Educational attainment and smoking among women: risk factors and consequences for offspring

Smoking abstinence-related expectancies among American Indians, African Americans, and women: potential mechanisms of tobacco-related disparities

Research has documented tobacco-related health disparities by race and gender. Prior research, however, has not examined expectancies about the smoking cessation process (i.e., abstinence-related expectancies) as potential contributors to tobacco-related disparities in special populations. This cross-sectional study compared abstinence-related expectancies between American Indian (n = 87), African American (n = 151), and White (n = 185) smokers, and between women (n = 231) and men (n = 270) smokers. Abstinence-related expectancies also were examined as mediators of race and gender relationships with motivation to quit and abstinence self efficacy. Results indicated that American Indians and African Americans were less likely than Whites to expect withdrawal effects, and more likely to expect that quitting would be unproblematic. African Americans also were less likely than Whites to expect smoking cessation interventions to be effective. Compared with men, women were more likely to expect withdrawal effects and weight gain. These expectancy differences mediated race and gender relationships with motivation to quit and abstinence self-efficacy. Findings emphasize potential mechanisms underlying tobacco-related health disparities among American Indians, African Americans, and women and suggest a number of specific approaches for targeting tobacco dependence interventions to these populations.

Understanding disparities in subpopulations of women who smoke

Tobacco use is the leading known cause of preventable death and disease among women. In this paper we use fundamental concepts and definitions from the general health-disparities literature to examine smoking behavior among subpopulations of women. We focus on three factors associated with disparities in smoking behavior among subgroups of women-race and/or ethnicity, educational status, and acculturation. We suggest that research on smoking behavior among subpopulations of women is beginning to reveal not only different smoking behavior but disparities among women in different subpopulations. We conclude that subpopulation-based understanding of gender differences and disparities in smoking is critical to improvement of research design, intervention objectives, and public health policy on smoking in women.

Academic performance, educational aspiration and birth outcomes among adolescent mothers: a national longitudinal study

BACKGROUND

Maternal educational attainment has been associated with birth outcomes among adult mothers. However, limited research explores whether academic performance and educational aspiration influence birth outcomes among adolescent mothers.

METHODS

Data from Waves I and IV of the National Longitudinal Study of Adolescent Health (Add Health) were used. Adolescent girls whose first pregnancy occurred after Wave I, during their adolescence, and ended with a singleton live birth were included. Adolescents' grade point average (GPA), experience of ever skipping a grade and ever repeating a grade, and their aspiration to attend college were examined as predictors of birth outcomes (birthweight and gestational age; n = 763). Univariate statistics, bivariate analyses and multivariable models were run stratified on race using survey procedures.

RESULTS

Among Black adolescents, those who ever skipped a grade had higher offspring's birthweight. Among non-Black adolescents, ever skipping a grade and higher educational aspiration were associated with higher offspring's birthweight; ever skipping a grade was also associated with higher gestational age. GPA was not statistically significantly associated with either birth outcome. The addition of smoking during pregnancy and prenatal care visit into the multivariable models did not change these associations.

CONCLUSIONS

Some indicators of higher academic performance and aspiration are associated with better birth outcomes among adolescents. Investing in improving educational opportunities may improve birth outcomes among teenage mothers.

Preconception mental health predicts pregnancy complications and adverse birth outcomes: a national population-based study

