Health Promotion International, Vol. 16, No. 4, 355-365,
December 2001
© Oxford University Press 2001
Determinants of smoking and cessation during and after pregnancy
Centre for Public Health Research, Queensland University of Technology, Kelvin Grove, Queensland 4059, Australia
Address for correspondence: Ying Lu Centre for Public Health Research Queensland University of Technology Kelvin Grove Queensland 4059 Australia E-mail: Y0.lu{at}qut.edu.au
SUMMARY
Smoking during pregnancy is harmful to both the foetus and the woman herself. However, in spite of educational efforts, a substantial proportion of pregnant women continue to smoke and many women who do stop smoking during pregnancy resume smoking following childbirth. To foster successful maternal smoking cessation, public health professionals need to focus on the major determinants of smoking and cessation during and after pregnancy, and then to address these with their intervention efforts. It is important to review contemporary epidemiological evidence on this significant public health issue. We have identified nine cohort studies, published in international peer-reviewed journals, that have examined determinants of smoking and cessation in pregnant women. The results indicate that the determinants of pregnant smoking and cessation include maternal age, dose and duration of smoking, partner's smoking habit, socioeconomic status, level of eduction, age to start smoking, level of addiction, parity and passive smoking. However, many other psychosocial factors, which may affect smoking status among pregnant women, remain to be identified. Evidence reviewed here suggests that a more focused, integrated approach and a more comprehensive assessment of major determinants of smoking and cessation during pregnancy will be required as part of any future intervention effort.
Key words: cessation; determinants; pregnant women; smoking
INTRODUCTION
The epidemiological studies over the past 35 years have identified smoking during pregnancy as exerting an independent, adverse effect on a variety of reproductive and other health outcomes (Dolan-Mullen et al., 1994
). Parental smoking also has harmful effects on children's health, especially on the respiratory system (NHMRC, 1997). In 1980, the US Surgeon General stated that smoking during pregnancy is the single most important preventable cause of foetal loss (USDHS, 1980). Research has identified a wide range of health effects associated with smoking during pregnancy, including childhood cancer and cognitive deficits (Simpson et al., 1957; Stewart et al., 1958; Dunn et al., 1976; Naye et al., 1984; Nylander, 1986; Matheson and Nylander, 1989; Callan and Witter, 1990; Haglund and Cnattingius, 1990; John et al., 1991; Kandall and Gaines, 1991; Pershagen et al., 1992; Tong and McMichael, 1992; Raymond et al., 1994). Thus, there is a particularly strong case for public health action to reduce and prevent smoking among pregnant women.
In Connecticut, according to the 1988 Behavioral Risk Factor Surveillance System (BRFSS), 25.8% of women reported that they were current cigarette smokers (CDC, 1990). The 1989 BRFSS findings indicate an even higher smoking prevalence rate (34.8%) among women of reproductive age between 18 and 44 years old (CDC, 1991). Nationwide data from birth certificates revealed that 19.1% of women reported smoking during their pregnancy, although this rate varied with socioeconomic status (CDC, 1992). Internationally, the smoking rate among pregnant women in Norway in 1987 was around 35%, and 82% did not change their smoking habits during pregnancy (Peen et al., 1991). In the same year, Sweden had a smoking prevalence of 28% among pregnant women (Cnattingius et al., 1992). In Finland, 21% of the pregnant women smoked (Bardy et al., 1994). In Canada and England, 30–40% of pregnant women have been found to smoke in early pregnancy (Stewart and Dunkley, 1985; Madeley et al., 1989). In Australia, 34.2% of women at the first clinic visit were identified as smokers (Kendrick and Merritt, 1996). It was estimated that smoking during pregnancy causes 7% of perinatal mortality and 23% of low birth weight in Australia (English et al., 1995).
It is well known that smoking during pregnancy is harmful to both the foetus and pregnant women themselves. However, in spite of educational efforts, a substantial proportion of pregnant women continue to smoke, and many who do stop smoking during pregnancy resume smoking after delivery (Stewart and Dunkley, 1985; Madeley et al., 1989). It has also been reported that smoking during pregnancy may be associated with such characteristics as social status, level of education, age to start smoking, level of addiction, parity and passive smoking (Stewart and Dunkley, 1985; Madeley et al., 1989; Oakley, 1989).
