples collected at the first visit and in late pregnancy were assayed for cotinine to validate smoking status. A cut-off urinary concentration of > or = 653 nmol/L cotinine was used to determine active smoking. At the first visit, 20% of the self-declared spontaneous quitters were smoking and by late pregnancy, regardless of their initial biochemically verified status, 27% were smoking. Spontaneous quitters were different from women who said they were still smoking at their first antenatal visit, in a range of demographic variables and measures of addictive behaviour.