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Review

Smoking and Pregnancy — A Review on the First Major Environmental Risk Factor of the Unborn

by
Mathias Mund
1,
Frank Louwen
2,
Doris Klingelhoefer
1,* and
Alexander Gerber
1
1
Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
2
Department of Gynecology and Obstetrics, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2013, 10(12), 6485-6499; https://doi.org/10.3390/ijerph10126485
Submission received: 8 October 2013 / Revised: 12 November 2013 / Accepted: 13 November 2013 / Published: 29 November 2013
(This article belongs to the Special Issue Contemporary challenges in public health)
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Abstract

:
Smoking cigarettes throughout pregnancy is one of the single most important avoidable causes of adverse pregnancy outcomes and it represents the first major environmental risk of the unborn. If compared with other risk factors in the perinatal period, exposure to tobacco smoke is considered to be amongst the most harmful and it is associated with high rates of long and short term morbidity and mortality for mother and child. A variety of adverse pregnancy outcomes are linked with cigarette consumption before and during pregnancy. Maternal prenatal cigarette smoke disturbs the equilibrium among the oxidant and antioxidant system, has negative impact on the genetic and cellular level of both mother and fetus and causes a large quantity of diseases in the unborn child. These smoking-induced damages for the unborn offspring manifest themselves at various times in life and for most only a very limited range of causal treatment exists. Education, support and assistance are of high importance to decrease maternal and fetal morbidity and mortality, as there are few other avoidable factors which influence a child’s health that profoundly throughout its life. It is imperative that smoking control should be seen as a public health priority.

Graphical Abstract

1. Introduction

The fact that smoking cigarettes throughout pregnancy is one of the single most important avoidable cause of adverse pregnancy outcomes, resulting in severe short- and long-term negative effects for the mother and the unborn child has been proven by many different studies [1,2,3,4]. It can be regarded as the first major environmental risk factor that can be encountered by the unborn in the developed and undeveloped world. If compared with other risk factors in the perinatal period, exposure to tobacco smoke is considered to be amongst the most harmful. The byproducts of combustion are believed to inflict more damage on the fetus than the nicotine itself, but due to the complexity and number of dangerous substances it is unknown which toxic effect is caused by exactly which product [5]. This is especially significant as the majority of the smoking-induced harm for the unborn fetus is permanent. Even today modern medicine offers very little or no therapeutic treatments for the long-term negative consequences of being exposed to smoke in-utero [6]. According to a 2010 study from the USA, one of the most significant behavior changes a future mother can make is the complete cessation of smoking in pregnancy, with numerous health benefits for both the woman and her offspring [7].

2. Epidemiology and Risk Factors

In 1990 in Germany, a multicenter allergy study surveying 5,395 postpartum women concluded that 28.6% smoked during pregnancy [8]. These results are supported by a second German study from 2001–2002 investigating the cotinine-concentration in the urine of 323 pregnant women in the second trimester. Approximately one quarter of German future mothers smoked during pregnancy (Figure 1) [4], although the rate of smokers varies from state to state. From 1998–2000, the highest frequencies in Germany were observed in the states of Mecklenburg-Vorpommern and Hamburg, whereas the lowest rates were found in Saxony, Thuringia and Bavaria (Figure 2) [9]. In the first years of the new millennium the rate of smoking pregnant women in Germany declined further to approximately 20% [10].
Indicators of socio-economic status are an independent, reliable correlate of active smoking during pregnancy. Studies from Australia and Texas, USA indicated that low socio-economic status three or more times below the poverty line combined with the absence of health insurance increase the risk for smoking during pregnancy, regardless of ethnicity. The smoking rate among Australian women with low socio-economic position, both Aboriginal and non-Aboriginal, was on both occasions approximately two and a half times that of high socio-economic status Aboriginal and non-Aboriginal women [11,12]. Women exposing their unborn child to tobacco smoke were more likely not to be married to the child’s father [11]. Furthermore, women educated only up to high school standard were generally more likely to smoke during pregnancy [13,14,15]. Women employed in serving-related occupations and food preparation were considerably more likely to continue to smoke during pregnancy. They were at a greater risk for drinking alcohol while being pregnant as well. Additionally, women of this risk group showed tendencies to neglect early prenatal care in comparison to women in different occupational groups (Odds Ratio (OR) 1.8–3.0). Female scientist and managers, businesswomen, female artists and other women with higher education were much less likely to smoke during pregnancy compared to the general population of pregnant women (OR 0.2–0.5) [13].
Ijerph 10 06485 g001 1024
Figure 1. Written information on smoking behavior of 310 pregnant women in Berlin 2001–2002; with kind permission and modified after [4].
Figure 1. Written information on smoking behavior of 310 pregnant women in Berlin 2001–2002; with kind permission and modified after [4].
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Ijerph 10 06485 g002 1024
Figure 2. Smoking behavior of pregnant women in different German states 1998–2000; with kind permission and modified after [5].
Figure 2. Smoking behavior of pregnant women in different German states 1998–2000; with kind permission and modified after [5].
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Ethnic minorities often have an increased risk of smoking due to a variety of reasons. According to a Canadian study from 2011, 92% of pregnant Inuit women from Arctic Quebec smoked cigarettes [16]. Roma women in Eastern Europe were 5.2 times more likely (p < 0.01) to continue smoking during pregnancy instead of quitting (OR 0.32; 95% Confidence Interval (CI) 0.14–0.72) [17].

