Isolation, Marginalisation and Disempowerment – Understanding How Interactions with Health Providers Can Influence Smoking Cessation in Pregnancy

BackgroundMaternal smoking during pregnancy can lead to serious adverse health outcomes for both women and their infants. While smoking in pregnancy has declined over time, it remains consistently higher in women with lower socioeconomic circumstances. Furthermore, fewer women in this group will successfully quit during pregnancy. AimThis study explores the barriers to smoking cessation experienced by socially disadvantaged pregnant women and investigates how interactions with health providers can influence their smoking cessation journey.Methodsomen (either pregnant or birthed in the previous 10 years, who smoked or quit smoking in pregnancy) were recruited from a metropolitan public hospital antenatal clinic in South Australia and community organisations in surrounding suburbs. Seventeen women participated in qualitative semi-structured small focus groups or interviews. The focus groups and interviews were recorded, transcribed and thematically analysed. FindingsFour interconnected themes were identified: 1) smoking embedded in women’s challenging lives and pregnancies, 2) cyclic isolation and marginalisation, 3) feeling disempowered, and 4) autonomy and self-determination. Themes 3 and 4 are characterised as being two sides of a single coin in that they coexist simultaneously and are inseparable. A key finding is a strong unanimous desire for smoking cessation in pregnancy but women felt they did not have the necessary support from health providers or confidence and self-efficacy to be successful.ConclusionWomen would like improvements to antenatal care that increase health practitioners’ understanding of the social and contextual healthcare barriers faced by women who smoke in pregnancy. They seek assistance from health providers to make informed choices about smoking cessation and would like women-centred care. Women feel that with greater support, consistency and encouragement from health providers they could be more successful at antenatal smoking cessation.

Smoking influence on early and late fetal growth

Objectives Smoking during pregnancy is a leading and modifiable risk factor for fetal growth restriction (FGR) and low birthweight (<10th centile). We studied the effects of smoking in the development of early and late FGR or low birthweight, as well as in uteroplacental and fetoplacental hemodynamics of growth-restricted fetuses. Methods Retrospective cohort study of 5,537 consecutive singleton pregnancies delivered at ≤34 + 0 (“early delivery” group, n=95) and >34 + 0 (“late delivery” group, n=5,442) weeks of gestation. Each group was divided into smokers and non-smokers. Prenatal diagnosis of FGR was based on customized fetal growth standards and fetal Doppler, and postnatal birthweight was assessed using the Olsen newborn chart. Results There were 15/95 (15.8%) and 602/5,442 (11.1%) smokers in the early and late delivery groups, respectively. In early deliveries, FGR was diagnosed in 3/15 (20%) of smokers and in 20/80 (25%) of non-smokers (p=0.68). We also found no differences in birthweights and hemodynamics. In late deliveres, FGR was detected in 30/602 (5%) smokers and 64/4,840 (1.3%) non-smokers (p<0.001). Birthweights <3rd centile and <10th centile were more common in smokers vs. non-smokers: 38/602 (6.3%) vs. 87/4,840 (1.8%) and 89/602 (14.8%) vs. 288/4,840 (6%), respectively (all p<0.01). Fetal Doppler of late FGR showed slightly higher umbilical artery resistances in smokers. Conclusions Smoking in pregnancy is associated with FGR, low birthweight and higher umbilical artery Doppler resistances after 34 weeks of gestation, but we could not confirm this association in earlier deliveries.

Improving Clinicians’ Implementation of Guidelines to Help Women Stop Smoking in Pregnancy: Developing Evidence-Based Print and Video Materials

Smoking in pregnancy remains a public health challenge. Our team developed a comprehensive intervention using the Behaviour Change Wheel to support clinicians’ implementation of guidelines on supporting women to stop smoking in pregnancy. Integral to the intervention was a suite of evidence-based video and print materials. This paper describes the rationale and process for developing these materials. Comprehensive mixed methods research was undertaken to identify the key barriers and enablers for clinicians in implementing the guidelines. This research identified which behaviours required change, and which behaviour change techniques were best suited to effecting that change. Materials were developed based on this understanding, in a collaborative process with multiple stakeholders, and their feasibility and acceptability explored in a small trial. Materials developed included leadership, clinician and client resources. There are considerable advantages to systematically and collaboratively developing materials which are integral to a behaviour-change intervention even though it is resource intensive to do so.