Pregnancy complications and poor birth outcomes can affect the survival and long-term health of children. The preconception period represents an opportunity to intervene and improve outcomes; however little is known about women's mental health prior to pregnancy as a predictor of such outcomes. We sought to determine if and to what extent women's preconception mental health status impacted subsequent pregnancy complications, non-live birth, and birth weight using a nationally representative, population-based sample. We used pooled 1996-2006 data from the nationally-representative Medical Expenditure Panel Survey (MEPS). Poor preconception mental health was defined as women's global mental health rating of "fair" or "poor" before conception. Logistic regression was used to assess the association between preconception mental health and pregnancy complications, non-live birth, and having a low birth weight baby within the follow up period. Poor preconception mental health was associated with increased odds of experiencing any pregnancy complication (AOR 1.40, 95% CI: 1.02-1.92), having a non-live birth (AOR 1.48, 95% CI: 0.96-2.27), and having a low birth weight baby (AOR 1.99, 95% CI: 1.00-3.98), all controlling for maternal age, race/ethnicity, marital status, education, health insurance status, income, and number of children in the household. Significant racial and ethnic disparities exist for pregnancy complications and non-live births, but not for low birth weight. Women's preconception mental health is a modifiable risk factor that stands to reduce the incidence of adverse pregnancy complications and birth outcomes.

Lower glial metabolite levels in brains of young children with prenatal nicotine exposure

Many pregnant women smoke cigarettes during pregnancy, but the effect of nicotine on the developing human brain is not well understood, especially in young children. This study aims to determine the effects of prenatal nicotine exposure (PNE) on brain metabolite levels in young (3-4 years old) children, using proton magnetic resonance spectroscopy ((1)H MRS). Twenty-six children with PNE and 24 nicotine-unexposed children (controls) were evaluated with a structured examination, a battery of neuropsychological tests, and MRI/(1)H MRS (without sedation). Concentrations of N-acetyl compounds (NA), total creatine (tCR), choline-containing compounds (CHO), myo-inositol (MI), and glutamate+glutamine (GLX) were measured in four brain regions. Children with PNE had similar performance to controls on neuropsychological testing. However, compared to controls, the PNE group had lower MI (repeated measures ANOVA-p = 0.03) and tCr levels (repeated measures ANOVA-p = 0.003), especially in the basal ganglia of the girls (-19.3%, p = 0.01). In contrast, GLX was elevated in the anterior cingulate cortex of the PNE children (+9.4%, p = 0.03), and those with the highest GLX levels had the poorest performance on vocabulary (r = -0.67; p < 0.001) and visual motor integration (r = -0.53; p = 0.01). The amount of prenatal nicotine exposure did not correlate with metabolite concentrations. These findings suggest that PNE may lead to subclinical abnormalities in glial development, especially in the basal ganglia, and regionally specific changes in other neurometabolites. These alterations were not influenced by the amount of nicotine exposure prenatally. However, the effects of PNE on energy metabolism may be sex specific, with greater alterations in girls.

Prenatal exposure to tobacco and future nicotine dependence: population-based cohort study

BACKGROUND

Maternal smoking during pregnancy may increase the risk of nicotine dependence, especially in girls, but data are conflicting and confounding by other familial factors cannot be ruled out.

AIMS

To clarify the relationship between prenatal tobacco exposure and adolescent tobacco uptake and dependence in boys and girls respectively, while taking confounding factors into close consideration.

METHOD

We conducted a prospective longitudinal study, comprising 3020 Swedish youths followed from 11 to 18 years of age. Exposure and outcome information was elicited via self-administered parental and repeated youth questionnaires. Hazard ratios (HRs), odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated as measures of associations.

RESULTS

Girls prenatally exposed to maternal tobacco use had a two- to threefold increased odds of experiencing a high number of withdrawal symptoms (OR = 2.83, 95% CI 1.68-4.87), craving for tobacco (OR = 2.04, 95% CI 1.28-3.32) and heavy tobacco use (five or more cigarettes or snus dips per day) (OR = 1.93, 95% CI 1.30-2.86). These associations were weaker among boys, and did not reach formal statistical significance. Associations between prenatal tobacco exposure and onset of regular tobacco use in both genders appeared to be mostly explained by parents' social position and postnatal smoking behaviour.

CONCLUSIONS

Prenatal exposure to tobacco is linked to an increased risk of nicotine dependence among adolescent girls.