Most intervention programmes to assist smoking women to quit have yielded moderate effects, and a recent review found that smoking cessation programmes in pregnancy appear to reduce smoking, low birthweight and pre-term birth (Lumley et al., 1999). However, studies have confirmed the difficulty of maintaining post-partum non-smoking status (Dolan-Mullen et al., 1994; Dolan-Mullen et al., 1997; Mcbride et al., 1999). Smoking interventions usually rely on information and personal advice being given to women during pregnancy. The family and social situation, and especially the partner's smoking habits may be of importance for changes in women's smoking behaviour. Studies prior to the mid-1980s suggested that the proportion of smokers who quit by the time of their first antenatal visit was around 18% (Lumley, 1987). Some studies (Rubin et al., 1986; Kleinman and Kopstein, 1987; Wakefield and Jones, 1991) suggest that this proportion is increasing and the US Surgeon General (1990) has estimated that ~30% of US women who are cigarette smokers spontaneously quit after becoming aware of their pregnancy. Other studies have shown that 11–48% of pregnant women cease smoking at some stage during their pregnancy (McKnight and Merret, 1986; Cnattingius and Thorslund, 1990; Cnattingius et al., 1992; Isohanni et al., 1995; Thue et al., 1995; Mas et al., 1996; Nafstad et al., 1996; Morales et al., 1997; Eriksson et al., 1998; Najman et al., 1998). However, research from England indicates that the prevalence of smoking in pregnancy and the rates of quitting during pregnancy have not changed significantly over the past 10 years (Owen et al., 1998). There is also evidence indicating that spontaneous quitters are different from women who said they were still smoking, in a range of demographic variables and measures of addictive behaviour (Panjari et al., 1997).
To foster successful maternal smoking cessation, public health professionals need to focus on the major determinants of smoking and cessation during and after pregnancy, and then to address these with their intervention efforts. This paper reviews contemporary epidemiological evidence on this important public health issue, and discusses methodological and other issues, which need to be considered in future studies.
METHODS FOR LITERATURE SEARCHING AND EVALUATION
Cross-sectional studies suggest that a variety of sociodemographic and psychological factors are associated with smoking and/or cessation before, during and after pregnancy (Kleinman and Kopstein, 1987; Fingerhut et al., 1990; Oldenburg and Pope, 1990; King et al., 1993; Forrest et al., 1995; Steyn et al., 1997). However, cross-sectional studies are clearly vulnerable to bias (e.g. selection bias and information bias), due to the inherent limitations of such a research design (Rothman and Greenland, 1998). It remains unclear about the extent to which these cross-sectional findings have been substantiated by relevant longitudinal cohort studies, as well as the relative importance of these factors in determining smoking/cessation during and after pregnancy.
Nine cohort studies that assessed determinants of smoking and cessation in pregnant women were identified by using the following key words in various combinations: correlates, determinants, smoking, cessation, quitting, pregnancy; and the databases searched included Medline, Current Contents and PsycLIT. Of nine studies, two were conducted in Norway (Nafstad et al., 1996; Eriksson et al., 1998), one each was conducted in England (Morales et al., 1997), Northern Ireland (McKnight and Merret, 1986), Australia (Najman et al., 1998), Sweden (Cnattingius and Thorslund, 1990; Cnattingius et al., 1992), Finland (Isohanni et al., 1995) and Spain (Mas et al., 1996), and another multi-centre cohort study was conducted in a number of Scandinavian countries (Thue et al., 1995). These studies primarily examined the determinants of smoking during pregnancy, and a few of them assessed the smoking correlates both during and after pregnancy.
To evaluate the international evidence on correlates of pregnant smoking, we adopted and modified the framework that was proposed by Shiffman (Shiffman et al., 1986) and developed further by Oldenburg and Pope (Oldenburg and Pope, 1990). The potential determinants of pregnant smoking were grouped into seven categories: environmental, social, biological, psychological, personal, and demographic- and smoking-related factors. The following criteria were used in the assessment of evidence on correlates of pregnant smoking: +, a significant relationship was observed in 
2 studies; ++, a consistent and significant relationship was found in 3–4 studies; +++, a consistent and significant relationship was found in 5–6 studies; and –, no consistent relationship was observed.