3. Decreased Fertility and Pregnancy Complications Due to Smoking

For women of childbearing age, active and passive smoking is linked to reduced fertility [18]. Several studies agree that smoking women were more likely to have an abortion, with the total rate of abortion increasing up to 33% [19,20,21,22]. A Japanese case-cohort analysis from 2001 to 2005 involving 180,855 pregnant women concluded that women smoking during pregnancy had statistically considerably elevated risks for various obstetric complications and their rate for stillbirth was estimated by a British study to be increased by 23% (Table 1) [23,24]. For example, a woman who smokes while being pregnant is more than 50% more likely to expose her unborn child to an infection within the womb in comparison to a non-smoker, as the smoker’s Absolute Risk Reduction (ARR) is 1.67 compared to the non-smoker.
Table
Table 1. Pregnancy complications due to smoking; modified after [23,24].
Table 1. Pregnancy complications due to smoking; modified after [23,24].
Pregnancy complicationARRORCI (95%)
Preterm rupture of membrane1.671.43–1.96
Chorioamnionitis1.651.36–2.00
Incompetent cervix1.631.35–1.96
Threatened premature delivery1.381.17–1.64
Placental abruption1.371.10–1.72
Pregnancy-induced hypertension1.201.01–1.41
Stillbirth1.231.09–1.38
Even though in this UK study none of the relations with specific congenital abnormalities were significant by themselves, the overall risk of giving birth to a child with a congenital malformation increased by 13% (OR1.13; 95% Confidence interval (CI) 1.01–1.26) [24].

4. Biochemical Changes and Alterations

The placenta is an important source of hormones, pro-oxidant agents and antioxidant enzymes and in a physiological pregnancy this vital organ is able to control lipid peroxidation [10]. Several studies concluded that maternal prenatal cigarette smoking disturbs the equilibrium among the oxidant and antioxidant system, thus causing additional oxidative stress and augmenting lipid peroxidation. Smoking during pregnancy increases the free radical damage to the unborn fetus as well as to the mother [10,25,26].

5. Smoking and Intrauterine Growth Retardation

Intrauterine growth retardation of the unborn child is the most important smoking-induced pathology [6]. Two studies from 1999 and 2006 associated maternal smoking with an augmented dose-dependent risk for not only adverse birth outcomes such as small-for-gestational age (SGA) and intra-uterine growth restriction but for preterm birth (Adjusted Odds Ratio (AOR) 1.42; 95% CI 1.27–1.59) for both male and female babies as well [2,27]. These findings are supported by numerous studies, which all concluded that children born to mothers who have smoked during pregnancy had significantly decreased birth weights when compared with offspring of non-smokers [28,29,30,31,32,33,34,35,36]. A Brazilian study about newborns exposed to tobacco smoke throughout pregnancy presented an average decrease in birth weight of 223.4 g (95% CI 156.7–290.0), a decrease in birth length of 0.94 cm (95% CI 0.60–1.28), and a decrease in head circumference of 0.69 cm (95% CI 0.42–0.95) [37]. Quitting smoking may have a greater impact on birth weight than refraining from illegal hard drug use, a study by the Quillen College of Medicine, USA examining 265 infants discovered. Among pregnant women who used hard illicit drugs and did not smoke, the adjusted mean birth weight increased 317 g compared to smokers who did not use any illegal drugs [6].

6. Alterations in the Genetic and Cellular Level

Smoking cigarettes has a tremendous negative impact on the genetic and cellular level of not only the mother but of the fetus as well, as numerous studies have proven. If certain genetic predispositions are present, the adverse effects of smoking during pregnancy are multiplied [30,32,38]. Genetic and epigenetic mechanisms in combination with cytogenetic damage are believed by a 2012 study from North Carolina, USA, to play an important role in the pathogenesis of malformations and adverse outcomes associated with smoking and pregnancy. In the study, methylation changes in a set of genes (Cytochrome P450 1A1 (CYP1A1), AHRR and GFI1) were present at birth in offspring whose mothers consumed tobacco during pregnancy. These genes seem to play an important role in the aryl hydrocarbon signaling pathway, which mediates the clearance and detoxification of the poisonous components of tobacco smoke [38].
In a Dutch study from May 2012 investigating the effects of smoking on the maternal immune system by examining first-trimester decidual tissue and peripheral blood, researchers concluded that mothers smoking during pregnancy have an altered local and systemic immune system. Using real-time reverse transcription-polymerase chain reaction, flow cytometry and immune-histochemical investigations, the study indicated that more natural-killer cells and inflammatory macrophages are present locally if the woman smokes cigarettes. According to the study smoking mothers have lower percentages of regulatory T-cells than pregnant women who do not smoke [30].

7. Diseases Caused by Smoking during Pregnancy

Cigarettes are legal poisons, which damage not only the health of the mother, but jeopardize the health of the unborn child as well. These smoking-induced damages for the unborn offspring manifest themselves at various times in life, some being clearly visible from birth on, others becoming evident only in the following generation. These diseases have one thing in common: the vast majority of them are permanent and for most only a very limited range of causal treatment exists. For many of these diseases only symptomatic therapeutic treatments are available at best [6].

7.1. Heart Diseases and Cardiovascular Diseases

The risk of fetal congenital heart defects has been shown by two studies to be at least partially linked to exposure to maternal smoking in early pregnancy or to be directly linked to maternal smoking during pregnancy for some specific subtypes [39,40].
A positive correlation between maternal smoking during pregnancy and the risk for congenital heart defects (Table 2) was observed by a study from Atlanta, GA, USA [41] and backed up by a British meta-analysis, which also detected a significant positive correlation between maternal cigarette smoking and fetal cardiovascular and heart defects (OR 1.09; 95% CI 1.02–1.17) (Table 2) [42]. Twelve of 17 subtypes of fetal congenital heart defects have been proven to be more closely associated to maternal cigarette consumption than the other five subtypes. In the study, these twelve subtypes accounted for 71% of fetal congenital heart defects. Fetal septal heart defects as a group were the highest risk for any subtype (Table 2). The incidence of septal defects as a group, atrial septal defects and atrioventricular-septal defects correlated directly with the number of maternal cigarettes smoked [43].
Table
Table 2. Smoking and fetal congenital heart defects; modified after [41,42,43].
Table 2. Smoking and fetal congenital heart defects; modified after [41,42,43].
Congenital heart defectRRORCI (95%)n
Congenital heart defects (total)1.111.091.02–1.2118,282
Septal heart defects1.441.16–1.792,977
Secundum-type atrial septal defects1.361.04–1.78
Right ventricular outflow tract defects1.321.06–1.65
Pulmonary valve stenosis1.351.05–1.74
Truncus arteriosus1.901.04–3.45
Transposition of the great arteries1.791.04–3.10

7.2. Hypertension and Kidney Diseases

Maternal cigarette smoking during pregnancy might also affect fetal kidney development. A dose-dependent relationship between the number of cigarettes consumed during pregnancy and fetal kidney volume was observed by a Dutch prospective cohort study of 1,072 children. Researchers found that maternal smoking of ten cigarettes per day correlated with a decreased fetal combined kidney volume compared to women who smoked less than five cigarettes per day (p = 0.002). This could predispose the offspring to the development of kidney disease and hypertension later in adult life [44].

