Smoking in Pregnancy: Causes and consequences

1
Smoking in PregnancyCauses and consequences

• Kate E. Pickett, PhD
• Department of Health Sciences
• University of York
• Hull-York Medical School

2
Prevalence and Patterns

• 32 women smoke in year before pregnancy
• Half quit just before or during pregnancy
• 17 are persistent smokers
• Most who quit, relapse
• Patterns are complex

3
Changes in smoking status among women who
reported any pregnancy smoking in NHIS-S
Pickett KE, Wakschlag LS, Leventhal BL.
Fluctuations in maternal smoking during
pregnancy. Obstetrics and Gynecology
2003101140-7.
4
Fluctuations in self-reported smoking during
pregnancy for 4 women in the FHDP
Pickett KE, Wakschlag LS, Leventhal BL.
Fluctuations in maternal smoking during
pregnancy. Obstetrics and Gynecology
2003101140-7.
5
Fluctuations in smoking intensity in MISSEB
Pickett KE, Rathouz PJ, Kasza K,, Wakschlag LS,
Wright RJ. Self-reported smoking, cotinine levels
and patterns of smoking in pregnancy. Paediatric
and Perinatal Epidemiology 199519368376 .
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Marital status
Kiernan, K, Pickett KE. Marital status
disparities in maternal smoking during pregnancy,
breastfeeding and maternal depression. Social
Science and Medicine 200663335-346
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Interpersonal problems
Wakschlag LS, Pickett KE, Middlecamp M, Walton L,
Leventhal BLL. Pregnant smokers who quit,
pregnant smokers who cant Does history of
problem behavior make a difference? Social
Science and Medicine 2003562449-2460.
8
Pickett K.E, Wilkinson RG, Wakschlag
LS (Forthcoming) The psychosocial context of
pregnancy smoking and quitting in the
Millennium Cohort Study.
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Odds ratios for smoking during pregnancy by
neighbourhood social class
Pickett KE, Wakschlag LS, Rathouz P, Leventhal B,
Abrams B. The working class context of pregnancy
smoking. Health and Place 20028167-175.
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Consequences infancy

• Congenital malformations
• Cleft lip, cleft palate
• Limb reductions
• Genitourinary tract
• Low birth weight
• Preterm delivery, RR1.5-2
• Foetal growth restriction
• ETS also a risk

• Infant mortality
• RR1.4 for first month
• Risk higher after 1 month and among heavy smokers
• Sudden Infant Death Syndrome
• RR2-3

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Consequences childhood

• Lung function and respiratory illness
• Persists into adulthood
• RR1.3-2 for wheezing
• RR1.8 for asthma
• Respiratory tract infections
• Obesity
• Higher BMI despite lower birth weight

• Diabetes
• Type II, dose response relationship
• RR4.5 for heavy smoking
• Cancer
• Brain tumours
• Leukemia
• Lymphoma
• Chromosomal instability and damage

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Understanding the impact of smoking in pregnancy
on intellectual development and behaviour of
offspring
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Population Attributable Risk
WAKSCHLAG, L. S., LEVENTHAL, B. L., COOK, E.
PICKETT, K. E. (2000) Intergenerational health
consequences of maternal smoking. The Economics
of Neuroscience (TEN), 2, 47-54.
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Methodological Issues

• Randomized controlled trials
• Confounding
• Domains
• Socio-demographic
• Parental psychiatric factors
• Parenting and quality of home environment
• Perinatal and child factors
• Causal criteria temporality, consistency,
  strength of association, dose-response,
  biological plausibility

WAKSCHLAG, L. S., PICKETT, K. E., COOK, E., JR.,
BENOWITZ, N. L. LEVENTHAL, B. L. (2002)
Maternal smoking during pregnancy and severe
antisocial behavior in offspring a review. Am J
Public Health, 92, 966-74.
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Advances in measurement

• Comparing recall to prospective measurement
• Missed smokers vs. smokers
• Older
• Less likely to own their own home, be married,
  have low emotional health, problems with drug use
• Significantly lower scores of Conduct Disorder
  symptoms in offspring
• Undisclosed smokers vs. non-smokers
• More likely public benefits, low self-rated
  health, live in violent neighbourhood
• Less likely to own their home, be married
• Combined best estimate measure
• Can detect significant effects of 3rd trimester
  exposure on brainbody ratio

PICKETT, K. E., KASZA, K., BIESECKER, G., WRIGHT,
R. J. WAKSCHLAG, L. S. (Forthcoming) Women who
remember, women who dont maternal recall of
smoking in pregnancy. PICKETT, K. E., RATHOUZ, P.
J., DUKIC, V., KASZA, K., NIESSNER, M., WRIGHT,
R. J. WAKSCHLAG, L. S. (In press) The complex
enterprise of modelling prenatal exposure to
cigarettes What is enough? Paediatr Perinat
Epidemiol.
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Adjusted effects of smoking on temperament at 9
months
OR
P0.01
P0.02
P0.01
PICKETT, K. E., WOOD, C., ADAMSON, J., DESOUZA,
L. WAKSCHLAG, L. S. (2008) Meaningful
differences in maternal smoking behaviour during
pregnancy implications for infant behavioural
vulnerability. J Epidemiol Community Health, 62,
318-24.
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Adjusted effects of smoking on behaviour in
toddlers
WAKSCHLAG, L. S., LEVENTHAL, B. L., PINE, D. S.,
PICKETT, K. E. CARTER, A. S. (2006) Elucidating
early mechanisms of developmental
psychopathology the case of prenatal smoking and
disruptive behavior. Child Dev, 77, 893-906.
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Adjusted effects of smoking on behaviour at 3
years
OR
Plt0.05
Plt0.05
HUTCHINSON, J., PICKETT, K. E., GREEN, J.
WAKSCHLAG, L. S. (Forthcoming) The effect of
smoking in pregnancy on behavioural problems at
age 3 an analysis of the UK Millennium Cohort
Study by gender.
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Adjusted effect of smoking on age at onset of
delinquency
WAKSCHLAG, L. S., PICKETT, K. E., KASZA, K. E.
LOEBER, R. (2006) Is prenatal smoking associated
with a developmental pattern of conduct problems
in young boys? J Am Acad Child Adolesc
Psychiatry, 45, 461-7.
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Interaction of MAOA X Exposure Predicting Conduct
Symptoms
WAKSCHLAG, L., et al. (Forthcoming) Interaction
of prenatal exposure to cigarettes and MAOA
genotype in pathways to youth antisocial behavior.
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Implications

• Policy
• Need to understand how women understand risk
• Need to understand how policy and practice
  guidelines incorporate new knowledge

• Practice
• Heavy smokers are unlikely to benefit from
  usual-care antenatal smoking cessation programmes
• Need more intensive and targeted interventions.