Key determinants of smoking and cessation during and after pregnancy
The sample sizes of these cohort studies varied from 119 to 12 068 (McKnight and Merret, 1986; Cnattingius and Thorslund, 1990; Cnattingius et al., 1992; Isohanni et al., 1995; Thue et al., 1995; Mas et al., 1996; Nafstad et al., 1996; Morales et al., 1997; Eriksson et al., 1998; Najman et al., 1998). The major finding and critical aspects of these studies are presented in Table 1. Each study is described briefly below.
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Oslo Cohort Study (Norway) (Nafstad et al., 1996
)In this study, of 3039 pregnant women recruited, 31% smoked in early pregnancy, 23% in late pregnancy and 28% 1 year after delivery. Of those women smoking in early pregnancy, 44% stopped and of those who did not smoke, 7% started smoking during pregnancy. Of 685 smoking mothers at delivery, 90 (13%) stopped during the first year after childbirth, and among 2354 non-smoking mothers, 243 (10%) started smoking during the first year after childbirth. Multiple logistic regression analyses showed that risk factors for pregnant smoking included lower educational attainment, younger ages and a smoking cohabitant. The cessation rate in pregnancy among women who had a higher education and lived with a non-smoking cohabitant was seven times higher than that in those who had a lower education and lived with a smoking cohabitant. Breastfeeding, education and having a non-smoking cohabitant were associated with a long-term cessation.
Norwegian Multi-Centre Study (Eriksson et al., 1998)
A large number of pregnant women (4766) were recruited in this prospective study. The prevalence of smoking among these women were 34 and 21% 3 months before pregnancy and at 18 weeks of pregnancy, respectively. Multivariate analyses revealed that a low number of cigarettes smoked per day during the last 3 months before pregnancy was the best predictor for smoking cessation (e.g. the women who smoked less than five cigarettes per day were 18 times more likely to stop smoking in early pregnancy than those who smoked 20 cigarettes or more). Educational level, maternal age, parity and civil status (single or living with a cohabitant) were also statistically significant contributors to smoking cessation.
London Cohort Study (UK) (Morales et al., 1997)
One-hundred-and-nineteen pregnant woman who had their first babies were recruited in early pregnancy from a General Hospital Obstetric Service in London, and were followed up throughout the pregnancy and then until 4 years after the birth of the baby. The prevalence of smoking was 23.5, 23.7 and 24.3% at 12, 24 and 36 weeks, respectively. There was a significant difference in socioeconomic groups by occupation. Smokers and their husbands were more often in the working class, while others were more often in a group of professionals. But there were no significant differences between smokers and non-smokers in age and working status during pregnancy. It is interesting to note that there were significant differences between smokers and non-smokers with respect to variables associated with fertility and subfertility. More smokers spent a year or more trying to get pregnant. Smokers were more likely to have had previous miscarriages and/or terminations than non-smokers (p < 0.001).
Belfast Cohort Study (Northern Ireland) (McKnight and Merret, 1986)
In the Queen's University of Belfast study, 380 pregnant women were investigated. Of these, 191 (50.3%) were smokers, only 11.5% of which stopped smoking after becoming pregnant. Smokers were in the lower social class (
2 = 37.6, p < 0.001) had fewer educational qualifications (2 = 27.4, p < 0.001) and were less likely to be in employment (2 = 19.5, p < 0.001) than non-smokers. The partners of smokers were more likely to smoke than those of non-smokers (69.6 vs 33.7%). This study also shows that nearly 65% of smokers knew that smoking could have an effect on the baby and 76.5% of these women knew that the effect might be a reduction in birth weight. A further 14.6% thought that smoking could cause some other problems, such as prematurity, miscarriage and handicap, yet only 11.5% of smokers actually stopped smoking. The study found that only 19.4% of smokers claimed that their general practitioner had discussed smoking with them, and less than half of the smokers claimed that their obstetrician had discussed their smoking habit with them.