Maternal smoking cessation and reduced academic and behavioral problems in offspring

BACKGROUND

There is some debate whether smoking during pregnancy causes or is only a risk factor for negative academic outcomes and increased risk of psychopathology in offspring. This study evaluated whether maternal smoking cessation would reduce the risk of adverse outcomes in school-aged children.

METHODS

Women completed an online survey that included items about child scholastic performance and the Child Behavior Checklist (CBCL). Mothers were divided based on pre-pregnancy and pregnancy smoking status into: (1) Nonsmokers (N=320); (2) Women that smoked in the 3 months preceding and throughout pregnancy (Smokers, N=83); and (3) Smoking before, but not during pregnancy (Quitters, N=72).

RESULTS

The Smokers and Quitters groups each had lower education and incomes compared to Nonsmokers but were indistinguishable from each other on these measures. The offspring of Smokers were more likely (p<.05) to be behind their peers on standardized tests in math (27.8%) relative to both Nonsmokers (17.4%) and Quitters (13.0%) with similar findings for reading. Smokers reported more behavioral problems by their children in several areas including Hyperactivity and Impulsivity, Social problems, and Externalizing problems including Aggression and Rule-Breaking. Further, the children of Quitters had significantly fewer Attention and Externalizing problems than Smokers. These outcomes were observed even after accounting for the variance attributable to maternal education and several other potential confounds.

CONCLUSIONS

Together, these findings indicate that smoking cessation is associated with reduced risk of having children with academic and neuropsychological difficulties. These outcomes are discussed within the framework that nicotine may be a neurobehavioral teratogen.

Predictors of persistent nicotine dependence among adults in the United States

BACKGROUND

Evidence suggests that nicotine dependence is the key barrier to successful smoking cessation. No previous study has documented predictors of persistent nicotine dependence among adults in the community. The goal of this study is to prospectively identify predictors of continued nicotine dependence over a 3-year period among adults.

METHODS

Data were drawn from Waves I and II of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults in the United States. Logistic regression analyses were used to estimate the odds of persistent nicotine dependence at Wave 2 given the presence of various sociodemographic and psychiatric predictors at Wave 1.

RESULTS

Mood, anxiety, personality and illicit substance use disorders were associated with significantly increased risk of persistent nicotine dependence. The strength of these relationships was attenuated slightly after adjusting for demographic differences, but remained statistically significant. Persistent nicotine dependence was more common among unmarried, younger females with lower income levels and lower educational attainment.

CONCLUSIONS

To our knowledge, this study is the first to prospectively identify predictors of persistent nicotine dependence among adults. Our results suggest that the incorporation of mental health treatment into alternative smoking cessation approaches may help to increase the effectiveness of these programs and that a greater focus of these services on vulnerable segments of the population is needed in order to reduce continued disparities in smoking in the general population.

Sensitivity to secondhand smoke exposure predicts future smoking susceptibility

OBJECTIVE

Susceptibility to cigarette smoking in tobacco-naive youth is a strong predictor of smoking initiation. Identifying mechanisms that contribute to smoking susceptibility provide information about early targets for smoking prevention. This study investigated whether sensitivity to secondhand smoke exposure (SHSe) contributes to smoking susceptibility.

PARTICIPANTS AND METHODS

Subjects were high-risk, ethnically diverse 8- to 13-year-old subjects who never smoked and who lived with at least 1 smoker and who participated in a longitudinal SHSe reduction intervention trial. Reactions (eg, feeling dizzy) to SHSe were assessed at baseline, and smoking susceptibility was assessed at baseline and 3 follow-up measurements over 12 months. We examined the SHSe reaction factor structure, association with demographic characteristics, and prediction of longitudinal smoking susceptibility status.