7.3. Pulmonary Diseases

A study from Detroit, MI, USA, has shown that smoking and pregnancy is significantly linked with a decrease in pulmonary function in offspring later in life [43]. An important increase in pediatric hospitalization and mortality because of respiratory infections in early childhood independent of both birth weight and gestational age was associated by a retrospective case-control analyses of infants born in Washington State from 1987–2004 with having been exposed to maternal smoking in-utero (AOR 1.69; 95% CI 1.63–1.76) [26].
Studies from the New York University School of Medicine, USA and from the Karolinska Institute, Sweden, found that pregnant women who have smoked cigarettes increased the risk of wheezing and asthma for their children. If children have been exposed to maternal smoking in-utero, but not in the first year after birth, the AOR increased for wheeze and asthma. At the age of four to six years the OR increased to 1.39 for wheeze (95% CI 1.08–1.77) and 1.65 for asthma (95% CI 1.18–2.31). The likeliness to suffer from these two diseases in later childhood increased significantly in relation to the amount of exposure to maternal cigarette smoke in-utero during the first trimester of pregnancy [37,44].

7.4. Gastrointestinal Diseases

A Danish follow-up study of singleton infants concluded that maternal smoking during pregnancy increases the risk for infantile colic even after adjustment for factors like maternal age, birth weight, gestational age, breastfeeding and paternal smoking. A two-fold increased risk for infantile colic was observed in offspring of women who smoked at least 15 cigarettes per day during their pregnancy (Table 3) [45]. These findings are consistent with a study from the UK on non-chromosomal birth defects, which discovered that babies of mothers who have smoked during pregnancy were also at higher risk for gastrointestinal defects, gastroschisis and anal atresia (Table 3) [40].
Table
Table 3. Maternal smoking and gastrointestinal diseases in the offspring; modified after [42,45].
Table 3. Maternal smoking and gastrointestinal diseases in the offspring; modified after [42,45].
Gastrointestinal diseaseRRORCI (95%)
Gastrointestinal defects1.271.18–1.36
Infantile colic2.11.4–3.2
Gastroschisis1.51.28–1.76
Anal atresia1.21.06–1.36

8. BMI and Obesity

Multiple studies agree that maternal smoking during pregnancy harms linear growth, promotes increased Body Mass Index (BMI) in children and augments the risk for obesity in childhood and adult life [46,47,48,49]. Exposure to cigarettes in-utero causes increased mean BMI, pulse rate, waist circumference and waist-hip-ratio. Offspring of mothers who smoked at other times in the child’s life but not during their pregnancy have similar mean risk factors compared to children whose mothers never smoked. Among children of mothers who smoked during pregnancy, the degree of overweight children with an increased BMI is positively correlated with the duration of the maternal smoking, which is due to reduced height and increased amount of body fat [47,49,50,51].

9. Alterations in Neurology and Psychological Behavior

Early child neurodevelopment plays a key role in the potential of preserving human intelligence and health in the next generation, as stated in a study from the University of Iowa, USA [52]. Similarly, a review from Providence, RI, USA concluded that the various adverse aspects of long-term in-utero exposure to active and passive smoking on the neurological development of the child and its behavior have become the focus of a few investigations in recent years [53].
Maternal smoking during pregnancy has been linked to growth restriction and decrease in the size of the fetal brain by numerous studies. It has been proven that the density of important parts of the fetal brain, namely the cerebellum and the corpus callosum is diminished. A decrease in coordination within the different parts of the fetal brain during processing of information and a deceleration in the ability to adequately respond to external stimuli and subtly diminished motor competence predominantly on the non-dominant side have been shown by these studies [53,54,55].
In a 2011 Finish cohort study investigating various cognitive functions such as general reasoning, visual-motor integration, verbal competence and language comprehension in 1,019 infants, researchers found a pattern between heavy cigarette consumption prior to pregnancy with poorer cognitive executive function proficiency in the offspring. Interestingly, the results indicated a poorer performance of the offspring even if the woman had ceased smoking before conception. Children of mothers who smoked more than ten cigarettes per day before pregnancy but none during pregnancy scored 12.07 (95% CI 4.07–20.08) age-standardized points less in general reasoning and 11.23 (95% CI 2.81–19.66) age-standardized points less in language comprehension tests compared to children of mothers who never smoked [56]. Independent of maternal education levels offspring born to smoking mothers were also more probable to achieve less in math (OR 2.78; 95% CI 1.59–4.87) and reading (OR 2.00; 95% CI 1.10–3.63) compared to children of non-smokers [57].

10. Addiction

Pregnancy functions as a motivator to quit smoking and is a good time to stop smoking since pregnant women are more probable to be in an advanced phase of behavioral change. This was proven by a study from Philadelphia, PA, USA to be true even for pregnant nicotine- and opioid-dependent patients in substance abuse programs [58]. In a comparative study by the University of Padua, Italy pregnant women reported decreased levels of nicotine use and lower level of self-reported cigarette cravings reaching a statistically significant level in comparison to non-pregnant female patients [59].
Generally a low uptake of smoking cessation programs among pregnant females has been observed by many different studies. Pregnant females with high levels of nicotine dependence and several occupational groups such as women in serving-related occupations and in food preparation were the most unlikely socio-economic group to give up smoking during pregnancy or to take advantage of smoking cessation interventions [13,17,60,61]. In particular, smoking cessation programs for pregnant low-income smokers were for the most part unsuccessful, a study from Buffalo, NY, USA discovered [62].
Several studies indicated that even if the pregnant woman has been able to quit or reduce smoking, the smoking rate increased again after giving birth. During pregnancy, 45% of smoking women were able to quit smoking but at 24 weeks post-delivery only 34.6% of women remained abstinent and almost 80% continued to smoke within one year postpartum [3,63,64]. Unfortunately, quitting smoking during pregnancy was proven by a study from Vermont, GA, USA, investigating data from over 40,000 adults, not to be significantly connected to the smoking status three years later [65].

