Smoking during pregnancy was up to 70% more common in the most deprived municipalities - a multilevel analysis of all singleton births during 2005-2010 in Finland

Prevalence of smoking during pregnancy and associated social inequalities in developed countries over the 1995-2020 period: A systematic review

BACKGROUND

Smoking during pregnancy (SDP) is an important source of preventable morbidity and mortality for both mother and child.

OBJECTIVES

The aim of this study was to describe changes in the prevalence of SDP over the last 25 years in developed countries (Human Development Index >0.8 in 2020) and associated social inequalities.

DATA SOURCES

A systematic review was conducted based on a search in PubMed, Embase and PsycInfo databases and government sources.

STUDY SELECTION AND DATA EXTRACTION

Published studies between January 1995 and March 2020, for which the primary outcome was to assess the national prevalence of SDP and the secondary outcome was to describe related socio-economic data were included in the analysis. The selected articles had to be written in English, Spanish, French or Italian.

SYNTHESIS

The articles were selected after successive reading of the titles, abstracts and full-length text. An independent double reading with intervention of a third reader in case of disagreement allowed including 35 articles from 14 countries in the analysis.

RESULTS

The prevalence of SDP differed across the countries studied despite comparable levels of development. After 2015, the prevalence of SDP ranged between 4.2% in Sweden and 16.6% in France. It was associated with socio-economic factors. The prevalence of SDP slowly decreased over time, but this overall trend masked inequalities within populations. In Canada, France and the United States, the prevalence decreased more rapidly in women of higher socio-economic status, and inequalities in maternal smoking were more marked in these countries. In the other countries, inequalities tended to decrease but remained significant.

CONCLUSIONS

During pregnancy, that is a period described as a window of opportunity, smoking and social vulnerability factors need to be detected to implement targeted prevention strategies aiming at reducing related social inequalities.

Effectiveness of an App for tobacco cessation in pregnant smokers (TOBBGEST): study protocol

BACKGROUND

Tobacco consumption during pregnancy is one of the most modifiable causes of morbidity and mortality for both pregnant smokers and their foetus. Even though pregnant smokers are conscious about the negative effects of tobacco consumption, they also had barriers for smoking cessation and most of them continue smoking, being a major public health problem. The aim of this study is to determine the effectiveness of an application (App) for mobile devices, designed with a gamification strategy, in order to help pregnant smokers to quit smoking during pregnancy and in the long term.

METHODS

This study is a multicentre randomized community intervention trial. It will recruit pregnant smokers (200 participants/group), aged more than 18 years, with sporadically or daily smoking habit in the last 30 days and who follow-up their pregnancy in the Sexual and Reproductive Health Care Services of the Camp de Tarragona and Central Catalonia Primary Care Departments. All the participants will have the usual clinical practice intervention for smoking cessation, whereas the intervention group will also have access to the App. The outcome measure will be prolonged abstinence at 12 months after the intervention, as confirmed by expired-carbon monoxide and urinary cotinine tests. Results will be analysed based on intention to treat. Prolonged abstinence rates will be compared, and the determining factors will be evaluated using multivariate statistical analysis.

DISCUSSION

The results of this study will offer evidence about the effectiveness of an intervention using a mobile App in smoking cessation for pregnant smokers, to decrease comorbidity associated with long-term smoking. If this technology is proven effective, it could be readily incorporated into primary care intervention for all pregnant smokers.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT05222958 . Trial registered 3 February 2022.

Estimating cumulative spatial risk over time with low-rank kriging multiple membership models

Many health outcomes result from accumulated exposures to one or more environmental factors. Accordingly, spatial risk studies have begun to consider multiple residential locations of participants, acknowledging that participants move and thus are exposed to environmental factors in several places. However, novel methods are needed to estimate cumulative spatial risk for disease while accounting for other risk factors. To this end, we propose a Bayesian model (LRK-MMM) that embeds a multiple membership model (MMM) into a low-rank kriging (LRK) model in order to estimate cumulative spatial risk at the point level while allowing for multiple residential locations per subject. The LRK approach offers a more computationally efficient means to analyze spatial risk in case-control study data at the point level compared with a Bayesian generalized additive model, and as increased precision in spatial risk estimates by analyzing point locations instead of administrative areas. Through a simulation study, we demonstrate the efficacy of the model and its improvement upon an existing multiple membership model that uses area-level spatial random effects to estimate risk. The results show that our proposed method provides greater spatial sensitivity (improvements ranging from 0.12 to 0.54) and power (improvements ranging from 0.02 to 0.94) to detect regions of elevated risk for disease across a range of exposure scenarios. Finally, we apply our model to case-control data from the New England bladder cancer study to estimate cumulative spatial risk while adjusting for many covariates.