RESULTS

Factor analysis identified "physically unpleasant" and "pleasant" reaction factors. Reported SHSe reactions did not differ across gender or family smoking history. More black preteens reported feeling relaxed and calm, and fewer reported feeling a head rush or buzz compared with non-Hispanic white and Hispanic white counterparts. Longitudinally, 8.5% of subjects tracked along the trajectory for high (versus low) smoking susceptibility. Reporting SHSe as "unpleasant or gross" predicted a 78% reduction in the probability of being assigned to the high-smoking susceptibility trajectory (odds ratio: 0.22 [95% confidence interval: 0.05-0.95]), after covariate adjustment.

CONCLUSIONS

Assessment of SHSe sensitivity is a novel approach to the study of cigarette initiation etiology and informs prevention interventions.

Comorbid psychiatric disorders and nicotine dependence in adolescence

AIMS

To examine bidirectional influences of onset of psychiatric disorders and nicotine dependence among adolescent smokers.

DESIGN

A prospective longitudinal cohort of adolescents and mothers drawn from a large city school system. Adolescents were interviewed five times and mothers three times over 2 years.

SETTING

Chicago, Illinois.

PARTICIPANTS

Subsample of adolescent smokers (n = 814).

MEASUREMENTS

Selected DSM-IV psychiatric disorders, nicotine dependence and selected risk factors were ascertained.

FINDINGS

Among lifetime smokers, 53.7% experienced at least one nicotine dependence criterion; 26.1% full dependence; 14.1% experienced an anxiety disorder, 18.8% a mood disorder and 29.5% a disruptive disorder. Nicotine dependence and psychiatric disorders were comorbid: nicotine-dependent youths had higher rates of individual and multiple disorders than those not dependent. Controlling for other covariates, mood disorder and nicotine dependence did not predict each other; anxiety disorder predicted nicotine dependence. Bidirectional influences were observed for disruptive disorder and nicotine dependence. Predictors of onset of full nicotine dependence included earlier onset age of tobacco use, high initial pleasant sensitivity to tobacco, alcohol and illicit drug use, abuse and dependence and parental nicotine dependence. Predictors of psychiatric disorder onset included gender, race/ethnicity, other psychiatric disorders, illicit drug abuse or dependence and parental depression and delinquency.

CONCLUSIONS

Initial pleasant experiences of smoking are predictive of later development of nicotine dependence. There may be reciprocal influences between disruptive disorder and development of nicotine dependence in adolescence, and intergenerational transmission of parental nicotine dependence and psychopathology.

Smoking in pregnancy and parenting stress: maternal psychological symptoms and socioeconomic status as potential mediating variables

INTRODUCTION

The purpose of this study was to examine the impact of smoking in pregnancy on parenting stress. Maternal psychological symptoms and socioeconomic status (SES) were evaluated as potential mediating factors between prenatal cigarette use and later parenting stress.

METHOD

The sample included 218 mothers who were recruited at the hospital after birth and completed a 6-month visit with their infants at a university laboratory. Based on the mothers' responses to interviews at the hospital on tobacco use during pregnancy, the sample included 77 nonsmokers and 141 smokers. Information on sociodemographic variables, prenatal care, and other substance use during pregnancy was collected at the hospital interview. At the 6-month visit, the mothers completed measures of parenting stress and psychological symptoms. Cotinine levels were assessed at both timepoints.

RESULTS

Regression analysis showed that maternal smoking during pregnancy predicted parenting stress in infancy. Maternal symptoms of psychological distress and SES were evaluated simultaneously to determine whether they functioned as mediating variables between smoking in pregnancy and parenting stress. A multiple mediation analysis (Preacher & Hayes, 2008a) showed that maternal psychological symptoms functioned as a mediating variable but that SES did not.

CONCLUSIONS

Results suggest that mothers who smoke in pregnancy are likely to experience higher levels of psychological symptoms, which, in turn, predict higher levels of parenting stress. Smoking in pregnancy may be a marker for symptoms of psychological distress in mothers.