11. Therapy and Anti-Smoking Programs

Pregnant women who smoke welcome receiving advice on how to quit or reduce smoking from midwives, a comparative study from the UK discovered. Nevertheless, according to the study, they tend to have negative expectations of smoking cessation programs services, even though the experiences of those who have participated are positive [66]. A South African study on midwives concluded that the way in which medical personal communicate about the issue of smoking and pregnancy is of high importance. The most positive response from pregnant women was obtained by the patient-centered approach which is based on short motivational interviewing and a trusting and cooperative connection between midwife and patient. Medical personal practicing this modern approach was more successful in fulfilling their function in smoking cessation programs [67].
A comparative study from Italy recommended that smoking cessation campaigns should not only target the smoking future mother. Instead, the social network including partners, roommates, family and friends who smoke should be included as well, especially in postpartum women [59]. A systematic literature review from Vancouver, BC, Canada attributed a significant role to the male partner’s smoking behavior. Their support for the woman’s efforts to diminish or abstain from smoking cigarettes may impact her success in doing so. Regardless of the significance of partner smoking, there are only a small number of effective anti-smoking programs for pregnant and postpartum females that take male partners into consideration [68].
In comparison to smoking pregnant women who received only brief routine advice to quit, a US randomized controlled trial discovered that women who were additionally educated by a “Commit to Quit” video, a “Pregnant Woman’s Guide to Quit Smoking” and counseling achieved a significantly higher cessation rate (17.3% vs. 8.8%) [69].
Unconventional methods can be effective if additionally added to established methods of treatment. A small Japanese study (n = 48) investigating the effectiveness of an e-learning program which supports pregnant women willing to quit smoking by use of a cell phone internet connection reported a high achievement rate of 71.1%. The maternal carbon monoxide exhalation levels were significantly reduced from 6.43 (±4.5) ppm to 0.29 (±1.08) after three months (p < 0.001) [70]. These findings certainly have to be regarded in the context of a technologically highly advanced society, but the very principle should be applicable to a country of the developing world as well.
Two studies from Australia and Italy indicated that in addition to being significantly less likely to smoke cigarettes in general (AOR 0.10; 95% CI 0.02–0.68), women breastfeeding their children were in the short and long term more likely to stay abstinent or smoke less compared to non-breastfeeding women. Breastfeeding in itself may also indirectly support smoking cessation, even without the presence of specific anti-smoking campaigns and should therefore be widely promoted [71,72].
Additionally to high quality educational programs the pharmacological aspect needs to be taken more into consideration [73]. A Canadian study from 2012 emphasized on the importance of using suitable drugs which include nicotine in different forms as replacement therapy and sustained-release bupropion. In the study, nicotine replacement therapy and bupropion did not seem to augment the prenatal risk of malformations. For an additional drug varenicline, insufficient data has been collected to safely advise its use during pregnancy. Taking into consideration that these pharmacological agents on their own are only marginally successful in smoking cessation, their prescription should at all times be combined with behavioral counseling and education to optimize success rates [74].