Neighborhood Deprivation is Associated with Increased Risk of Prenatal Smoke Exposure

Despite years of advisories against the behavior, smoking among pregnant women remains a persistent public health issue in the USA. Recent estimates suggest that 9.4% of women smoke before pregnancy and 7.1% during pregnancy in the USA. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy, including educational attainment, employment status, housing conditions, poverty, and racial demographics. However, most of these studies have relied upon self-reported measures of smoking, which are subject to reporting bias. To more accurately and objectively assess smoke exposure in mothers during pregnancy, we used Bayesian index models to estimate a neighborhood deprivation index (NDI) for block groups in Durham County, North Carolina, and its association with cotinine, a marker of smoke exposure, in pregnant mothers (n = 887 enrolled 2005-2011). Results showed a significant positive association between NDI and log cotinine (beta = 0.20, 95% credible interval = [0.11, 0.29]) after adjusting for individual covariates (e.g., race/ethnicity and education). The two most important variables in the NDI according to the estimated index weights were percent females without a high school degree and percent Black population. At the individual level, Hispanic and other race/ethnicity were associated with lowered cotinine compared with non-Hispanic Whites. Higher education levels were also associated with lowered cotinine. In summary, our findings provide stronger evidence that the socio-geographic variables of educational attainment and neighborhood racial composition are important factors for smoking and secondhand smoke exposure during pregnancy and can be used to target intervention efforts.

What Regional Living Conditions Affect Individual Smoking of Adults in Russia

Objectives: Our study evaluated the impact of a wide range of characteristics of large administrative regions on the individual level of cigarette smoking in the Russian adult population. Methods: The pool of participants included 20,303 individuals aged 25-64 years. We applied 64 characteristics of the 12 Russian regions under study for 2010-2014. Using principal component analysis, we deduced five evidence-based composite indices of the regions. We applied the generalized estimating equation to determine associations between the regional indices and the individual level of smoking. Results: The increased Industrial index in the region is associated with the probability of smoking (odds ratio = 1.15; 95% confidence interval = 1.06-1.24). The other indices show associations with smoking only in separate gender and educational groups. Surprisingly, it was found that the Economic index has no associations with the probability of smoking. Conclusion: We evaluated the key associations of the territorial indices with the individual probability of smoking, as well as the mutual influence between the territorial indices and individual factors.

Validation of the 'EPICES' social deprivation score in a population of women who have just given birth: a French cross-sectional study

OBJECTIVES

To assess the diagnostic performance of the EPICES score for identifying social deprivation during pregnancy in a population of women in the immediate postpartum period.

STUDY DESIGN

This cross-sectional survey took place between 5th June and 5th August 2017, among women who had just given birth in either of the maternity units in Clermont-Ferrand, France.

METHODS

A self-administered questionnaire was completed by women. The questionnaire came in two parts: the EPICES index and the criteria for social deprivation defined by French law. These criteria were chosen to define the reference standard. The women were classified into two groups, living in precarious circumstances or not, according to the criteria defined by the French law (reference standard). To determine the most relevant threshold of the EPICES score, the precision associated with the threshold (the fraction of those predicted positive who are true positives: positive predictive value) was balanced with its sensitivity. EPICES scores above the threshold were classified as deprived, those below as non-deprived.

RESULTS

Of the 947 women who gave birth during the study period, 700 (73.9%) completed the self-administered questionnaire. The best trade-off between precision and sensitivity was obtained with a threshold of 22. For this threshold value, the positive predictive value was 42.3% and the sensitivity 70.3%.

CONCLUSIONS

The EPICES score with a threshold validated in the population of pregnant women is a useful, rapid, and easy-to-use tool that makes it possible to identify maternal deprivation at an individual level.

