The prevalence of smoking among pregnant and postpartum women in Israel

The prevalence of smoking among pregnant and postpartum women in Israel

Reported, December 24, 2011

One-third of the global adult population, or 1.1 billion people, use tobacco . Since the release of the ?rst
U.S. Surgeon General’s report on smoking and health in 1964, the concept that ‘cigarette smoking is a health
hazard of suf?cient importance to warrant appropriateremedial action’ has achieved worldwide recognition.
The WHO ‘Tobacco Free Initiative Atlas’ concludes that tobacco use is one of the leading preventable causes
of death, and the second major cause of death worldwide.Approximately 250,000,000 women in the world are
daily smokers . The ?rst Surgeon General’s report on women and smoking was published in 1980.
Women who smoke are at risk for cancer, cardiovascular disease and chronic obstructive pulmonary disease
as are male smokers .Female smokers in addition are at risk for many reproductive related disorders.
The incidence of self reported amenorrhea tends to be about 50% higher among smokers than among nonsmokers. Cigarette smoking is associated with an increased risk of primary and secondary infertility.
The pregnancy rate of smokers over time is 60–90% of that of nonsmokers .Once fertilization is achieved, cigarette smoking is associated with an increased risk of ectopic pregnancy (RR = 1.8) . When the pregnancy is in utero, women who smoke have an increased risk of premature rupture of membranes associated with premature delivery.
Preterm delivery (<37 weeks gestation) is strongly associated with an increased risk for fetal, neonatal and
perinatal mortality. The 1980 Surgeon General’s report on the health consequences of smoking for women concluded that smoking during pregnancy increases the risk of preterm delivery, and that this risk
is incremental with the quantity of cigarettes smoked. The report estimated that 11–14% of preterm births
were attributable to smoking during pregnancy. Since then other studies have demonstrated similar ?ndings
. Smoking cessation during pregnancy seems to reduce the risk for preterm delivery, but reducing the amount of cigarettes smoked does not seem to have this effect . Smoking in pregnancy is associated with a reduced birth weight of approximately 250 g . The weight differential increases with and is apparently a direct function of the quantity smoked . Maternal smoking during pregnancy is a risk factor for low birth weight
(LBW < 2500 g) (RR = 1.5–3.5) and small for gestational age infants (SGA) (RR = 1.5–10) .
Cigarette smoking during pregnancy has been associated with an increased risk for stillbirth (fetal death affter 28 weeks gestation) and neonatal death (within 28 days of birth) . Of the 136,390 live births in Israel in 2001, over 9500 or 7.3% were LBW infants . Israeli infant mortality data for the birth cohort of 2001 reveal an overwhelming overrepresentation of LBW infants, and 62% of the mortality incidence is among infants who were LBW .A number of large studies have noted an increased risk for cleft lip with increasing amounts of maternal smoking. Czeizel reported an increased risk for limb reductions for infants born to mothers who
smoked during the pregnancy and in other studies maternal smoking was found to be a risk factor for congenital urinary tract abnormalities (RR = 2.3) .
Abruptio placenta has been associated with maternal cigarette smoking.In 2003, Law et al. reported that tobacco exposed newborns manifested a distinctive pattern of abnormal neurobehavioral functions including excitability, hypertonicity and increased settling time. There was a de?nite dose-response relationship with higher maternal salivary cotinine .
Smoking compromises breastfeeding, both in amount and duration. The daily milk production of lactating smokers is approximately 250 ml less than that of non-smokers. Reduced maternal milk supplies, negatively impact on breastfeeding duration .
In many studies maternal smoking during pregnancy has been associated with an increased risk for sudden
infant death syndrome (SIDS) (RR = 2.3–3).
Smoking while pregnant has also been indicated as a risk factor for the development of ADHD .
In addition to all of the obstetric and gynecological issues it is important to mention that the leading cause of death for women in Israel in the 25–44 year age bracket is cancer .The WHO has concluded that 30% of all cancer mortality is smoking related .
Among Israeli women aged 45–64, cardiovascular and heart disease is the predominant cause of mortality and
was responsible for over 40% of all deaths .
Smoking triples the risk of dying from ischemic heart disease, arteriosclerosis and aortic aneurisms among
middle-aged women and increases more than four-fold the risk of a CVA .
Given the vast array of insults to the woman, the fetus and the infant as a result of maternal smoking,
this study was undertaken as part of a national survey of pregnancy risk. Within the context of preconcep
tional folic acid utilization we assessed health habits of pregnant women and mothers of newborn infants and
addressed smoking prevalence in pregnant and postpartum women.