12. Conclusions

The epidemiology, pathogenesis and methods of education and prevention of smoking and pregnancy are of great interest and importance for public health, as there are few other avoidable factors which influence a child’s health that profoundly throughout its life. In 1990 in Germany, 28.6% of women smoke during pregnancy; the highest frequencies are observed in Mecklenburg-Vorpommern and Hamburg, the lowest in Saxony, Thuringia and Bavaria. In the first years of the new millennium the rate declines to approximately 20%. Low socio-economic status, lower education and belonging to an ethnic minority increase the risk for smoking during pregnancy significantly.
Smoking women are up to 33% more likely to have an abortion and suffer from considerably elevated risks for various obstetric complications. For smokers the rate for stillbirth is increased by 23% and the overall risk of giving birth to a child with a congenital malformation increases by 13%. Babies of smokers are more likely to be SGA and suffer from intra-uterine growth restriction as well as to be born before term.
Smoking cigarettes has a negative impact on the maternal and fetal genetic and cellular level; the increase in fetal septal heart defects correlate directly with the number of maternal cigarettes smoked during pregnancy. Maternal cigarette smoking during pregnancy is likely to affect fetal kidney development leading to kidney disease and hypertension later in adult life. Smoking and pregnancy is significantly linked with a decrease in pulmonary function in addition to wheezing, asthma and respiratory infections in offspring later in life. Additionally, an elevated risk for various gastrointestinal defects is observed in offspring of smokers. Smoking during pregnancy harms linear growth, promotes increased BMI in children and augments the risk for obesity in childhood and adult life. Maternal smoking during pregnancy has been linked to decrease in the size of the fetal brain as well as to diminish general reasoning, visual-motor integration, verbal competence and language comprehension in the offspring.
During pregnancy, 45% of smoking women are able to quit smoking, but almost 80% continue to smoke within one year postpartum. A low uptake of smoking cessation programs among pregnant females has been observed in particular among pregnant low-income smokers. Pregnant women who smoke welcome receiving advice on how to quit; the way in which medical personal communicate about the issue of smoking and pregnancy is of high importance. The most positive response is obtained by the patient-centered approach based on short motivational interviewing and a trusting and cooperative connection. For these reasons, medical personal should be specially trained in this highly sensitive task. Smoking cessation campaigns should target the smoking future mother as well as her social network. Male partners, roommates, family and friends should be included, especially in postpartum women. The importance of breastfeeding cannot be emphasized enough. Smoking cessation campaigns should combine these conventional methods with modern building blocks like multimedia, videos, computers and e-learning programs in addition to mobile telephone communication. Another focus should be set on the pharmacological aspect with nicotine replacement therapy and other suitable supporting drugs. Culturally and socio-economically sensitive smoking cessation programs need to be established for the ethnic and socio-economic groups of pregnant women most at risk.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Higgins, S.T.; Washio, Y.; Heil, S.H.; Solomon, L.J.; Gaalema, D.E.; Higgins, T.M.; Bernstein, I.M. Financial incentives for smoking cessation among pregnant and newly postpartum women. Prev. Med. 2011, 55, S33–S40. [Google Scholar]
  2. Bickerstaff, M.; Beckmann, M.; Gibbons, K.; Flenady, V. Recent cessation of smoking and its effect on pregnancy outcomes. Aust. N. Z. J. Obstet. Gynaecol. 2012, 52, 54–58. [Google Scholar] [CrossRef]
  3. El-Mohandes, A.A.; El-Khorazaty, M.N.; Kiely, M.; Gantz, M.G. Smoking cessation and relapse among pregnant African-American smokers in Washington, DC. Matern. Child Health J. 2011, 15, S96–S105. [Google Scholar] [CrossRef]
  4. Dudenhausen, J.W. Rauchen in der Schwangerschaft—Häufigkeit; (in German). Urban und Vogel: Munich, Germany, 2009. [Google Scholar]
  5. Knut-Olaf, H.; Groneberg, D. Tabakabhängigkeit—Gesundheitliche Schäden durch das Rauchen; (in German). Springer Verlag: Berlin, Germany, 2008. [Google Scholar]
  6. Thäle, V.; Schlitt, A. Effects of alcohol and smoking in pregnancy. Internist 2011, 52, 1185–1190. [Google Scholar] [CrossRef]
  7. Simmons, V.N.; Cruz, L.M.; Brandon, T.H.; Quinn, G.P. Translation and adaptation of smoking relapse-prevention materials for pregnant and postpartum Hispanic women. J. Health Commun. 2011, 16, 90–107. [Google Scholar]
  8. Rauchen Während Der Schwangerschaft Oder Niedriger Sozialstatus. Available online: https://www.thieme-connect.com/ejournals/abstract/10.1055/s-2001-18366 (accessed on 5 October 2013).
  9. Rauchen in der Schwangerschaft. Available online: http://www.stern.de/gesundheit/gesundheitsnews/rauchen-in-der-schwangerschaft-gewuerzgurken-und-glimmstaengel-608001.html (accessed on 5 October 2013).
  10. Dittrich, R.; Schibel, A.; Hoffmann, I.; Mueller, A.; Beckmann, M.W.; Cupisti, S. Influence of maternal smoking during pregnancy on oxidant status in amniotic fluid. In Vivo 2012, 26, 813–818. [Google Scholar]
  11. Page, R.L.; Padilla, Y.C.; Hamilton, E.R. Psychosocial factors associated with patterns of smoking surrounding pregnancy in fragile families. Matern. Child Health J. 2012, 16, 249–257. [Google Scholar] [CrossRef]
  12. Thrift, A.P.; Nancarrow, H.; Bauman, A.E. Maternal smoking during pregnancy among aboriginal women in New South Wales is linked to social gradient. Aust. N. Z. J. Public Health 2011, 35, 337–342. [Google Scholar] [CrossRef]
  13. Agopian, A.J.; Lupo, P.J.; Herdt-Losavio, M.L.; Langlois, P.H.; Rocheleau, C.M.; Mitchell, L.E.; National birth defects prevention study. Differences in folic acid use, prenatal care, smoking, and drinking in early pregnancy by occupation. Prev. Med. 2012, 55, 341–345. [Google Scholar] [CrossRef]
  14. Batista, J.; Albuquerque, M.F.; Ximenes, R.A.; Miranda-Filho, D.B.; Melo, H.R.; Maruza, M.; Moura, L.V.; Ferraz, E.J.; Rodrigues, L.C. Prevalence and socioeconomic factors associated with smoking in people living with HIV by sex, in Recife, Brazil. Rev. Bras. Epidemiol. 2013, 16, 432–443. [Google Scholar] [CrossRef]
  15. O’Callaghan, F.V.; O’Callaghan, M.; Najman, J.M.; Williams, G.M.; Bor, W.; Alati, R. Prediction of adolescent smoking from family and social risk factors at 5 years, and maternal smoking in pregnancy and at 5 and 14 years. Addiction 2006, 101, 282–290. [Google Scholar] [CrossRef]
  16. Muckle, G.; Laflamme, D.; Gagnon, J.; Boucher, O.; Jacobson, J.L.; Jacobson, S.W. Alcohol, smoking, and drug use among Inuit women of childbearing age during pregnancy and the risk to childre. Alcohol. Clin. Exp. Res. 2011, 35, 1081–1091. [Google Scholar] [CrossRef]