Smoking during pregnancy: changes and associated risk factors in Spain, 1980-2016

BACKGROUND

Trends for maternal smoking rates have varied substantially across industrialized countries. The objective was to describe how the prevalence of maternal smoking evolved in Spain during 1980-2016.

METHODS

Data came from the Spanish Collaborative Study of Congenital Malformations. Our sample consisted of 40 934 mothers of newborns with no congenital defects from hospitals all across Spain. We estimated change points in trend and the mean annual change in smoking prevalence using 'joinpoint' regression. Relevant potential factors (age, country of birth, education, parity, planned pregnancy and alcohol consumption) were examined using multivariate logistic regression.

RESULTS

Maternal smoking prevalence in 1980 and 2016 were 14.3% (95% confidence interval [CI]: 11.9-17.0) and 20.4% (95% CI: 15.9-25.8). We identified four periods with distinct trends: a sharp increase during the 80s, a plateau during the 90s, a decrease starting in 2000 and a slowdown of such decrease from 2009 on. Smoking was significantly higher among young women, Spain-born, with low education, unplanned pregnancy, and alcohol consumption.

CONCLUSIONS

Currently in Spain maternal smoking remains very high. Tobacco consumption trend showed an increase during the 80s, a plateau during the 90s, and a reduction in the 2000s. Several sociodemographic and behavioural factors were associated to greater likelihood of smoking.

Associations between maternal age and socioeconomic status with smoking during the second and third trimesters of pregnancy: a register-based study of 932 671 women in Finland from 2000 to 2015

OBJECTIVES

This study aimed to explore the association between maternal age and smoking during the second and third trimesters of pregnancy across socioeconomic groups and to evaluate the interacting effect of maternal age and socioeconomic status on smoking with a view to informing public health interventions.

DESIGN

This is a register-based study.

SETTINGS

Data from the Finnish Medical Birth Register were cross-linked with background data from Statistics Finland.

PARTICIPANTS

The information of 932 671 pregnant women who gave birth in Finland from 2000 to 2015.

MAIN OUTCOME MEASURES

Maternal smoking during the second and third trimesters of pregnancy by occupation and maternal age.

RESULTS

The proportion of women who smoked during the second and third trimesters of pregnancy was 10.5%. Using women 30-34 years as the reference group, adjusted ORs (aOR) and 95% CIs for smoking were 6.02 (5.81 to 6.24) in women below 20 years and 2.77 (2.71 to 2.84) in women 20 to 24 years. The prevalence of smoking across socioeconomic groups compared with upper-level employees increased, peaking for women in manual occupations (aOR 3.39, 95% CI 3.25 to 3.52) and unemployed women (aOR 4.49, 95% CI 4.30 to 4.68). Significant interactions on the additive scale with the relative excess risk due to interaction >2 were found for unemployed women aged 25-29 years and for teenage mothers and mothers aged 20-24 years across all socioeconomic groups, but not for self-employed women.

CONCLUSIONS

Smoking during the second and third trimesters of pregnancy was most common among teenage mothers across all socioeconomic groups. The association between maternal age and smoking differed by socioeconomic status for young mothers. Interventions should address a wider range of maternal risk factors among young mothers with low socioeconomic status and simultaneously target a broader number of women who smoke during the pregnancy.

Anxiety and depression symptoms among pregnant women with different smoking habits

Smoking during pregnancy is a major public health issue. The aim of this study isto describe the smoking habits of women during pregnancy and its association with clinically significant depressive and anxiety symptoms. 382 women answered to a socio-demographic questionnaire, the Hospital Anxiety Depression Scale (HADS) and the Edinburgh Postnatal Depression Scale (EPDS) at 33 weeks of gestation. Among pregnant woman, 284 are non-smokers, 38 are smokers and 60 quitted smoking during pregnancy. There was a significant association between maternal smoking status and marital status, education level and family income per month. Among smokers, the rate of quitters was quite similar among partnered and unpartnered women and higher in women with university degree and with higher family monthly income.  There was a significant association between maternal smoking status and clinically significant anxious symptoms [χ2(2)=8.535, p=0.014].  Among mothers with non-university education, smokers are more likely to have clinically significant anxiety symptoms than quitters (53.6% vs 24.3%) while among mothers in higher income families, smokers are more likely to have clinically significant depressive symptoms than quitters (100% vs 11.1%). This study provides important data to inform effective public health strategies directed to pregnant women.

