Tobacco use in the third trimester of pregnancy and its relationship to birth weight. A prospective study in Spain

ORIGINAL
RESEARCH
–
QUANTITATIVE
Tobacco
use
in
he
hi d
imes e
o
p egnancy
and
i s
ela ionship
o
bi h
weigh .
A
p ospec i e
s udy
in
Spain
Ra ael
Vila
Candel
a,b,
*,
F ancisco
J.
So iano-Vidal
b,c
,
En ique
He illa
Cuca ella
b,d
,
En ique
Cas o-Sa
´nchez
e
,
Jose
´M.
Ma in-Mo eno
,a
a
Depa men
o
Obs e ics
and
Gynecology,
Hospi al
Uni e si a io
de
la
Ribe a,
C a.
Co be a
km
1,
46.600
Valencia,
Spain
b
Depa men
o
Nu sing,
Uni e sidad
Ca o
´lica
de
Valencia,
C/
Jesu
´s,
10,
46.007
Valencia,
Spain
b
c
Depa men
o
Obs e ics
and
Gynecology,
Hospi al
Luis
Alcanyis,
A da.
Ausias
Ma ch,
46.800
Xa i a,
Spain
c
d
Depa men
o
Public
Heal h,
Conselle ia
de
Sani a
de
Valencia,
C/
Mice
Masco
´,
31,
46010
Valencia,
Spain
d
e
Na ional
Ins i u e
o
Heal h
Resea ch
Heal h
P o ec ion
Resea ch
Uni
(NIHR
HPRU)
in
Heal hca e
Associa ed
In ec ion
and
An imic obial
Resis ance
a
Impe ial
College
London,
Du
Cane
Road,
London
W12
0NN,
Uni ed
Kingdom
e
Depa men
o
P e en i e
Medicine
and
Public
Heal h,
Uni e si a
de
Valencia,
A da.
Blasco
Iban
˜ez,
15,
46.010
Valencia,
Spain
1.
In oduc ion
Op imal
oe al
g ow h
is
dependan
on
a
a ie y
o
physiological
and
pa hological
de e minan s.
1
Amongs
he
physiological
ac o s,
p e-ges a ional
body
mass
index
(BMI)
is
di ec ly
ela ed
o
bi h
weigh ,
wi h
highe
BMI
associa ed
wi h
highe
bi h
weigh .
2
On
he
con a y,
he
misuse
o
oxic
subs ances
du ing
p egnancy,
including
obacco,
can
lead
o oe alg ow h e a da ion
andlowbi h
weigh .
3,4
Nico ine
educes
he
blood
flow
o
he
placen a,
whils
ca bon
monoxide
p esen
in
smoke
educes
oxygena ion
o
he
e us.
5
Di e en
au ho s
ha e
analysed
obacco
use
du ing
p egnancy
using
di e en
me hods
including
sel - epo ed
ques ionnai es,
measu emen s
o
nico ine
concen a ion
in
u ine
o
expi ed
ca bon
monoxide.
6–8
In
Eu ope,
he
p e alence
o
obacco
use
du ing
p egnancy
is
app oxima ely
20%.
9
In
Spain,
figu es
a e
highe
and
Women
and
Bi h
28
(2015)
e134–e139
A
R
T
I
C
L
E
I
N
F
O
A icle
his o y:
Recei ed
8
Janua y
2015
Recei ed
in
e ised
o m
4
June
2015
Accep ed
22
June
2015
Keywo ds:
P egnancy
Tobacco
Bi h
weigh
BMI
Cessa ion
A
B
S
T
R
A
C
T
Backg ound:
Few
s udies
ha e
been
ca ied
ou
in
Spain
examining
he
use
o
obacco
amongs
expec an
mo he s
and
i s
e ec
on
bi h
weigh .
Aims:
To
obse e
he
p opo ion
o
expec an
mo he s
who
smoke
du ing
hei
p egnancy,
and
he
impac
o
obacco
consump ion
on
ma e nal
and
bi h
weigh .