Mater University Study of Pregnancy (Australia) (Najman et al., 1998)
Among 8556 consecutive patients attending for their first clinic visit at a large public hospital between 1981 and 1984, 7689 delivered their babies at the study hospital and 5147 remained in the study at the 5-year follow-up. Of these who remained in the cohort, 2326 (45.2%) reported they had smoked cigarettes before becoming pregnant. At the first clinic visit, 1759 (34.2%) continued to smoke, while 681 (38.7%) had stopped smoking. One-hundred-and-thirty-four (19.7%) who had stopped smoking were heavy smokers (
20 cigarettes/day). There were similar rates of maternal heavy smoking before pregnancy and at 6 months and 5 years after the birth. Also they reported that women in the lowest family-income group (estimated income of $4144 per year) had the highest rates of cigarette use before, during and after pregnancy. Smoking cessation rates were highest in the highest family-income group (those who smoked least), but relapse rates after the birth were similar for all income groups.
The Uppsala Prospective Study (Sweden) (Cnattingius and Thorslund, 1990; Cnattingius et al., 1992)
In this study, 96% (n = 3678) of all pregnant women in Uppsala in 1987 were investigated. Thirty-two per cent (n = 1160) of the women reported that they were daily smokers at the time of conception. At the first antenatal care appointment, 23% (n = 263) had quit smoking. Factors that were most strongly associated with smoking at time of conception were young age, involuntary unemployment, low education, not cohabiting with the infant's father and whether other people smoked daily at home. Among women employed at the time of interview (n = 3065), smoking at time of conception was also more prevalent if co-workers smoked. Logistic regression models indicate that low education, women not cohabiting with the infant's father and women exposed daily to other people's smoking at home were significantly at risk of smoking at the time of conception. Major reasons for stopping smoking in early pregnancy were concern about maternal and infant health (89%), nausea (31%) and cigarettes not tasting good (12%).
Northern Finland Longitudinal Study (Isohanni et al., 1995)
Data on maternal smoking, social background and the family's development during the 21 years after delivery were gathered for a prospective cohort study of 12 068 pregnant women and their children in Northern Finland in 1966, and for a second birth cohort of 9362 mothers in 1985– 1986. The study found that the prevalence of smoking during pregnancy was 22% in 1966 and 29% in 1985–1986. Forty-eight per cent (1966) and 38% (1985–1986) of the smokers quit during pregnancy. Twelve per cent (1966) and 18% (1985–1986) of women continued smoking through their pregnancy. These results showed that mothers <23 years of age not only smoked more often than the older ones, but also quit more often, especially in the 1966 cohort. The primiparous mothers also smoked and quit more often than the multiparas. Also, urban residents smoked more often than women living in rural areas, especially in 1966. The mothers in low social classes, not married, minimally educated and employed smoked more often than those in either a high social class or a farmer, who were married, better educated and housewives. Mothers in gainful employment or with high education seemed to quit more often during pregnancy.
The Valencia Longitudinal Study (Spain) (Mas et al., 1996)
Of 593 pregnant women who carried out paid work during pregnancy and were personally interviewed in the maternity hospital, 62% of them smoked before pregnancy. Of these, 26.1, 35.1 and 38.8% smoked <10, between 10 and 19, and 20 cigarettes per day, respectively. Overall, 28% gave up smoking during pregnancy. Giving up smoking during pregnancy is more common among women of between 26 and 30 years of age [odds ratio (OR) = 2.1], those with a secondary level of education (OR = 2.6) and those with low cigarette intake (i.e. 1–9 cigarettes per day). The majority of pregnant smokers (66%) smoked <10 cigarettes per day and only 6% smoked 20 cigarettes per day. The average tobacco intake in women who continued to smoke during pregnancy fell significantly (p < 0.001) from 16 cigarettes per day before pregnancy to seven cigarettes per day during pregnancy.