Continued smoking versus spontaneous quitting among pregnant women living in a high risk environment

OBJECTIVES

In Hungary, 37% of women living in poverty were smokers in 2012. There are no valid data of pregnant women's spontaneous smoking cessation.

METHODS

Our retrospective cohort study (2009-2012) targeted the most underdeveloped regions with an estimated 6-8.5% of Roma population. The sample (N = 12,552) represented 76% of the target population i.e. women in four counties in a year delivering live born babies. Chi-square probe and multivariable logistic regression model (p < 0.05) were used to assess relationship between socio-demographic characteristics and spontaneous cessation.

RESULTS

Prior to pregnancy, the overall smoking rate was 36.8%. That of women in deep poverty and Roma was 49.7% and 51.1%, respectively. 70.3% of smokers continued smoking during the pregnancy. Among them 80.6% lived in deep poverty. Spontaneous quitting rate was 23.0%. Factors correlated with continued smoking included being Roma (OR = 1.95), undereducated (OR = 2.66), living in homes lacking amenities (OR = 1.48), and having regularly smoking partner (OR = 2.07). Cessation was promoted by younger age (≤ 18 years) (OR = 0.18), being married (OR = 0.50), and the first pregnancy.

CONCLUSIONS

Tailored cessation programmes are needed for Roma, older, low-income, and multiparous women who are less likely to quit on their own. Engaging husbands/partners is essential to reduce smoking among pregnant women and second-hand smoke exposure.

Neighborhood affluence protects against antenatal smoking: evidence from a spatial multiple membership model

A spatial multiple membership model formalizes the effect of neighborhood affluence on antenatal smoking. The data are geocoded New Jersey birth certificate records linked to United States census tract-level data from 1999 to 2007. Neighborhood affluence shows significant spatial autocorrelation and local clustering. Better model fit is observed when incorporating the spatial clustering of neighborhood affluence into multivariate analyses. Relative to the spatial multiple membership model, the multilevel model that ignores spatial clustering produced downwardly biased standard errors; the effective sample size of the key parameter of interest (neighborhood affluence) is also lower. Residents of communities located in high-high affluence clusters likely have better access to health-promoting institutions that regulate antenatal smoking behaviors.

Lung function in adults born preterm

Very preterm birth, before the gestational age (GA) of 32 weeks, increases the risk of obstructed airflow in adulthood. We examined whether all preterm births (GA<37 weeks) are associated with poorer adult lung function and whether any associations are explained by maternal, early life/neonatal, or current life factors. Participants of the ESTER Preterm Birth Study, born between 1985 and 1989 (during the pre-surfactant era), at the age of 23 years participated in a clinical study in which they performed spirometry and provided detailed medical history. Of the participants, 139 were born early preterm (GA<34 weeks), 239 late preterm (GA: 34-<37 weeks), and 341 full-term (GA≥37 weeks). Preterm birth was associated with poorer lung function. Mean differences between individuals born early preterm versus full-term were -0.23 standard deviation (SD) (95% confidence interval (CI): -0.40, -0.05)) for forced vital capacity z-score (zFVC), -0.44 SD (95% CI -0.64, -0.25) for forced expiratory volume z-score (zFEV1), and -0.29 SD (95% CI -0.47, -0.10) for zFEV1/FVC. For late preterm, mean differences with full-term controls were -0.02 SD (95% CI -0.17, 0.13), -0.12 SD (95% CI -0.29, 0.04) and -0.13 SD (95% CI -0.29, 0.02) for zFVC, zFEV1, and zFEV1/FVC, respectively. Examination of finer GA subgroups suggested an inverse non-linear association between lung function and GA, with the greatest impact on zFEV1 for those born extremely preterm. The subgroup means were GA<28 weeks: -0.98 SD; 28-<32 weeks: -0.29 SD; 32-<34 weeks: -0.44 SD; 34-<36 weeks: -0.10 SD; 36-<37weeks: -0.11 SD; term-born controls (≥37weeks): 0.02 SD. Corresponding means for zFEV1/FVC were -1.79, -0.44, -0.47, -0.48, -0.29, and -0.02. Adjustment for maternal pregnancy conditions and socioeconomic and lifestyle factors had no major impact on the relationship. Preterm birth is associated with airflow limitation in adult life. The association appears to be attributable predominantly to those born most immature, with only a modest decrease among those born preterm at later gestational ages.