We
also
aimed
o
iden i y
he
imes e
o
p egnancy
in
which
obacco
use
p oduced
he
g ea es
educ ion
in
bi h
weigh .
Me hods:
P ospec i e
obse a ional
s udy
in
Spain.
A
andom
sampling
s a egy
was
used
o
selec
heal h
cen es
and
pa icipan
women.
A
o al
o
137
indi iduals
we e
en olled
in
he
s udy.
Exposu e
o
obacco
was
measu ed
h ough
a
sel - epo ed
ques ionnai e.
Reg essions
we e
pe o med
o
ob ain
a
p edic i e
model
o
bi h
weigh
ela ed
o
smoking.
Findings:
O e all,
35%
o
s udy
pa icipan s
we e
smoke s
du ing
he
p e-ges a ional
pe iod
(27%
in
he
fi s
imes e ,
21.9%
in
he
second
and
21.2%
in
he
hi d).
38.7%
o
smoking
cessa ion
a emp s
ook
place
in
he
hi d- imes e .
P egnan
women
who
smoked
up
o
he
hi d
imes e
had
a
highe
isk
o
gi ing
bi h
o
a
baby
unde
3000
g,
compa ed
o
non-smoke s
(OR
=
5.94,
CI
95%:
1.94–18.16).
Each
addi ional
uni
o
obacco
consumed
daily
in
he
3 d
imes e
led
o
a
32
g
educ ion
in
bi h
weigh .
Conclusion:
An
impo an
p opo ion
o
p egnan
women
in
Spain
smoke
du ing
p egnancy.
P egnan
women
exposed
o
obacco
ha e
newbo ns
wi h
lowe
bi h
weigh .
Smoking
du ing
he
3 d
imes e
o
p egnancy
is
associa ed
wi h
he
g ea es
isk
o
lowe
bi h
weigh .
ß
2015
Aus alian
College
o
Midwi es.
Published
by
Else ie
Aus alia
(a
di ision
o
Reed
In e na ional
Books
Aus alia
P y
L d).
All
igh s
ese ed.
*Co esponding
au ho
a :
Depa men
o
Obs e ic
and
Gynecology,
Hospi al
Uni e si a io
de
la
Ribe a,
C a.
Co be a
km
1,
46.600
Alzi a,
Valencia,
Spain.
Tel.:
+34
962458100.
E-mail
add esses:
[email p o ec ed],
[email p o ec ed]
(R.
Vila
Candel),
[email p o ec ed]
(F.J.
So iano-Vidal),
[email p o ec ed]
(E.
He illa
Cuca ella),
[email p o ec ed]
(E.
Cas o-Sa
´nchez),
[email p o ec ed]
(J.M.
Ma in-Mo eno).
a
Di ec o ,
P og amme
Managemen
Wo ld
Heal h
O ganiza ion,
Eu ope.
b
Tel.:
+34
963637412.
c
Tel.:
+34
962218100.
d
Tel.:
+34
963869210.
e
Tel.:
+44
203
3132732.
Tel.:
+34
963864100.
Con en s
lis s
a ailable
a
ScienceDi ec
Women
and
Bi h
jo
u
n
al
h
om
ep
age:
w
ww.els
e ie .c
o
m/lo
c
a e/wo
mb
i
h p://dx.doi.o g/10.1016/j.wombi.2015.06.003
1871-5192/ß
2015
Aus alian
College
o
Midwi es.
Published
by
Else ie
Aus alia
(a
di ision
o
Reed
In e na ional
Books
Aus alia
P y
L d).
All
igh s
ese ed.
a ound
30–43%
o
expec an
mo he s
a e
smoke s
a
he
s a
o
hei
p egnancy.
6
Al hough
abou
40%
o
hem
qui
in
he
fi s
imes e ,
10
abou
13–25%
con inue
smoking
up
o
deli e y.
11
Spanish
s udies,
howe e ,
a e
a ec ed
by
me hodological
weaknesses.