  17. Foley, K.L.; Balázs, P.; Grenczer, A.; Rákóczi, I. Factors associated with quit attempts and quitting among Eastern Hungarian women who smoked at the time of pregnancy. Cent. Eur. J. Public Health 2011, 19, 63–66. [Google Scholar]
  18. Murin, S.; Rafii, R.; Bilello, K. Smoking and smoking cessation in pregnancy. Clin. Chest. Med. 2011, 32, 75–91. [Google Scholar] [CrossRef]
  19. Ahluwawalia, I.B.; Grummer-Strawn, L.; Scanlon, K.S. Exposure to environmental tobacco smoke and birth outcome: Increased effects on pregnant women aged 30 years and older. Am. J. Epidemiol. 1997, 146, 42–47. [Google Scholar] [CrossRef]
  20. Ananth, C.V.; Savitz, D.A.; Luther, E.R. Maternal cigarette smoking as a risk factor for placental abruption, placenta previa, and uteine bleeding in pregnancy. Am. J. Epidemiol. 1996, 144, 881–889. [Google Scholar] [CrossRef]
  21. Cnattingius, S.; Axelsson, O.; Eklund, G.; Lindmark, G. Smoking, maternal age, and fetal growth. Obstet. Gynecol. 1985, 66, 449–452. [Google Scholar]
  22. Wang, X.; Tager, I.B.; Van Vunakis, H.; Speizer, F.E.; Hanrahan, J.P. Maternal smoking during pregnancy, urine cotinine concentrations, and birth outcomes. A prospective cohort study. Int. J. Epidemiol. 1997, 26, 978–988. [Google Scholar] [CrossRef]
  23. Hayashi, K.; Matsuda, Y.; Kawamichi, Y.; Shiozaki, A.; Saito, S. Smoking during pregnancy increases risks of various obstetric complications: A case-cohort study of the Japan Perinatal Registry Network database. J. Epidemiol. 2011, 21, 61–66. [Google Scholar] [CrossRef]
  24. Leonardi-Bee, J.; Britton, J.; Venn, A. Secondhand smoke and adverse fetal outcomes in nonsmoking pregnant women: A meta-analysis. Pediatrics 2011, 127, 734–741. [Google Scholar] [CrossRef]
  25. Chelchowska, M.; Ambroszkiewicz, J.; Gajewska, J.; Laskowska-Klita, T.; Leibschang, J. The effect of tobacco smoking during pregnancy on plasma oxidant and antioxidant status in mother and newborn. Eur. J. Obstet. Gynecol. Reprod. Biol. 2011, 155, 132–136. [Google Scholar] [CrossRef]
  26. Sahinli, A.S.; Marakoğlu, K.; Kiyici, A. Evaluation of the levels of oxidative stress factors and ischemia modified albumin in the cord blood of smoker and non-smoker pregnant women. J. Matern. Fetal Neonatal Med. 2012, 25, 1064–1068. [Google Scholar] [CrossRef]
  27. Suzuki, K.; Kondo, N.; Sato, M.; Tanaka, T.; Ando, D.; Yamagata, Z. Gender differences in the association between maternal smoking during pregnancy and childhood growth trajectories: Multilevel analysis. Int. J. Obes. 2011, 35, 53–59. [Google Scholar]
  28. Metzger, M.J.; Halperin, A.C.; Manhart, L.E.; Hawes, S.E. Association of maternal smoking during pregnancy with infant hospitalization and mortality due to infectious diseases. Pediatr. Infect. Dis. J. 2012, 32, e1–e7. [Google Scholar]
  29. Erickson, A.C.; Arbour, L.T. Heavy smoking during pregnancy as a marker for other risk factors of adverse birth outcomes: A population-based study in British Columbia, Canada. BMC Public Health 2012, 12, 102. [Google Scholar] [CrossRef]
  30. Prins, J.R.; Hylkema, M.N.; Erwich, J.J.; Huitema, S.; Dekkema, G.J.; Dijkstra, F.E.; Faas, M.M.; Melgert, B.N. Smoking during pregnancy influences the maternal immune response in mice and humans. Am. J. Obstet. Gynecol. 2012, 207, 76.e1–76.e14. [Google Scholar] [CrossRef]
  31. Titova, O.E.; Ayvazova, E.A.; Bichkaeva, F.A.; Brooks, S.J.; Chumakova, G.N.; Schiöth, H.B.; Benedict, C. The influence of active and passive smoking during pregnancy on umbilical cord blood levels of vitamins A and E and neonatal anthropometric indices. Br. J. Nutr. 2012, 108, 1341–1345. [Google Scholar] [CrossRef]
  32. Tyrrell, J.; Huikari, V.; Christie, J.T.; Cavadino, A.; Bakker, R.; Brion, M.J.; Geller, F.; Paternoster, L.; Myhre, R.; Potter, C.; et al. Genetic variation in the 15q25 nicotinic acetylcholine receptor gene cluster (CHRNA5-CHRNA3-CHRNB4) interacts with maternal self-reported smoking status during pregnancy to influence birth weight. Hum. Mol. Genet. 2012, 21, 5344–5358. [Google Scholar] [CrossRef]
  33. Chertok, I.R.; Luo, J.; Anderson, R.H. Association between changes in smoking habits in subsequent pregnancy and infant birth weight in West Virginia. Matern. Child Health J. 2011, 15, 249–254. [Google Scholar] [CrossRef]
  34. Lelong, N.; Blondel, B.; Kaminski, M. Smoking during pregnancy in France between 1972 to 2003: Results from the national perinatal surveys. J. Gynecol. Obstet. Biol. Reprod. (Paris) 2011, 40, 42–49. [Google Scholar] [CrossRef]
  35. Pavić, I.; Dodig, S.; Jurković, M.; Krmek, T.; Spanović, D. The influence of mother’s active smoking during pregnancy on body mass index of newborns. Coll. Antropol. 2011, 35, 1149–1154. [Google Scholar]
  36. Lynch, C.M.; O’Kelly, R.; Stuart, B.; Treumann, A.; Conroy, R.; Regan, C.L. The role of thromboxane A(2) in the pathogenesis of intrauterine growth restriction associated with maternal smoking in pregnancy. Prostaglandins Other Lipid Mediat. 2011, 95, 63–67. [Google Scholar] [CrossRef]
  37. Zhang, L.; González-Chica, D.A.; Cesar, J.A.; Mendoza-Sassi, R.A.; Beskow, B.; Larentis, N.; Blosfeld, T. Maternal smoking during pregnancy and anthropometric measurements of newborns: A population-based study in southern of Brazil. Cad. Saude Publica 2011, 27, 1768–1776. [Google Scholar] [CrossRef]
  38. Joubert, B.R.; Håberg, S.E.; Nilsen, R.M.; Wang, X.; Vollset, S.E.; Murphy, S.K.; Huang, Z.; Hoyo, C.; Midttun, Ø.; Cupul-Uicab, L.A.; et al. 450K Epigenome-Wide Scan Identifies Differential DNA Methylation in Newborns Related to Maternal Smoking During Pregnancy. Environ. Health Perspect. 2012, 120, 1425–1431. [Google Scholar] [CrossRef]
  39. Allina, J.; Grabowski, J.; Doherty-Lyons, S.; Fiel, M.I.; Jackson, C.E.; Zelikoff, J.T.; Odin, J.A. Maternal allergy acts synergistically with cigarette smoke exposure during pregnancy to induce hepatic fibrosis in adult male offspring. J. Immunotoxicol. 2011, 8, 258–264. [Google Scholar] [CrossRef]
  40. Chehab, G.; El-Rassi, I.; Adhami, A.; Chokor, I.; Chatila, F.; Haddad, W.; Saliba, Z. Parental smoking during early pregnancy and congenital heart defects. J. Med. Liban. 2012, 60, 14–18. [Google Scholar]
  41. Alverson, C.J.; Strickland, M.J.; Gilboa, S.M.; Correa, A. Maternal smoking and congenital heart defects in the Baltimore-Washington Infant Study. Pediatrics 2011, 127, e647–e653. [Google Scholar] [CrossRef]
  42. Hackshaw, A.; Rodeck, C.; Boniface, S. Maternal smoking in pregnancy and birth defects: A systematic review based on 173 687 malformed cases and 11.7 million controls. Hum. Reprod. Update 2011, 17, 589–604. [Google Scholar] [CrossRef]
  43. Lee, L.J.; Lupo, P.J. Maternal Smoking During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Metaanalysis. Pediatr. Cardiol. 2012, 34, 398–407. [Google Scholar] [CrossRef]
  44. Taal, H.R.; Geelhoed, J.J.; Steegers, E.A.; Hofman, A.; Moll, H.A.; Lequin, M.; van der Heijden, A.J.; Jaddoe, V.W. Maternal smoking during pregnancy and kidney volume in the offspring: The Generation R Study. Pediatr. Nephrol. 2011, 26, 1275–1283. [Google Scholar] [CrossRef]