Smoking during pregnancy in Finland - Trends in the MATEX cohort

Aims: In Finland, smoking rates in the general population are decreasing due to increased awareness of the adverse effects and tightened tobacco legislation. However, previous studies have shown that smoking in pregnant Finnish women remained as high as in the general Finnish female population at around 15% in 2010. Our aim was to describe temporal and spatial trends in smoking behaviour, and determinants of changes in smoking behaviour between first and second pregnancy. Methods: Self-reported smoking from the Finnish Medical Birth Register covered the years 1991-2015 (N=1,435,009). The association of maternal age and socioeconomic status with smoking rate was analysed. Spatial trends were assessed at municipality level. Results: The overall smoking rate during early pregnancy remained fairly stable at around 15% from 1991 to 2015, but increased in teenage and young women below 25 years of age. The mean smoking rate (36%) was higher in these age groups than in older pregnant women (11%). Through the study period the smoking rate remained higher in blue collar workers compared with higher socioeconomic groups. Between the first and second child, on average only 4% of women started to smoke and 41% quitted. Smoking rates developed less favourably in Eastern Finland. Conclusions: The observed increase in smoking rate during pregnancy in teenage and young women is concerning. Pregnancy is a trigger point for smoking cessation in a big fraction of pregnant women. More studies are needed to explain the opposite trends of smoking rates in Northern and Western Finland compared with Eastern Finland.

Education is the strongest socio-economic predictor of smoking in pregnancy

AIMS

To investigate socio-economic disparities in smoking in pregnancy (SIP) by the mother's education, occupational class and current economic conditions.

DESIGN

Cross-sectional analysis with linked survey and register data.

SETTING

South-western Finland.

PARTICIPANTS

A total of 2667 pregnant women [70% of the original sample (n = 3808)] from FinnBrain, a prospective pregnancy cohort study.

MEASUREMENTS

The outcome was smoking during the first pregnancy trimester, measured from the Finnish Medical Birth Register. Education and occupational class were linked from population registers. Income support recipiency and subjective economic wellbeing were questionnaire-based measures of current economic conditions. These were adjusted for age, partnership status, residential area type, parental separation, parity, childhood socio-economic background, childhood adversities (the Trauma and Distressing Events During Childhood scale) and antenatal stress (Edinburgh Postnatal Depression Scale). Logistic regressions and attributable fractions (AF) were estimated.

FINDINGS

Mother's education was the strongest socio-economic predictor of SIP. Compared with university education, adjusted odds ratios (aORs) of SIP were: 2.2 [95% confidence interval (CI) = 1.2-3.9; P = 0.011] for tertiary vocational education, 4.4 (95% CI = 2.1-9.0; P < 0.001) for combined general and vocational secondary education, 2.9 (95% CI = 1.4-6.1; P = 0.006) for general secondary education, 9.5 (95% CI 5.0-18.2; P < 0.001) for vocational secondary education and 14.4 (95% CI = 6.3-33.0; P < 0.001) for compulsory schooling. The total AF of education was 0.5. Adjusted for the other variables, occupational class and subjective economic wellbeing did not predict SIP. Income support recipiency was associated positively with SIP (aOR = 1.8; 95% CI = 1.1-3.1; P = 0.022). Antenatal stress predicted SIP (aOR = 2.0; 95% CI = 1.4-2.8; P < 0.001), but did not attenuate its socio-economic disparities.

CONCLUSIONS

In Finland, socio-economic disparities in smoking in pregnancy are attributable primarily to differences in the mother's educational level (low versus high) and orientation (vocational versus general).

Barriers and facilitators to smoking cessation in pregnancy and in the post-partum period: The health care professionals' perspective

Objectives

Health care professionals and the health care environment play a central role in protecting pregnant and post‐partum women and their infants from smoking‐related harms. This study aimed to better understand the health professional's perspective on how interactions between women, health care professionals, and the environment influence how smoking is managed.

Design

Semi‐structured interviews and focus groups.