Fo
example,
he
majo i y
o
s udies
assessed
obacco
use
h ough
sel - epo ed
ins umen s,
which
may
acili a e
socially
desi able
esponses
and
hus
unde es ima e
smoking
s a us
by
11–26%.
6,10
Howe e ,
he
combined
e ec
o
BMI
and
obacco
on
bi h
weigh
emains
unclea
12
and
ew
s udies
on
obacco
p e alence
ha e
examined
he
e ec
o
qui ing
smoking
in
he
hi d-
imes e
o
p egnancy
and
bi h
weigh .
Some
au ho s
ha e
sugges ed
ha
ea ly
cessa ion
o
smoking
in
p egnancy
has
a
g ea e
impac
on
bi h
weigh
imp o emen
13,14
wi h
a
ela i ely
small
impac
i
qui ing
akes
place
du ing
he
hi d- imes e
o
p egnancy.
15
Howe e ,
o he
esea che s
ha e
claimed
ha
hi d-
imes e
ma e nal
ciga e e
consump ion
had
he
s onges
associa ion
wi h
bi h
weigh ,
ega dless
o
p e-p egnancy
consump ion
le els.
16
Ou
s udy
e alua ed
he
associa ion
o
p ena al
exposu e
o
ma e nal
smoking
wi h
bi h
weigh
in
di e en
s ages
o
p egnancy.
Addi ionally,
we
aimed
o
iden i y
he
imes e
o
p egnancy
in
which
obacco
use
p oduced
he
g ea es
educ ion
in
neona al
bi h
weigh .
2.
Subjec s
and
me hods
2.1.
Design
P ospec i e
obse a ional
s udy.
Pa icipa ing
expec an
mo he s
we e
classified
in o
wo
g oups
acco ding
o
hei
use
o
obacco
du ing
ges a ion.
A
sample
o
159
women
was
ob ained
om
Ap il
2011
o
Ma ch
2012.
A
wo-s age
sampling
app oach
was
used.
In
he
fi s
s age,
we
selec ed
heal h
cen es
in
Ca le
and
Benimodo
(Spain)
om
all
p ima y
ca e
cen es
o
La
Ribe a
heal h
dis ic
using
simple
andom
p obabili y
sampling
(p obabili y
=
2/13).
In
he
second
s age,
we
selec ed
p egnan
women
using
a
simila
p obabili y
sampling
wi h
sys ema ic
moni o ing
o
he
numbe
o
p egnan-
cies
pe
yea
on
each
heal h
cen e
(N
0
).
The
a io’s
alue
(k)
o
he
calcula ed
sample
size
(n)
was
2
(k
=
N
0
/n).
We
es ima ed
ha
o
180
p egnan
women
pe
yea
a ending
he
heal h
cen es,
a
minimum
sample
o
123
women
was
equi ed
(95%
confidence
in e al
(95%
CI),
5%
p ecision
e o ).
The
a ending
midwi es
ec ui ed
he
women
a
clinic
and
ob ained
hei
in o med
consen
o
pa icipa e.
O e all,
one
o
e e y
wo
p egnan
women
was
selec ed
un il
he
equi ed
sample
size
was
ob ained.
The
inclusion
c i e ia
we e:
a
ma e nal
age
o
18–36
yea s,
fi s
p ena al
isi
be ween
5
and
12
weeks
o
ges a ion,
and
single
oe us
wi h
no
mal o ma ions.
Exclusion
c i e ia
included:
pa ien
declined
o
pa icipa e
in
he
s udy,
language
ba ie ,
and
expec an
mo he s
wi h
pa hologies
ha
significan ly
modified
oe al
g ow h,
such
as
p e-ges a ional
diabe es,
essen ial
hype -
ension
p io
o
p egnancy,
ma e nal
in ec ion
o
o he
ch onic
ma e nal
pa hologies.
2.2.
E hics
The
Commi ee
o
E hics
and
Resea ch
o
he
Uni e si y
Hospi al
o
La
Ribe a
(UHLR)
app o ed
he
s udy
p oposal
in
Janua y
2011
(#11-415).