  45. Søndergaard, C.; Henriksen, T.B.; Obel, C.; Wisborg, K. Smoking during pregnancy and infantile colic. Pediatrics 2001, 108, 342–346. [Google Scholar] [CrossRef]
  46. Matijasevich, A.; Brion, M.J.; Menezes, A.M.; Barros, A.J.; Santos, I.S.; Barros, F.C. Maternal smoking during pregnancy and offspring growth in childhood: 1993 and 2004 Pelotas cohort studies. Arch. Dis. Child 2011, 96, 519–525. [Google Scholar] [CrossRef]
  47. Mamun, A.A.; O’Callaghan, M.J.; Williams, G.M.; Najman, J.M. Maternal smoking during pregnancy predicts adult offspring cardiovascular risk factors - evidence from a community-based large birth cohort study. PLoS One 2012, 7, e41106. [Google Scholar]
  48. Raum, E.; Küpper-Nybelen, J.; Lamerz, A.; Hebebrand, J.; Herpertz-Dahlmann, B.; Brenner, H. Tobacco smoke exposure before, during, and after pregnancy and risk of overweight at age 6. Obesity 2011, 19, 2411–2417. [Google Scholar] [CrossRef]
  49. Durmus, B.; Kruithof, C.J.; Gillman, M.H.; Willemsen, S.P.; Hofman, A.; Raat, H.; Eilers, P.H.; Steegers, E.A.; Jaddoe, V.W. Parental smoking during pregnancy, early growth, and risk of obesity in preschool children: The Generation R Study. Am. J. Clin. Nutr. 2011, 94, 164–171. [Google Scholar] [CrossRef]
  50. Ino, T.; Shibuya, T.; Saito, K.; Inaba, Y. Relationship between body mass index of offspring and maternal smoking during pregnancy. Int. J. Obes. (Lond) 2012, 36, 554–558. [Google Scholar] [CrossRef]
  51. Koch, S.; Vilser, C.; Groß, W.; Schleußner, E. Smoking during pregnancy: Risk for intrauterine growth retardation and persisting microsomia. Z. Geburtshilfe Neonatol. 2012, 216, 77–81. [Google Scholar] [CrossRef]
  52. Wehby, G.L.; Prater, K.; McCarthy, A.M. The Impact of Maternal Smoking during Pregnancy on Early Child Neurodevelopment. J. Hum. Cap. 2011, 5, 207–254. [Google Scholar] [CrossRef]
  53. Bublitz, M.H.; Stroud, L.R. Maternal smoking during pregnancy and offspring brain structure and function: Review and agenda for future research. Nicotine Tob. Res. 2012, 14, 388–397. [Google Scholar] [CrossRef]
  54. Cents, R.A.; Bublitz, M.H.; Stroud, L.R. Maternal smoking during pregnancy and child emotional problems: The relevance of maternal and child 5-HTTLPR genotype. Am. J. Med. Genet. B Neuropsychiatr Genet. 2012, 159, 289–297. [Google Scholar]
  55. Larsson, M.; Montgomery, S.M. Maternal smoking during pregnancy and physical control and coordination among offspring. J. Epidemiol. Community Health 2011, 65, 1151–1158. [Google Scholar] [CrossRef]
  56. Heinonen, K.; Räikkönen, K.; Pesonen, A.K.; Andersson, S.; Kajantie, E.; Eriksson, J.G.; Wolke, D.; Lano, A. Longitudinal study of smoking cessation before pregnancy and children’s cognitive abilities at 56 months of age. Early Hum. Dev. 2011, 87, 353–339. [Google Scholar] [CrossRef]
  57. Piper, B.J.; Corbett, S.M. Executive function profile in the offspring of women that smoked during pregnancy. Nicotine Tob. Res. 2012, 14, 191–199. [Google Scholar] [CrossRef]
  58. Holbrook, A.M.; Kaltenbach, K.A. Effectiveness of a smoking cessation intervention for methadone-maintained women: A comparison of pregnant and parenting women. Int. J. Pediatr. 2011, 2011, 567056. [Google Scholar] [CrossRef]
  59. Buja, A.; Guarnieri, E.; Forza, G.; Tognazzo, F.; Sandonà, P.; Zampieron, A. Socio-demographic factors and processes associated with stages of change for smoking cessation in pregnant versus non-pregnant women. BMC Womens Health 2011, 11, 3. [Google Scholar] [CrossRef]
  60. Blalock, J.A.; Nayak, N.; Wetter, D.W.; Schreindorfer, L.; Minnix, J.A.; Canul, J.; Cinciripini, P.M. The relationship of childhood trauma to nicotine dependence in pregnant smokers. Psychol. Addict. Behav. 2011, 25, 652–663. [Google Scholar] [CrossRef]
  61. Wang, C.Y.; Kuo, S.C. Pregnancy and the struggle to quit smoking. Hu Li Za Zhi 2011, 58, 87–92. [Google Scholar]
  62. Eiden, R.D.; Leonard, K.E.; Colder, C.R.; Homish, G.G.; Schuetze, P.; Gray, T.R.; Huestis, M.A. Anger, hostility, and aggression as predictors of persistent smoking during pregnancy. J. Stud. Alcohol Drugs. 2011, 72, 926–932. [Google Scholar]
  63. Nguyen, S.N.; Von Kohorn, I.; Schulman-Green, D.; Colson, E.R. The importance of social networks on smoking: Perspectives of women who quit smoking during pregnancy. Matern. Child Health J. 2012, 16, 1312–1318. [Google Scholar] [CrossRef]
  64. Levine, M.D.; Cheng, Y.; Marcus, M.D.; Kalarchian, M.A. Relapse to smoking and postpartum weight retention among women who quit smoking during pregnancy. Obesity (Silver Spring) 2012, 20, 457–459. [Google Scholar] [CrossRef]
  65. Grover, K.W.; Zvolensky, M.J.; Lemeshow, A.R.; Galea, S.; Goodwin, R.D. Does quitting smoking during pregnancy have a long-term impact on smoking status? Drug. Alcohol Depend. 2012, 123, 110–114. [Google Scholar] [CrossRef]
  66. Herberts, C.; Sykes, C. Midwives’ perceptions of providing stop-smoking advice and pregnant smokers’ perceptions of stop-smoking services within the same deprived area of London. J. Midwifery Womens Health 2012, 57, 67–73. [Google Scholar] [CrossRef]
  67. Everett-Murphy, K.; Paijmans, J.; Steyn, K.; Matthews, C.; Emmelin, M.; Peterson, Z. Scolders, carers or friends: South African midwives’ contrasting styles of communication when discussing smoking cessation with pregnant women. Midwifery 2011, 27, 517–524. [Google Scholar] [CrossRef]
  68. Hemsing, N.; Greaves, L.; O’Leary, R.; Chan, K.; Okoli, C. Partner support for smoking cessation during pregnancy: A systematic review. Nicotine Tob. Res. 2012, 14, 767–776. [Google Scholar] [CrossRef]
  69. Windsor, R.; Woodby, L.; Miller, T.; Hardin, M. Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) methods in Medicaid-supported prenatal care: Trial III. Health Educ. Behav. 2011, 38, 412–422. [Google Scholar] [CrossRef]
  70. Fujioka, N.; Kobayashi, T.; Turale, S. Short-term behavioral changes in pregnant women after a quit-smoking program via e-learning: A descriptive study from Japan. Nurs. Health Sci. 2012, 14, 304–311. [Google Scholar] [CrossRef]
  71. Lauria, L.; Lamberti, A.; Grandolfo, M. Smoking behaviour before, during, and after pregnancy: The effect of breastfeeding. Sci. World J. 2012, 2012, 154910. [Google Scholar] [CrossRef]
  72. Xu, H.; Wen, L.M.; Rissel, C.; Baur, L.A. Smoking Status and Factors Associated with Smoking of First-Time Mothers During Pregnancy and Postpartum: Findings from the Healthy Beginnings Trial. Matern. Child Health J. 2012, 17, 1151–1157. [Google Scholar]
  73. Filion, K.B.; Abenhaim, H.A.; Mottillo, S.; Joseph, L.; Gervais, A.; O’Loughlin, J.; Paradis, G.; Pihl, R.; Pilote, L.; Rinfret, S. The effect of smoking cessation counselling in pregnant women: A meta-analysis of randomised controlled trials. BJOG 2011, 118, 1422–1428. [Google Scholar] [CrossRef]
  74. Cressman, A.M.; Pupco, A.; Kim, E.; Koren, G.; Bozzo, P. Smoking cessation therapy during pregnancy. Can. Fam. Physician 2012, 58, 525–527. [Google Scholar]