A total of 1661 (71%) questionnaires were returnedfr om 395 MCHC (76%). The 395 MCHC that responded had received a total of 1757 questionnaires.The compliance rate from the individual MCHC that
took part in the study was 95%.Smoking status data was available for 1613 (97.0%)of survey respondents. The respondent population was comprised of 1064 (66.0%) Jews, 350 (21.7%) Arab Moslems, 67 (4.2%) Arab Christians, 76 (4.2%) Druze and 56 (3.5%) ‘other/or religion unknown’ women.Due to the small numbers involved, the non-Jewish minorities were combined (N= 493, 31%), and treated as one bloc for statistical analysis. The data was examined as it related to Jewish and Arab blocs. Jewish women
surveyed were signi?cantly older (P < .001), had significantly fewer pregnancies (P = .003), and signi?cantly
more years of education (P < .001) than Arab women.

Smoking prevalence
The overall smoking prevalence in the study population was 12.8% (N= 207) (Table 1). The smoking
prevalence in Jewish women (17.2%) was signi?cantly greater than that of Arab women (3.0%). The difference in prevalence between Jewish and Arab women remained signi?cant after adjusting for age, education and parity differentials between the two groups (OR = 7.5, CI = 4.2–13.4).
Women interviewed postnataly (N= 781), had a smoking prevalence of 15.2% (N= 119). Women interviewed while pregnant (N= 783) reported a significantly lower smoking prevalence of 10.7% (N= 84).
This difference remained signi?cant even after adjusting for education, parity and age (P = .003, OR = 0.615,
CI = 0.446–0.847).When examining Jewish women as a subgroup, the smoking prevalence was 18.3% for women interviewed as mothers of newborns and 16.0% for women inter-
viewed while pregnant. This difference was not signi?cant (P = .076). Among Arab women the overall smoking prevalence among women interviewed as mothers of newborns was 5.0%, and for women interviewed while pregnant, the overall smoking prevalence was 2.0%. This difference in prevalence was signi?cant after adjusting for education, parity and age (P = .022,OR = 0.26, CI = 0.082–0.822). Due to the small number of actual smokers among Arab women interviewed (15/493), only a partial further analysis was done for Arab women smokers.

Smoking intensity
An analysis of Jewish smokers revealed that 27.9% (N= 51) were light smokers (smoking 1–5 cigarettes
daily), 27.3% (N= 50) were average smokers (smoking 6–10 cigarettes daily), 37.2% (N= 68) were heavy
smokers (smoking 11–20 cigarettes per day) and 7.7% (N= 14) were very heavy smokers (smoking more than 20 cigarettes daily).

Demographics and smoking indicators
Jewish women, 30 years of age and older had the highest rate of smoking. Smoking intensity also increased with age. Not only did older women tend to smoke, they also smoked more cigarettes than their younger smoking counterparts, though not signi?cantly (P = .251) . Jewish women smokers had signi?cantly fewer children and less years of education than Jewish non-smokers.

The prevalence of smoking decreased with increasing education in the Jewish population.
While the trend was signi?cant in the Jewish population (P < .001), in the Arab population smoking
prevalence actually increased with increasing education (3.0–4.5%) though not signi?cantly. Smoking intensity also decreased with increasing education in the Jewish population .
More than half (53.6%) of the Jewish women smokers (98/183), reported that they had stopped smoking
for at least 3 months while pregnant as opposed to less than half (40.0%) of the Arab women smokers (6/15).
The prevalence of smoking throughout the pregnancy was 8.0% for Jewish women and 1.8% for Arab women.
Approximately one third (19/62) of the Jewish ‘mothers of newborns’, who reported a smoking cessation in the ?nal 3 months of pregnancy, had resumed smoking by the time of the postpartum interview.
A Jewish light smoker was more than twice as likely to have stopped smoking while pregnant than a Jewish heavy and very heavy smoker (P = .024). Among Jewish women who reported smoking cessation while pregnant, average smokers were less likely to have resumed smoking postpartum (P = .012) than heavy and
very heavy smokers.
Preconceptional folic acid utilization among Jewish smokers was signi?cantly lower (25.1%) than among
Jewish non-smokers (36.5%), even after adjusting for
age and education (P = .038, OR = 0.67, CI = 0.46–98).
Arab women smokers also had decreased folic acid utilization (13.3%) versus their non-smoking Arab
counterparts (20.9%) though the differential was not signi?cant.

Credits:
Nirah Fisher,Yona Amitai, Miri Haringman,Hana Meiraz,Nira Baramb & Alex Leventhal
More information at:
http://www.health.gov.il/PublicationsFiles/
The_prevalence_of_smoking_among_pregnant_and
_postpartum_women.