National Institute Children Health Human Development Study (multi-centre study) (Thue et al., 1995)
In this multi-centre cohort study (including Sweden and Norway), 775 smokers were recruited. Four-hundred-and-seventy-two (61%) smoked <15 cigarettes per day and 305 (39%) smoked 15 cigarettes per day. The results show that 145 (19%) had stopped smoking before delivery, 440 (57%) smoked 1–14 cigarettes per day and 190 (25%) were heavy smokers (>15 cigarettes/day). The more women smoked at the time of the conception, the less the probability of them quitting. While 26% of the women who smoked 1–14 cigarettes at conception stopped smoking, only 8% of the women who smoked 15 cigarettes quit (p < 0.001). Also, age <25 years, education 9 years, single state and poor economy were significantly associated with heavy smoking in the third trimester. The study also found that 59% of single mothers smoked heavily before delivery, compared with 20% of married and 29% of cohabitant mothers (p = 0.0006).
Many socio-psychological and demographic factors can influence smoking/cessation behaviour. The available evidence on correlates of smoking during and after pregnancy is summarized in Table 2. The determinants of smoking during pregnancy include maternal age, dose and duration of smoking, parity, partner's and/or friends' smoking habits, educational attainment and socioeconomic status. Relatively few cohort data are available on smoking during the postpartum period, but there is evidence suggesting several key correlates of smoking after pregnancy, i.e. dose and duration of smoking before postpartum period, non-breastfeeding, less awareness of the effect of passive smoking on the infant, and partner's and/or friends' smoking habits. Compared with the framework proposed by Shiffman and modified by Oldenburg and Pope, it is evident that only a small proportion of the smoking factors has been investigated in the prospective studies. Many other factors, such as environmental, psychological, biological and personal aspects, may also influence pregnant smoking status, but they have not yet been thoroughly investigated.
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DISCUSSION
This review of epidemiological evidence on smoking and pregnancy is suggestive of a variety of sociodemographic factors that are associated with smoking and cessation, including maternal age, dose and duration of smoking, age to start smoking, partner's and/or friends' smoking habits, educational attainment and socioeconomic status. These factors are similar to determinants of smoking in other population subgroups (Oldenburg and Pope, 1990). However, many other psychosocial factors that may affect smoking status among pregnant women remain to be identified. It is important to assess the whole spectrum of key determinants of smoking and cessation in future research, but in particular those that are specifically relevant to this subpopulation group of pregnant women.
Methodological issues
Key methodological issues, which need to be addressed in future longitudinal studies, include: (i) comparability; (ii) the potential bias due to misclassification and/or failure to follow-up; (iii) confounding effects; (iv) interactive effects; and (v) the problem of relapse.
Comparability
The cohort studies reviewed above are not directly comparable for the following reasons. (i) Most of these studies were not specifically designed to investigate the determinants of smoking during and after pregnancy, and therefore their research objectives and methodologies varied substantially. (ii) The target populations were different (Cnattingius and Thorslund, 1990; Cnattingius et al., 1992; Thue et al., 1995; Mas et al., 1996; Eriksson et al., 1998). (iii) The study sample sizes varied from 119 (Morales et al., 1997) to 12 068 pregnant women (Isohanni et al., 1995). (iv) Observations were made at different points of time and the period of follow-up differed markedly between these cohort studies. And finally, (v) different statistical methods were used in data analyses. In future research, clearly, efforts should be made on the standardization of outcome measures (e.g. self-reported smoking status plus biochemical validation) and observation time-points [e.g. at the time of conception, first clinical visit (i.e. pregnant for 12–15 weeks), at delivery, and at 1, 6 and 12 months after delivery]. These efforts would substantially improve the comparability of studies.
The potential bias due to misclassification and/or failure to follow-up
All these cohort studies obtained information on smoking status through a questionnaire. None of them has used any biochemical measures to verify information on smoking habits, although the literature demonstrates the importance of biochemical validation for this particular population (Apseloff et al., 1994; Panjari et al., 1997). Thus, the potential for misclassification bias cannot be ruled out. Furthermore, the nature, direction and magnitude of the potential bias due to failure to follow-up were not formally evaluated, although the proportion of the cases in which follow-up was not conducted varied markedly between these studies.