Methods

Data were from 48 health care staff involved in antenatal or post‐partum care at two UK sites, including midwives, obstetricians, health visitors, GPs, pharmacists, service commissioners, and Stop Smoking Service (SSS) advisors and managers. Thematic analysis was guided by a social–ecological framework (SEF).

Results

Themes were divided across three SEF levels and represented factors connected to the management of smoking in the health care context and the beliefs and behaviour of pregnant or post‐partum smokers. Organizational level: Service reconfigurations, ‘last resort’ nicotine replacement therapy prescribing policies, and non‐mandatory training were largely negative factors. There were mixed views on opt‐out referral pathways and positive views on carbon monoxide monitoring. Interpersonal level: Protection of client–professional relationships often inhibited frank discussions about smoking, and weak interservice relationships affected SSS referral motivation and quality. Individual level: Professionals felt community midwives had primary responsibility for managing smoking, although midwives felt underskilled doing this. Midwives’ perceived priority for addressing smoking was influenced by the demands from unrelated organizational initiatives.

Conclusions

Opportunities to improve clinical support for pregnant smokers exist at organizational, interservice, and health care professional levels. Interactions between levels reflect the importance of simultaneously addressing different level‐specific barriers to smoking cessation in pregnancy.

Neighborhood context and birth outcomes: Going beyond neighborhood disadvantage, incorporating affluence

•

Neighborhood affluence protects against the risk of poor birth outcome.

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The protective effect of affluence holds for Whites, Blacks, Hispanics and Asians.

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Mediation of these pathways by prenatal smoking varies by racial group.

•

The discourse on neighborhoods and birth outcomes should include affluence.

First-trimester smoking cessation in pregnancy did not increase the risk of preeclampsia/eclampsia: A Murmansk County Birth Registry study

Background

Although prior studies have shown that smoking reduces preeclampsia/eclampsia risk, the consequence of giving up this habit during pregnancy should be assessed. The aims of the current study were threefold: (i) describe maternal characteristics of women with preeclampsia/eclampsia; (ii) examine a possible association between the number of cigarettes smoked daily during pregnancy and the development of this affliction; and (iii) determine if first-trimester discontinuation of smoking during pregnancy influences the risk.

Methods

A registry-based study was conducted using data from the Murmansk County Birth Registry (MCBR). It included women without pre-existing hypertension, who delivered a singleton infant during 2006–2011 and had attended the first antenatal visit before 12 week of gestation. We adjusted for potential confounders using logistic regression.

Results

The prevalence of preeclampsia/eclampsia was 8.3% (95%CI: 8.0–8.6). Preeclampsia/eclampsia associated with maternal age, education, marital status, parity, excessive weight gain and body mass index at the first antenatal visit. There was a dose-response relationship between the number of smoked cigarettes per day during pregnancy and the risk of preeclampsia/eclampsia (adjusted OR_{1-5 cig/day} = 0.69 with 95%CI: 0.56–0.87; OR_{6-10 cig/day} = 0.65 with 95%CI: 0.51–0.82; and OR_{≥11 cig/day} = 0.49 with 95%CI: 0.30–0.81). There was no difference in this risk among women who smoked before and during pregnancy and those who did so before but not during pregnancy (adjusted OR = 1.10 with 95%CI: 0.91–1.32).

Conclusions

Preeclampsia/eclampsia was associated with maternal age, education, marital status, parity, excessive weight gain, and body mass index at the first antenatal visit. There was a negative dose-response relationship between the number of smoked cigarettes per day during pregnancy and the odds of preeclampsia/eclampsia. However, women who gave up smoking during the first trimester of gestation had the same risk of preeclampsia/eclampsia as those who smoked while pregnant. Consequently, antenatal clinic specialists are advised to take these various observations into account when counselling women on smoking cessation during pregnancy.

Large multi-centre pilot randomized controlled trial testing a low-cost, tailored, self-help smoking cessation text message intervention for pregnant smokers (MiQuit)

AIMS

To estimate the effectiveness of pregnancy smoking cessation support delivered by short message service (SMS) text message and key parameters needed to plan a definitive trial.

DESIGN

Multi-centre, parallel-group, single-blinded, individual randomized controlled trial.

SETTING

Sixteen antenatal clinics in England.

