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Health Policy 73 (2005) 1–9 The prevalence of smoking among pregnant and postpartum women in Israel: a national survey and review Nirah Fishera,c,∗ , Yona Amitaia,c , Miri Haringmana,c , Hana Meirazb,c , Nira Baramb,c , Alex Leventhalc a Department of Mother, Child and Adolescent Health, Ministry of Health, 20 King David Street, Jerusalem 91010, Israel b Public Health Nursing, Ministry of Health, Jerusalem 91010, Israel c The Public Health Service, Ministry of Health, Jerusalem 91010, Israel Abstract Background: Cigarette smoking during pregnancy is a significant health risk to the developing fetus. In order to develop and implement an appropriate preconceptional and prenatal smoking cessation program a national pregnancy risk survey was done. Methods: The survey was conducted through the Public Health Service’s, Mother and Child Health Clinics (MCHC). The nursing staff initiated structured interviews with pregnant women and mothers of newborn infants. Questions included in the survey addressed folic acid utilization, smoking habits, onset of prenatal care and demographic characteristics. Results: Overall, of the 1613 questionnaires received with smoking data, 12.8% of the women had smoked either in the 3 months preceding their current pregnancy and/or during their pregnancy. The smoking prevalence in Jewish women, was significantly greater then that found among Arab women (17.2 and 3.0%, P < .001, OR = 7.5, CI = 4.2−13.4). The prevalence of smoking for the duration of the pregnancy was 8.0% among Jewish women and 1.8% among Arab women. Among Jewish women, smoking prevalence was significantly associated with education, women who had completed 12 years of education were more likely to be nonsmokers (P = .034, OR = 1.8, CI = 1.0–3). Conclusion: Smoking in the preconceptional and prenatal period is a significant problem among Jewish women. Since less years of education is a significant risk factor, smoking cessation programs should focus on this subgroup of Jewish women. © 2004 Elsevier Ireland Ltd. All ; rights reserved. Keywords: Smoking; Prenatal; Survey; Review; Preconceptional 1. Introduction ∗ Corresponding author. Tel.: +972 2 6228834; fax: +972 2 6228907. E-mail address: email@example.com (N. Fisher). One-third of the global adult population, or 1.1 billion people, use tobacco . Since the release of the first U.S. Surgeon General’s report on smoking and health in 1964, the concept that ‘cigarette smoking is a health hazard of sufficient importance to warrant appropriate 0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2004.11.003 2 N. Fisher et al. / Health Policy 73 (2005) 1–9 remedial action’ has achieved worldwide recognition [1,2]. 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 first 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 [1–4]. Female smokers in addition are at risk for many reproductive related disorders [3–29]. 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 [6,7]. The pregnancy rate of smokers over time is 60–90% of that of nonsmokers [5–7]. 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 [1,3,4,9]. 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 findings [1,4,9,10]. 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 [4,10]. Smoking in pregnancy is associated with a reduced birth weight of approximately 250 g [1,3,4,9–14]. The weight differential increases with and is apparently a direct function of the quantity smoked [3,4,13,14]. 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) [1,3,4,9–14]. Cigarette smoking during pregnancy has been associated with an increased risk for stillbirth (fetal death af- ter 28 weeks gestation) and neonatal death (within 28 days of birth) [1,3,4,15,16]. 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 [1,4,18,19]. 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) [1,4,20–22]. Abruptio placenta has been associated with maternal cigarette smoking [4,23]. 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 definite 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 [4,25]. In many studies maternal smoking during pregnancy has been associated with an increased risk for sudden infant death syndrome (SIDS) (RR = 2.3–3) [1,4,26]. Smoking while pregnant has also been indicated as a risk factor for the development of ADHD [4,27,28]. 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 [29,30]. 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 [1,29,31]. 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- N. Fisher et al. / Health Policy 73 (2005) 1–9 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. 3 asked if they were currently smoking, and if so how many cigarettes daily. Religion was classified as Jewish, Moslem Arab, Christian Arab, Druze and other and/or unknown. Statistical analysis was performed using SPSS 11. 