W i en
in o med
consen
was
ob ained
om
all
women.
The
pa icipan s
we e
ee
o
decline
hei
pa icipa ion
and
wi hd aw
om
he
esea ch
a
any
ime.
2.3.
S udy
a iables
The
ques ionnai e
was
pu posely
designed
wi h
ag eemen
om
he
esea ch
eam.
Bi h
weigh
was
conside ed
he
dependen
a iable,
and
was
eco ded
in
he
deli e y
oom
ollowing
he
clamping
and
sepa a ion
o
he
umbilical
co d,
using
a
digi al
scale
(SECA
1
,
Vogel
&
Halke
GmbH
&
Co,
Hambu g,
Ge many),
o
an
accu acy
o
10
g.
The
independen
a iables
included
socio-demog aphic
cha -
ac e is ics
(ma e nal
age,
coun y
o
o igin,
ma i al
s a us,
educa ional
le el,
occupa ional
s a e),
an h opome ic
measu e-
men s
(p e-ges a ional
BMI,
as
calcula ed
om
sel - epo ed
body
weigh
a
2–3
mon hs
p io
o
p egnancy
and
eco ded
a
he
fi s
p ena al
isi ;
absolu e
ges a ional
weigh
gain;
and
di e ence
be ween
final
weigh
on
he
day
o
deli e y
and
p e-ges a ional
weigh ),
and
obs e ic-neona al
ea u es
(newbo n
gende
and
ges a ional
age
a
bi h
exp essed
in
days
o
ges a ion
om
he
end
o
he
mo he ’s
las
mens ual
cycle).
Women
selec ed
o
inclusion
in
ou
s udy
p o ided
an
es ima e
o
hei
p e-p egnancy
day
ciga e e
consump ion.
Sel - epo ed
a e age
obacco
con-
sump ion
was
used
o
es ima e
p e-ges a ional
obacco
misuse.
Equally,
women
we e
asked
o
epo
he
mean
numbe
o
ciga e es
consumed
pe
day
in
he
7
days
p io
o
he
en olmen
in
he
s udy,
and
again
o
each
imes e
on
appoin men
wi h
he
midwi e.
Da a
collec ion
also
included
he
equency
o
smoking
cessa ion
a emp s
and
elapses
du ing
p egnancy
and
o
a
pe iod
o
30
days
pos pa um.
2.4.
S a is ical
analysis
An
analysis
o
he
dependen
a iables
was
ca ied
ou
o
each
o
he
ca ego ies
o
p e-ges a ional
BMI,
using
desc ip i e
me hods.
A e wa ds,
he
no mali y
o
he
dis ibu ion
o
con inuous
a iables
was
examined
using
he
Kolmogo o –
Smi no
es .
S a is ical
significance
was
se
a
he
0.05
le el.
Bi a ia e
co ela ion
analyses
using
Pea son
co ela ion
coe ficien
we e
ini ially
used
o
explo e
ac o s
associa ed
wi h
neona al
bi h.
The
compa ison
o
mul iple
a e ages
was
ca ied
ou
using
analysis
o
a iance
es s
(ANOVA),
a e
assessmen
o
he
homogenei y
and
no mali y
o
he
da a
wi h
he
Le ene
es .
The
magni ude
o
he
e ec
o
fi s -hand
exposu e
o
obacco
on
ca ego ised
bi h
weigh
was
es ima ed
using
mul iple
logis ic
eg ession,
wi h
bi h
weigh
(<3000
g
o
>3000
g)
as
he
ou come
measu e
and
adjus ed
o
p e-ges a ional
ma e nal
BMI
(WHO
ca ego ies:
unde weigh
(UW)
<18.5
kg/m
2
,
no mal
weigh
(NW)
18.5–24.9
kg/m
2
,
o e weigh
(OW)
25.0–29.9
kg/m
2
,
obese
(OB)
>30
kg/m
2
)
17
as
explana o y
a iable.