Maternal smoking during pregnancy and asthma during the first year of life: a comparative study between smokers and non-smoker mothers

Background: We investigated the relationship between maternal smoking in pregnancy and health care problems in the offspring during the first year of life, particularly asthma.Material and Methods: A cohort of 648 consecutive infants born at term and alive at Hospitalde Sagunto (Valencia, Spain) over one year period was followed for 12 months. Clinical data of the infants were prospectively collected from the database of ambulatory medical records (ABUCASIS) of the Valencia health system.Results: Smoking during pregnancy was recorded in 164 (25.3%) mothers. During the first year of life, asthma was diagnosed in 101 infants, with an incidence of 15.7%. The diagnoses of asthma (25.6% vs. 12.3%; P < 0.0001) and bronchiolitis (44.5% vs. 28.6%; P = 0.0002) during the first year of life were more common among infants in the smoking group. The probability of developing asthma during the first year of life was two-fold higher for the male gender and 2.5 times higher when mothers smoked while pregnant. Up to 52% of asthma cases could have been avoided in infants born to smoking mothers if they did not smoke during pregnancy. Infants in the smoking group showed a lower weight and length at birth than infants in the nonsmoking group differences almost disappeared at 6 months and 12 months.Conclusion: Asthma during the first year of life showed a clear relationship with maternal smoking in pregnancy. Pregnant women should be advised of the significant perinatal risk for respiratory diseases associated with tobacco use.

Changes in Smoking Habits in Pregnant Women During COVID-19 Pandemic. A Comparison of Two Cohorts

Background: Although smoking in pregnancy has well known deleterious effects, about 50% women who smoked out of the pregnancy continue to smoke while pregnant. The main is to study changes in smoking in pregnancy during covid-19 pandemic.Methods: We compare two cohorts of pregnant women: one recruited in 2018 (pre-pandemic cohort) and one recruited from March 2020 on (pandemic cohort).Results: The percentage of women who smoked decreased from 13% in the pre-pandemic cohort to 8% in the pandemic cohort (p<0.001). This step-down was similar in all age groups and both employed and unemployed/no active women. Among women in the pandemic cohort, those whose pregnancy began after March-2020 (when the pandemic was declared) reported 1% smoking prevalence, which is much lower than smoking prevalence in women whose pregnancy began before the pandemic was declared.Conclusion: Smoking was less frequent in pregnancies during the covid-19 pandemic and even less frequent in women whose pregnancy began after the pandemic was declared. The effect that lockdown, stay-at-home orders or healthier behaviour habits could have had on smoking in pregnancy would require further research.Trial registration: The study was approved by the Clinical Research Ethics Committee of Cantabria (reference: 2020.174).

Ancestral smoking and developmental outcomes: A review of publications from a population birth cohort

The adverse effects on the child of maternal smoking in pregnancy is well-recognised, but little research has been carried out on the possible non-genetic effects of ancestral smoking prior to the pregnancy including parental initiation of cigarette smoking in their own childhoods or a grandmother smoking during pregnancy. Here we summarise the studies that have been published mainly using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). We demonstrate evidence that ancestral smoking prior to or during pregnancy can often be beneficial for offspring health and both ancestor- and sex-specific. More specifically, we report evidence of (i) adverse effects of the father starting to smoke pre-puberty on his son’s development; (ii) beneficial effects on the grandson if his maternal grandmother had smoked in pregnancy; and (iii) mainly adverse effects on the granddaughter when the paternal grandmother had smoked in pregnancy. The ancestor- and sex-specificity of these results is consistent with earlier studies reporting associations of health and mortality with ancestral food supply in their parents’ and grandparents’ pre-pubertal childhoods.

Electronic cigarette use (vaping) and patterns of tobacco cigarette smoking in pregnancy–evidence from a population-based maternity survey in England