2. Methods 3. Results The target population consisted of all pregnant women and recently pregnant, mothers of infants under age 2 months, who presented at the MCHC for either prenatal or newborn care. The survey was conducted both on women in the prenatal service and women who entered the service for newborn care within 2 months of having given birth. We surveyed the pregnant population in order to minimize bias recall. Approximately 60% of Israeli women are followed by the public health services clinics at some point in their prenatal care. Prenatal care is offered at the MCHC and also through the ‘kupot cholim’ (sick funds – HMOs). In regards to the newborn and toddler population, the government sponsored MCHC provide care to approximately 84% of all children from birth to school age. Both groups of women were therefore included in order to insure a representative population. In August 2002, a total of 2334 questionnaires were distributed via district health offices to 521 MCHC, throughout the country. Three to five questionnaires were distributed to each MCHC, in proportion to the population served. The public health nursing staff at the individual clinics conducted a structured interview. During the study period sampling was done on the first women who presented at the individual child health clinics. Women were asked if they had smoked in the 3 months preceding their pregnancy, and if so how many cigarettes daily. Having smoked in the 3 months preceding the pregnancy and or during the pregnancy was defined as ‘smoking prevalence’. In order to assess the prevalence of smoking, while pregnant; mothers of newborns were asked if they had smoked in the final 3 months of their pregnancy, and pregnant women were asked if they had smoked in the 3 months preceding the administration of the questionnaire. Smokers were designated as ‘smoked throughout the pregnancy’ if they had responded affirmatively to either question. In addition, mothers of newborns were A total of 1661 (71%) questionnaires were returned from 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 significantly older (P < .001), had significantly fewer pregnancies (P = .003), and significantly more years of education (P < .001) than Arab women (Table 1). 3.1. 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 significantly greater than that of Arab women (3.0%). The difference in prevalence between Jewish and Arab women remained significant 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 significant 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- 4 N. Fisher et al. / Health Policy 73 (2005) 1–9 Table 1 Survey demographics and self reported smoking prevalence Total (N = 1613) N Age Mean (S.D.) Median Number of children Mean/S.D./Median Years of education Mean/S.D./Median Jewish women Arab women Jewish smokers Jewish non-smokers Arab smokers Arab non-smokers 1060 489 183 881 15 478 28.8 (5.3) 28a 27 (5.1) 26 29 (5.3) 28 28.7 (5.3) 28 29 (6.5) 29 27.0 (5.0) 26 2.3 (1.8) 2.0b 2.5 (1.5) 2.0 1.8 (1.4) 1.0 2.4 (1.9) 2.0d 2.5 (1.9) 2.0 2.5 (1.5) 2.0 13.7 (2.6) 13.0c 11.6 (2.8) 12 13.0 (2.0) 12 13.8 (2.7) 13e 10.9 (2.6) 10.5 11.6 (2.9) 12 Smoking prevalence Non-smokers Smokers Smoked throughout pregnancy a b c d e f Total (N = 1613) (%) Jewish (N = 1064) (%) Arab Moslem, Christian and Druze (N = 493) (%) Unknown and other (N = 56) (%) N = 1406 N = 207 N = 98 N = 881 N = 183 N = 85 N = 478 N = 15 N=9 N = 47 N=9 N=4 87.2 12.8 6.1 82.8 17.2f 8.0 97.0 3.0 1.8 83.9 16.1 7.1 P < .001, OR = 1.1, CI = 1.05–1.11. P < .003, OR = 0.883, CI = 0.81–0.96. P < .001, OR = 1.3, CI = 1.3–1.4. P < .001, OR = 1.24, CI = 1.11–1.39. P = .001, OR = 1.12, CI = 1.05–1.19. P < .001, OR = 7.5, CI = 4.2–13.4. Jewish women vs. Arab women after adjusting for age, education, and parity. viewed while pregnant. This difference was not significant (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 significant 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. 3.2. 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) (Table 2C). 3.3. 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 significantly (P = .251) (Table 2A). Jewish women smokers had significantly fewer children and less years of education than Jewish non-smokers (Table 1). The prevalence of smoking decreased with increasing education in the Jewish population (Table 2B). While the trend was significant in the Jewish population (P < .001), in the Arab population smoking prevalence actually increased with increasing education (3.0–4.5%) though not significantly. Smoking intensity also decreased with increasing education in the Jewish population (Table 2C). 