PARTICIPANTS

Four hundred and seven participants were randomized to the intervention (n = 203) or usual care (n = 204). Eligible women were < 25 weeks gestation, smoked at least one daily cigarette (> 5 pre-pregnancy), were able to receive and understand English SMS texts and were not already using text-based cessation support.

INTERVENTION

All participants received a smoking cessation leaflet; intervention participants also received a 12-week programme of individually tailored, automated, interactive, self-help smoking cessation text messages (MiQuit).

OUTCOME MEASUREMENTS

Seven smoking outcomes, including validated continuous abstinence from 4 weeks post-randomization until 36 weeks gestation, design parameters for a future trial and cost-per-quitter.

FINDINGS

Using the validated, continuous abstinence outcome, 5.4% (11 of 203) of MiQuit participants were abstinent versus 2.0% (four of 204) of usual care participants [odds ratio (OR) = 2.7, 95% confidence interval (CI) = 0.93-9.35]. The Bayes factor for this outcome was 2.23. Completeness of follow-up at 36 weeks gestation was similar in both groups; provision of self-report smoking data was 64% (MiQuit) and 65% (usual care) and abstinence validation rates were 56% (MiQuit) and 61% (usual care). The incremental cost-per-quitter was £133.53 (95% CI = -£395.78 to 843.62).

CONCLUSIONS

There was some evidence, although not conclusive, that a text-messaging programme may increase cessation rates in pregnant smokers when provided alongside routine NHS cessation care.

Associations between racial discrimination, smoking during pregnancy and low birthweight among Roma

Background

Racial discrimination may increase the risk of low birthweight (LBW), but has not been studied among Roma, the largest minority population in Europe. Moreover, few studies test both institutional and interpersonal forms of racial discrimination on health. Our objective was to examine associations between institutional and interpersonal racial discrimination with LBW, and to test potential mediation by smoking during pregnancy. In 2012-2013, Romani women interviewers surveyed 410 Romani women in Serbia and Macedonia. We measured institutional discrimination (neighborhood segregation, legal status of housing and neighborhood socioeconomic status), interpersonal discrimination [Everyday Discrimination Scale (EDS)], birthweight and smoking by self-report or interviewer report. We estimated relative risks for discrimination on LBW and separately on smoking during pregnancy using log-binomial regression, adjusting for age, parity, years at residence and wealth. The indirect effect of high EDS via smoking on LBW was estimated using inverse odds weighting mediation. Living in a low SES neighborhood showed a 2-fold risk of LBW [adjusted risk ratio (aRR) = 2.4, 95% CI = 1.2, 5.0]; aRRs for segregation and illegal housing were weaker (aRR = 1.8, 95% CI = 0.7, 4.3; aRR = 1.3, 95% CI = 0.6, 2.6, respectively). Institutional measures were not associated with smoking. High EDS was associated with LBW (aRR = 2.4, 95% CI = 1.1, 5.2) and smoking during pregnancy (aRR = 1.4, 95% CI = 1.1, 1.8); the indirect effect of EDS on LBW via smoking was not significant. Interpersonal discrimination and living in a low SES neighborhood were associated with LBW among Roma. Interventions to improve Romani health may benefit from a human rights approach.

Maternal and infant characteristics: differences and similarities between the Nordic countries and the US

Background

Data from the Nordic health care registers have been of great value in perinatal epidemiological research. It has been assumed that findings from the Nordic population (Denmark, Finland, Iceland, Norway, and Sweden) are applicable to other populations as well, including the population of the US.

Objective

To describe and compare maternal and infant characteristics between the Nordic and the American populations as recorded in the official statistics.

Materials and methods

This population-based study included data on all females who gave birth and their infants in the Nordic countries and the US. The data were obtained from the US National Center for Health Statistics and the official statistics data for the Nordic countries. The data from all six countries included births from 2006 to 2010.

Results

The mean maternal age at delivery was lower in the US than in the Nordic countries (27.5 vs 30.3 years). Cesarean sections (32.2% vs 17.9%), low birth weight (8.2% vs 4.8%), and preterm birth (12.3% vs 5.9%) were more common in the US than in the Nordic countries. Smoking during early pregnancy was slightly less common in the US compared with Nordic countries (9.8% vs 11.2%). Restricting the data from the US to females with a university degree, characteristics such as age at delivery, birth weight, and preterm deliveries were more in alignment with the Nordic data.