Sensitivity to secondhand smoke exposure predicts smoking susceptibility in 8-13-year-old never smokers

PURPOSE

To investigate the sensitivity to secondhand smoke exposure (SHSe) in preteens aged 8-13 years who have never smoked, and to determine whether it predicts smoking susceptibility.

METHODS

We assessed the sensitivity to SHSe using reactions commonly used for the assessment of sensitivity to the first-smoked cigarette (e.g., feeling dizzy), and investigated the factor structure of these reactions for the purpose of data reduction. We examined the association of each reaction measure and summary score with demographic characteristics and smoking susceptibility, using logistic regression and ordinal logistic regression.

RESULTS

One factor was identified that captured the physical and/or unpleasant reactions. Older preteens and preteens with more highly educated parents reported fewer reactions to SHSe. More African American preteens reported feeling relaxed or calm compared with all other racial/ethnic groups. Experiencing physical and/or unpleasant reactions to SHSe predicted lower risk for smoking susceptibility.

CONCLUSIONS

This was the first study to extend analytical methodology for sensitivity to active smoking to sensitivity to SHSe in youth who had never smoked. Results suggest a desensitization process with age and lower sensitivity to some reactions in preteens from more highly educated households. Preteens who have more aversive experiences with SHSe tend to be less susceptible to smoking than those who experience fewer aversive reactions. Assessment of sensitivity to SHSe is a novel approach to the study of cigarette use etiology and may contribute to better prediction of smoking initiation.

Addiction in pregnancy

Substance abuse in pregnancy has increased over the past three decades in the United States, resulting in approximately 225,000 infants yearly with prenatal exposure to illicit substances. Routine screening and the education of women of child bearing age remain the most important ways to reduce addiction in pregnancy. Legal and illegal substances and their effect on pregnancy discussed in this review include opiates, cocaine, alcohol, tobacco, marijuana, and amphetamines. Most literature regarding opiate abuse is derived from clinical experience with heroin and methadone. Poor obstetric outcomes can be up to six times higher in patients abusing opiates. Neonatal care must be specialized to treat symptoms of withdrawal. Cocaine use in pregnancy can lead to spontaneous abortion, preterm births, placental abruption, and congenital anomalies. Neonatal issues include poor feeding, lethargy, and seizures. Mothers using cocaine require specialized prenatal care and the neonate may require extra supportive care. More than 50% of women in their reproductive years use alcohol. Alcohol is a teratogen and its effects can include spontaneous abortion, growth restriction, birth defects, and mental retardation. Fetal alcohol spectrum disorder can have long-term sequelae for the infant. Tobacco use is high among pregnant women, but this can be a time of great motivation to begin cessation efforts. Long-term effects of prenatal tobacco exposure include spontaneous abortion, ectopic pregnancy, placental insufficiency, low birth weight, fetal growth restriction, preterm delivery, childhood respiratory disease, and behavioral issues. Marijuana use can lead to fetal growth restriction, as well as withdrawal symptoms in the neonate. Lastly, amphetamines can lead to congenital anomalies and other poor obstetric outcomes. Once recognized, a multidisciplinary approach can lead to improved maternal and neonatal outcomes.

Educational disadvantage and cigarette smoking during pregnancy

This study examined the influence of education on smoking status in a cohort (n=316) of pregnant women who were smokers at the time they learned of the current pregnancy. Subjects were participants in clinical trials examining the efficacy of monetary-based incentives for smoking-cessation and relapse prevention. In multivariate analyses, educational achievement was a robust predictor of smoking status upon entering prenatal care, of achieving abstinence antepartum among those still smoking at entry into prenatal care, and of smoking status at 6-month postpartum in the entire cohort and the subsample who received smoking-cessation treatment. In addition to educational attainment, other predictors of smoking status included smoking-related characteristics (e.g., number of cigarettes/day smoked pre-pregnancy), treatment, maternal age, and stress ratings. We suggest that strategies to increase educational attainment be included with more conventional tobacco-control policies in efforts to reduce smoking among girls and young women.