Addi ional
explana o y
a iables
included
ges a ional
age
a
bi h
(days).
To
analyse
he
ela ionship
be ween
bi h
weigh
(dependen
a iable)
and
obacco
use
by
he
expec an
mo he
(independen
a iable),
an
adjus ed
mul iple
linea
eg ession
model
was
applied
using
a
s epwise
me hod
o
a iables
shown
o
ha e
an
e ec
on
bi h
weigh .
Smoking
indica o s
examined
included
he
numbe
o
ciga e es
consumed
pe
day
be o e
p egnancy,
a
he
ime
o
egis a ion
in o
he
s udy
(fi s
imes e ),
and
in
he
second
and
hi d
imes e .
Pa ial
co ela ion
coe ficien s
ep e-
sen
he
s eng h
o
he
linea
ela ionship
be ween
each
independen
a iable
and
bi h
weigh ,
a e
con olling
o
o he
p edic o s
in
he
eg ession
model.
The
da a
was
analysed
using
SPSS
S a is ics
e sion
22.
3.
Resul s
Ou
o
a
o al
o
159
expec an
mo he s
ini ially
included
in
he
s udy,
we
excluded
22
cases
(10
cases
o
spon aneous
misca iage
in
he
fi s
imes e ,
1
case
o
oe al
mal o ma ion
in
he
second
imes e ,
2
cases
o
loss
o
ollow-up
du ing
he
p egnancy,
and
9
cases
o
ges a ional
diabe es).
The e o e,
he
final
sample
included
137
expec an
mo he s.
R.
Vila
Candel
e
al.
/
Women
and
Bi h
28
(2015)
e134–e139
e135
Table
1
p o ides
a
de ailed
desc ip ion
o
ma e nal
and
neona al
cha ac e is ics.
Smoke s
we e
30–34
yea s
old,
less
educa ed,
ma ied,
employees
and
mo e
equen ly
wi hin
no mal
weigh
han
non-smoke s
a
each
co esponding
poin
du ing
ges a ion.
The
neona al
bi h
weigh
o
smoking
mo he s
was
235
g
lowe
han
non-smoke s
(p
=
0.006).
Table
2
p esen s
obacco
s a uses.
Rega ding
p e-p egnancy
obacco
use,
64.2%
(88)
did
no
smoke,
35.8%
(49)
did,
and
0.8%
(1)
qui
p io
o
becoming
p egnan .
A
he
beginning
o
p egnancy,
he
p opo ion
o
smoke s
was
35%,
o
whom
14.6%
we e
unde weigh ,
68.8%
we e
no mal
weigh
and
26.7%
we e
o e weigh .
None
o
he
mo he s
smoking
p io
o
p egnancy
we e
obese.
In
e ms
o
smoking
cessa ion
du ing
p egnancy,
cessa ion
a es
inc eased
p og essi ely
du ing
he
h ee
imes e s
(8%,
13.1%
and
13.9%
espec i ely).
We
did
no
find
any
expec an
mo he s
who
elapsed
du ing
p egnancy
o
du ing
30
days
o
pos -
pa um.
Unde weigh
smoke s
accoun ed
o
he
la ges
p opo -
ion
o
hose
who
s opped
smoking
(44.5%)
when
compa ed
o
women
who
ei he
had
no mal
weigh
(12.6%)
o
we e
o e weigh
(10%).
Addi ionally,
unde weigh
smoke s
achie ed
a
g ea e
educ ion
in
he
a e age
numbe
o
ciga e es
smoked
compa ed
o
women
who
had
no mal
weigh
(4.3
ewe
daily
ciga e es
compa ed
o
1.0).
O e weigh
smoke s,
on
he
con a y,
had
inc eased
hei
daily
a e age
consump ion
by
3.1
ciga e es
by
he
end
o
hei
p egnancies.
The
esul s
o
he
bi a ia e
analysis
on
obacco
s a us
and
bi h
weigh
o
di e en
imes e s
o
ges a ion,
acco ding
o
ca e-
go ised
p e-ges a ional
ma e nal
BMI
a e
displayed
in
Table
3.