Objectives Exposure to tobacco products during pregnancy presents a potential harm to both mother and baby. This study sought to estimate the prevalence of vaping during pregnancy and to explore the factors and outcomes associated with vaping in pregnancy. Setting England. Participants Women who gave birth between 15th and 28th October 2017. Methods A cross-sectional population-based postal survey of maternal and infant health, the National Maternity Survey (NMS) 2018. The prevalence of vaping and patterns of cigarette smoking were estimated, and regression analysis was used to explore associations between maternal characteristics and vaping, and between vaping and birth outcomes. Outcome measures Unweighted and weighted prevalence of vaping with 95% confidence intervals, and unadjusted and adjusted relative risks or difference in means for the association of participant characteristics and secondary outcomes with vaping. Secondary outcome measures were: preterm birth, gestational age at birth, birthweight, and initiation and duration of breastfeeding. Results A total of 4,509 women responded to the survey. The prevalence of vaping in pregnancy was 2.8% (95%CI 2.4% to 3.4%). This varied according to the pattern of cigarette smoking in pregnancy: 0.3% in never-smokers; 3.3% in ex-smokers; 7.7% in pregnancy-inspired quitters; 9.5% in temporary quitters; and 17.7% in persistent smokers. Younger women, unmarried women, women with fewer years of formal education, women living with a smoker, and persistent smokers were more likely to vape, although after adjusting for pattern of cigarette smoking and maternal characteristics, persistent smoking was the only risk factor. We did not find any association between vaping and preterm birth, birthweight, or breastfeeding. Conclusions The prevalence of vaping during pregnancy in the NMS 2018 was low overall but much higher in smokers. Smoking was the factor most strongly associated with vaping. Co-occurrence of vaping with persistent smoking has the potential to increase the harms of tobacco exposure in pregnant women and their infants.

Overweight in childhood and early adulthood is associated with parental Body Mass Index and perinatal risk factors

Background: To investigate the associations of pregnancy and pre-pregnancy parental characteristics on child’s weight and progression at the early adulthood. Material and Methods: Α random sample of 5,125 dyads children and their mothers was assessed. Mothers were asked to provide information contained in their medical booklets and pregnancy ultrasound records. With the use of a standardized questionnaire, telephone interviews were carried out for the collection of parental factors and offspring’s BMI. Results: Mother’s overweight (including obesity) before pregnancy was found to significantly increase the likelihoods of offspring’s overweight (including obesity) at the age of 8-9 years and 15-25 years (odds ratio (OR) 1.97; 95% confidence interval %CI: 1.65, 2.30 and OR 2.0; 95%CI: 1.67, 2.36, respectively). Paternal BMI (OR 1.41; 95% CI: 1.20–1.62), maternal smoking at pregnancy (OR 1.22; 95% CI: 1.14–1.30), gestational weight gain (OR 1.44; 95% CI 1.24–1.66), and gestational hypertension OR 1.30; 95% CI 1.14–1.49) were also found to significantly increase the odds of children’s obesity. Conclusion: Among prenatal factors considered, mother’s pre-pregnancy and father’s BMI, GWG, not breastfeeding, smoking in pregnancy and gestational hypertension increased the odds of offspring’s overweight/obesity in childhood and early adulthood, even after adjustment for several covariates.

Prenatal and prepubertal exposures to tobacco smoke in men may cause lower lung function in future offspring: a three-generation study using a causal modelling approach

Mechanistic research suggests that lifestyle and environmental factors impact respiratory health across generations by epigenetic changes transmitted through male germ cells. Evidence from studies on humans is very limited.We investigated multi-generation causal associations to estimate the causal effects of tobacco smoking on lung function within the paternal line. We analysed data from 383 adult offspring (age: 18–47; female: 52.0%) and their 274 fathers, who had participated in the ECRHS/RHINESSA generation study and had provided valid measures of pre-bronchodilator lung function. Two counterfactual-based, multi-level mediation models were developed with: paternal grandmothers’ smoking in pregnancy and fathers’ smoking initiation in prepuberty as exposures; fathers’ FEV1 and FVC, or FEV1/FVC z-scores as potential mediators (proxies of unobserved biological mechanisms that are true mediators); offspring's FEV1 and FVC, or FEV1/FVC z-scores as outcomes. All effects were summarised as differences in expected z-scores related to fathers’ and grandmothers’ smoking history.Fathers’ smoking initiation in prepuberty had a negative direct effect on both offspring's FEV1 (−0.36; 95% confidence interval: −0.63, −0.10) and FVC (−0.50; −0.80, −0.20) compared to fathers’ never smoking. Paternal grandmothers’ smoking in pregnancy had a negative direct effect on fathers’ FEV1/FVC (−0.57; −1.09, −0.05) and a negative indirect effect on offspring's FEV1/FVC (−0.12; −0.21, −0.03) compared to grandmothers’ not smoking before fathers’ birth nor during fathers’ childhood.Fathers’ smoking in prepuberty and paternal grandmothers’ smoking in pregnancy may cause lower lung function in offspring. Our results support the concept that lifestyle-related exposures during these susceptibility periods influence the health of future generations.