Conclusion

There are differences in some key maternal and neonatal characteristics between the Nordic countries and the US. However, some characteristics are related to socioeconomic status, suggesting that the Nordic data seem to be applicable to the part of the population in the US with a higher socioeconomic status.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Prevalence of smoking before and during pregnancy and changes in this habit during pregnancy in Northwest Russia: a Murmansk county birth registry study

Background

Smoking during pregnancy leads to adverse maternal and birth outcomes. However, the prevalence of smoking among women in Russia has increased from < 5 % in the 1980s to > 20 % in the 2000s. We conducted a registry-based study in Murmansk County, Northwest Russia. Our aims were twofold: (i) assess the prevalence of smoking before and during pregnancy; and (ii) examine the socio-demographic factors associated with giving up smoking or reducing the number of cigarettes smoked once pregnancy was established.

Methods

This study employs data from the population-based Murmansk County Birth Registry (MCBR) collected during 2006–2011. We used logistic regression to investigate associations between women’s socio-demographic characteristics and changes in smoking habit during pregnancy. To avoid departure from uniform risk within specific delivery departments, we employed clustered robust standard errors.

Results

Of all births registered in the MCBR, 25.2 % of the mothers were smokers before pregnancy and 18.9 % continued smoking during pregnancy. Cessation of smoking during pregnancy was associated with education, marital status and parity but not with maternal age, place of residence, and ethnicity. Women aged ≤ 20–24 years had higher odds of reducing the absolute numbers of cigarettes smoked per day during pregnancy than those aged ≥ 30–34 years. Moreover, smoking nulliparae and pregnant women who had one child were more likely to reduce the absolute numbers of cigarettes smoked per day compared to women having ≥ 2 children.

Conclusions

About 25.0 % of smoking women in the Murmansk County in Northwest Russia quit smoking after awareness of the pregnancy, and one-third of them reduced the number cigarettes smoked during pregnancy. Our study demonstrates that women who have a higher education, husband, and are primiparous are more likely to quit smoking during pregnancy. Maternal age and number of children are indicators that influence reduction in smoking during pregnancy. Our findings are useful in identifying target groups for smoking intervention campaigns.

Understanding Inequalities of Maternal Smoking--Bridging the Gap with Adapted Intervention Strategies

Women who are generally part of socially disadvantaged and economically marginalized groups are especially susceptible to smoking during pregnancy but smoking rates are underreported in both research and interventions. While there is evidence to support the short-term efficacy of nicotine replacement therapy (NRT) use in pregnancy, long-term abstinence rates are modest. Current health strategies and interventions designed to diminish smoking in pregnancy have adopted a simplified approach to maternal smoking-one that suggests that they have a similar degree of choice to non-pregnant smokers regarding the avoidance of risk factors, and overlooks individual predictors of non-adherence. As a result, interventions have been ineffective among this high-risk group. For this reason, this paper addresses the multiple and interacting determinants that must be considered when developing and implementing effective strategies that lead to successful smoking cessation: socioeconomic status (SES), nicotine dependence, social support, culture, mental health, and health services. Based on our review of the literature, we conclude that tailoring cessation programs for pregnant smokers may ultimately optimize NRT efficacy and reduce the prevalence of maternal smoking.

A Meta-Analysis of Maternal Smoking during Pregnancy and Autism Spectrum Disorder Risk in Offspring

The association between maternal smoking during pregnancy and autism spectrum disorder (ASD) risk in offspring has been investigated in several studies, but the evidence is not conclusive. We, therefore, conducted this meta-analysis to explore whether an association exists between maternal smoking during pregnancy and ASD risk in offspring. We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies of maternal smoking during pregnancy and ASD risk in offspring up to 10 June 2015. The random-effects model was used to combine results from individual studies. 15 observational studies (6 cohort studies and 9 case-control studies), with 17,890 ASD cases and 1,810,258 participants were included for analysis. The pooled odds ratio (OR) was 1.02 (95% confidence interval (CI): 0.93-1.13) comparing mothers who smoked during pregnancy with those who did not. Subgroup and sensitivity analysis suggested the overall result of this analysis was robust. Results from this meta-analysis indicate that maternal smoking during pregnancy is not associated with ASD risk in offspring. Further well-designed cohort studies are needed to confirm the present findings.