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 (Fig. 1). Approximately one third (19/62) of the Jewish ‘mothers of newborns’, who reported a smoking cessation in the final 3 months of pregnancy, had re- N. Fisher et al. / Health Policy 73 (2005) 1–9 5 Table 2 Smoking prevalence and smoking intensity: correlates of age and education Age group 17–24 25–29 ≥30 (A) Smoking prevalence and age groupings Jewish survey respondents (N = 1059) Smoking prevalence (N = 181, total Jewish smokers) (%) Heavy and very heavy smokers (N = 82) (%) N = 236 N = 36 (15.3) N = 16 (6.8) N = 399 N = 68 (17.0) N = 28 (7.0) N = 424 N = 77 (18.2) N = 38 (9.0) Years of education Total Jewish women (B) Educational groupings smoking prevalence ≤12 years N = 506 13–15 years N = 297 ≥16 years N = 257 Jewish smokers* N (%) Total Arab women Arab smokers N (%) 114 (22.5) 42 (14.1)a 26 (10.1) N = 363 N = 67 N = 54 11 (3.0) 3 (4.5) 0 (0.0) Years of education** 1–5 Light smokers N (%) 6–10 Average smokers N (%) 11–20 Heavy smokers N (%) >20 Very heavy smokers N (%) (C) Smoking intensity (Number of daily cigarettes): distribution among Jewish women as correlates of educational group ≤12 29 (5.8) 31 (6.3) 43 (8.7) 11 (2.2) 13–15 12 (4.7) 14 (4.9) 17 (5.9) 2 (0.7) ≥16 9 (3.1) 5 (2.0) 8 (3.1) 1 (0.4) Total 50 (27.5) 50 (27.5) 68 (37.4) 14 (7.7) Due to small number of smokers in the Arab population intensity and age-group analysis was done only on Jewish women. a Jewish women with 13–15 years of education were more likely to be non-smokers (P < 0.001, OR = 2.5, CI = 1.6–4.0) than Jewish women with ≤12 years of education, age NS. ∗ P < 0.001 in Jewish women between educational group and smoking: even after controlling for age. ∗∗ P = <0.001 between educational group and smoking intensity group. sumed smoking by the time of the postpartum interview (Table 3). 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 (Table 3). Preconceptional folic acid utilization among Jewish smokers was significantly lower (25.1%) than among Jewish non-smokers (36.5%), even after adjusting for Table 3 Smoking habits of Jewish smokers as defined by smoking group and postnatal smoking behavior Smoking group and daily cigarette consumption Light smokers 1–5 cigarettes Average smokers 6–10 cigarettes Heavy and very heavy smokers ≥11 cigarettes Total N Smoked throughout the pregnancy N (% of smokers in that group) Smoking cessation of 3 months while pregnant N (% of smokers in that group) Mothers of newborns in smoking cessation group Mothers of newborns in smoking cessation group who resumed smoking postpartum N (%) 51 15 (29.0) 36 (71.0)a N = 25 7 (28.0) 50 24 (48.0) 25 (50.0) N = 17 5 (29.0)b 82 45 (55.0) 37 (45.0) N = 20 7 (35.0) 183 84 (46.0) 98 (54.0) N = 62 19 (31.0) a Light smokers were more likely to have stopped smoking while pregnant versus heavy and very heavy smokers, controlling for age and education (P = 0.024, OR = 2.6, CI = 1.14–6.11). b Average smokers were less likely to have resumed smoking postpartum than heavy and very heavy smokers, controlling for age and education (P = 0.012, OR = 0.278, CI = 0.103–0.752). 6 N. Fisher et al. / Health Policy 73 (2005) 1–9 Fig. 1. Smoking patterns in currently pregnant and recently pregnant israeli women. 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 significant. 4. Discussion In a survey of women aged 21–54 conducted by the Israel Center for Disease Control (ICDC), the prevalence of smoking in women varied by age group (18.8–25.7%) and older women tended to be the heaviest smokers . Our study focused only on currently and recently pregnant women. Smoking prevalence overall in our study was 12.8% with a worrisome prevalence of 17.2% reported by Jewish women, preconceptionaly. Jewish women gave birth to 94,327 babies in 2002 . We can now postulate that over 16,000 of those pregnancies began while the woman was smoking. Arab women gave birth to 40,931 babies in 2002 . With a smoking prevalence of 3.0% approximately 1200 births were affected. It is important to note that the proportion of the Arabs in the general population in Israel is approximately 19%. Their representative participation in the survey however, was 32%, which is similar to their proportion of births in 2001 . In our survey the prevalence of smoking among women increases with age; older women have a higher prevalence of smoking and tend to be heavier smokers. In 2002, the number of births for Jewish women aged N. Fisher et al. / Health Policy 73 (2005) 1–9 30 and above was 44,075 an increase of 31.0% for that age bracket from 1992, while the overall Jewish birth rate rose by only 21.0% [30,33]. The age of women having babies is increasing and older women have a higher smoking prevalence. If we extrapolate from our survey at a smoking prevalence of 9.1% for heavy and very heavy smokers in the Jewish population, over 4000 babies are being born a year to women who are over age 30 and are heavy and very heavy smokers. Close to half of our smoking, survey respondents reported that they had a smoking cessation hiatus of at least 3 months while pregnant. In a study reported by Moore et al. in 2002, the self-reported smoking cessation rate by English pregnant women was 27.4% while the documented rate by urine assay of cotinine was in fact 19.8% . Though self-report is an easy and