Confounding
Since most of these studies were not specifically designed to investigate the determinants of pregnant smoking, there is generic insufficiency in considering, measuring and identifying confounding factors. Many cohort studies considered only a limited number of potential determinants of pregnant smoking (Table 1
), although there is evidence that smoking habit can be influenced by many sociodemographic and psychological factors (Oldenburg and Pope, 1990). The potential confounding effects of these factors on the assessment of the determinants of smoking have not been well understood.
Interactive effects
There is little information available about relative importance and possible interactive effects of sociodemographic and psychological factors in the modification of smoking behaviour.
The problem of relapse
The outcome of smoking cessation has traditionally been seen as a simple dichotomy, i.e. the subjects are classed as either smokers or quitters. As research into smoking behaviour has advanced, the problems of relapse and recidivism have been increasingly recognized. There is clear evidence that the relapse rate of smoking after pregnancy is considerably high (Wakefield and Jones, 1991; Dolan-Mullen et al., 1997; Najman et al., 1998). Many cohort studies did not address this issue adequately, partly because they were not designed to do so, and thus missed the opportunity to understand key factors in relation to the maintenance of smoking abstinence in both the short and long term.
Implications for smoking intervention among pregnant women
Despite the enormous health costs attributable to smoking during and after pregnancy, little is still known about how health care providers might best go about helping pregnant women to stop smoking and maintain smoking abstinence (Floyd et al., 1993; Walsh and Redman, 1993). Although the contemporary evidence suggests that prenatal smoking interventions are generally effective in terms of rates of smoking cessation, with quit rates ranging from 4.9 to 31.9% (Dolan-Mullen et al., 1994; Mcbride et al., 1999), the relative effectiveness of specific components of interventions and sustainability of smoking cessation after pregnancy remains unclear. There is an urgent need for further research and more effective smoking intervention programmes. In order to develop appropriate strategies for cessation programmes for this target population, it is vitally important to identify and evaluate further the epidemiological evidence regarding the major determinants of smoking and cessation during and after pregnancy.
Evidence reviewed here suggests that a more focused and integrated approach, and a more comprehensive assessment of major determinants of pregnant smoking and cessation will be required in future studies. Although there are several methodological limitations in previous research, the data from cohort studies do indicate that psychosocial factors are among the key determinants of pregnant smoking and cessation. Several studies revealed a few factors that were independently associated with long-term cessation—having previously quit for >1 week, high confidence that they could maintain non-smoking, having a non-smoking partner, and believing that the children of smokers are more likely to get infections (Wakefield and Jones, 1991; Dolan-Mullen et al., 1997). These findings may have several important implications for planning pregnant smoking cessation programmes. First, epidemiological evidence suggests that cessation programming should begin as early as possible and continue throughout the whole ante- and post-natal period. Secondly, it might be more effective if intervention programmes target various groups of women using different approaches. For example, minimal contact programmes are less successful in women with lower socioeconomic status than in those in higher social classes (Floyd et al., 1993). Successful intervention programmes that target women in lower social classes may need more intensive and multicomponent interventions. Thirdly, the partner's smoking status is a key determinant of both smoking during pregnancy and cessation. However, previous intervention programmes have hardly taken this factor into account (Floyd et al., 1993; Dolan-Mullen et al., 1994). Involvement of partners should be incorporated in future pregnant smoking intervention programmes. Finally, the relapse rate is considerably high after pregnancy (Wakefield et al., 1991; Dolan-Mullen et al., 1997; Najman et al., 1998). Women who resume smoking after delivery may be less aware of the effect of passive smoking on the infant. Therefore, it is necessary to increase the awareness of this problem among mothers after the child's birth.
The challenge that epidemiologists, behavioural scientists and other health professionals confront is how to integrate contemporary epidemiological evidence on major determinants of pregnant smoking with our knowledge of theories about the cessation process. Clearly, the comprehensive assessment of key determinants of pregnant smoking and cessation is essential and then concerted efforts are required to develop appropriate strategies for cost-effective intervention programmes among pregnant women.
ACKNOWLEDGEMENTS
Ms Ying Lu is supported by Owen J. Wordsworth Memorial Scholarships at the Queensland University of Technology.
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