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MDPI and ACS Style

Mund, M.; Louwen, F.; Klingelhoefer, D.; Gerber, A. Smoking and Pregnancy — A Review on the First Major Environmental Risk Factor of the Unborn. Int. J. Environ. Res. Public Health 2013, 10, 6485-6499. https://doi.org/10.3390/ijerph10126485

AMA Style

Mund M, Louwen F, Klingelhoefer D, Gerber A. Smoking and Pregnancy — A Review on the First Major Environmental Risk Factor of the Unborn. International Journal of Environmental Research and Public Health. 2013; 10(12):6485-6499. https://doi.org/10.3390/ijerph10126485

Chicago/Turabian Style

Mund, Mathias, Frank Louwen, Doris Klingelhoefer, and Alexander Gerber. 2013. "Smoking and Pregnancy — A Review on the First Major Environmental Risk Factor of the Unborn" International Journal of Environmental Research and Public Health 10, no. 12: 6485-6499. https://doi.org/10.3390/ijerph10126485

APA Style

Mund, M., Louwen, F., Klingelhoefer, D., & Gerber, A. (2013). Smoking and Pregnancy — A Review on the First Major Environmental Risk Factor of the Unborn. International Journal of Environmental Research and Public Health, 10(12), 6485-6499. https://doi.org/10.3390/ijerph10126485

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