accessible survey methodology the question of accuracy, reliability and predictive value remains. In our study, mothers of newborns reported significantly higher rates of smoking. It is possible that once no longer pregnant, women feel freer to relate their smoking histories, which they might very well feel obligated to deny while pregnant. Whether our numbers are real or whether they are severely underestimated, we have a significant health problem. One of the major indicators or correlates with smoking status in our survey was the woman’s years of education. Women who have less years of education are at a greater risk for being not only smokers, but also heavy smokers. Most tobacco use starts during childhood and adolescence [1,4,35–37]. A survey conducted by the Israeli Defense Forces Army in 2002, reported that between the years 1990–2000, there was an 86% increase in the prevalence of women who smoked before their conscription. Women conscripted in 2002, reportedly began smoking on average by age 15.7 years . We must consequently focus not only on the older women who are having babies but on the teenagers as well since they represent the pool of future mothers and the teenage years is when the groundwork is being laid or corrupted in regards to future health habits. The United Nations Tobacco Free Initiative recommends using schools as the ideal venue for imparting not only ‘knowledge about the harmful effects of smoking but also knowledge of the manipulations of the tobacco industry and techniques for refusal’ . Implementing a high school and elementary school 7 smoking cessation program would appear to be in order as the average age of smokers is getting younger. Preventing initiation of tobacco use among young adults and youth is more effective than providing smoking cessation counseling once smoking has begun [1,4,37]. Nearly 10,000 babies born in Israel in 2001 were designated LBW [17,33]. The smoking attributable cost of neonatal health care per LBW birth in the US is estimated to be US$ 1388 in 1999 . It has been estimated that elimination of maternal smoking could lead to at least a 10% reduction in all infant deaths and 12% reduction in death from perinatal conditions [1,4,31,37]. Economics alone would seem to dictate the necessity for a cogent and effective smoking prevention program and in this review we have not even addressed the ramifications of passive smoke exposure on the newborn and infant in terms of SIDS and infectious disease. In 1988, the US Surgeon General’s report concluded that cigarettes and other forms of tobacco are addictive, that nicotine is the drug in tobacco that causes addiction and finally that the pharmacological and behavioral processes that determine addiction are similar to those that determine addiction to such drugs as heroin and cocaine . No one would think of addressing drug addiction as solely an obstetric issue, similarly smoking cessation programs targeting women in order to be effective must span the entire life cycle and not be limited to the prenatal period. The Maternal Child Health staff at the MCHC provides ongoing comprehensive preventive care to women and children. As such the nurse establishes an ongoing relationship with the woman, as her caretaker during the pregnancy and family planning clinics, and as a health provider to the infant and toddler. There are multiple opportunities to reinforce and follow up on health education messages. Women are more motivated to stop smoking while pregnant and are in regular contact with health services . When providing prenatal care the nurse routinely addresses the issue of smoking cessation. It would appear that a preconceptional and a postnatal smoking cessation program are also needed in order to reinforce the message and insure that pregnancies are begun smoke free, remain smoke free throughout and that women, infants and toddlers remain smoke free postnatally. Any contact with a woman in the childbearing years must be viewed as an opportunity for health promotion, health education, 8 N. Fisher et al. / Health Policy 73 (2005) 1–9 positive behavior reinforcement, and an opportunity to reiterate and follow up on and reinforce a smoke free message. As Israel adapts a consumer-oriented lifestyle, hopefully we will forego the number one selling consumer product in the world – cigarettes, by adapting a multidisciplinary approach that includes mass media, legislation and educational programs. The Minister of Health in Israel in his 2003 report on smoking has recommended this approach . According to the WHO bans on advertising of tobacco products and tobacco tax increases are among the most cost effective population based strategies available for tobacco control. This approach does not require a behavior change on the part of the consumer/user, but in effect alters the environment in order to promote better health habits . 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