Ma e nal
smoking
was
associa ed
wi h
bi h
weigh
only
a
NW
p e-ges a ional
BMI.
O
he
smoking
indica o s
examined,
ciga e e
consump ion
was
significan ly
and
nega i ely
co ela ed
wi h
bi h
weigh
be o e
p egnancy
(R
=
0.243,
p
=
0.018),
as
well
as
he
second
(R
=
0.276,
p
=
0.007)
and
hi d
imes e
(R
=
0.304,
p
=
0.003).
Bi h
weigh
in
newbo ns
om
non-
smoking
mo he s
was
significan ly
highe
when
compa ed
wi h
smoking
pa icipan s
(3297.8
g
[95%
CI:
3187.6–3408.0]
compa ed
o
3070.1
g
[95%
CI:
2910.4–3229.8],
p
=
0.018).
Likewise,
expec-
an
mo he s
who
did
no
smoke
in
he
second
and
hi d
imes e s
had
babies
wi h
highe
bi h
weigh
han
mo he s
who
we e
smoke s
du ing
hose
pe iods
(3284.3
g
[95%
CI:
3179.8–3388.9]
s
2990.6
g
[95%
CI:
2816.7–3164.5]
o
he
second
imes e
and
3289.0
g
[3185.5–3392.6]
compa ed
o
2960.2
g
[95%
CI:
2789.8–
3130.6]
o
he
hi d),
wi h
s a is ically
significan
di e ences
(p
=
0.007
and
p
=
0.003,
espec i ely).
Table
4
desc ibes
he
isk
o
ha ing
a
newbo n
wi h
a
weigh
below
3000
g,
acco ding
o
smoking
beha iou
du ing
p egnancy,
and
adjus ed
o
p e-ges a ional
ma e nal
BMI
and
ges a ional
age
a
bi h.
Expec an
mo he s
exposed
o
obacco
du ing
he
hi d
imes e
we e
a
g ea e
isk
o
ha ing
a
lowe
neona al
weigh
han
hei
non-smoking
coun e pa s
(OR:
5.94
[CI
95%:
1.94–
18.16]).
The
esul s
o
he
mul iple
eg ession
analyses
(Table
5
and
Fig.
1)
sugges
ha
o
he
smoking
a iables
examined,
ma e nal
hi d
imes e
ciga e e
consump ion
was
he
s onges
p edic o
o
bi h
weigh
a e
adjus ing
o
ges a ional
age
and
p e-
ges a ional
ma e nal
BMI
(pa ial
R
=
0.253,
p
=
0.003).
Fo
each
addi ional
ciga e e
pe
day
smoked
in
he
hi d- imes e ,
he e
was
an
es ima ed
educ ion
in
bi h
weigh
o
32
g
(CI
95%:
53.08,
11.04).
Addi ional
di ec
independen
con ibu o s
o
bi h
Table
1
Dis ibu ion
o
socio-demog aphic,
obs e ics
and
neona al
a iables,
ca ego ised
acco ding
o
obacco
use
du ing
p egnancy.
Va iables
Smoking
s a us
p-Value
Non-smoke s
(n
=
89.
65%)
Smoke s
(n
=
48.
35%)
Final
no.
%
Final
no.
%
Ma e nal
age
(yea s)
<25
9
10.1
12
25.0
0.036
a
26–29
24
27.0
12
25.0
30–34
38
42.7
21
43.8
>35
18
20.2
3
6.3
Ma i al
s a us
Ma ied
80
89.9
32
66.7
0.001
a
Single
9
10.1
16
33.3
Coun y
o
o igin
Spain
78
87.6
39
81.3
0.312
a
O he
11
12.4
9
18.8
Educa ion
Up
o
p ima y
29
32.6
25
52.1
0.033
a
Up
o
seconda y
34
38.2
17
35.4
Uni e si y
deg ee
26
29.2
6
12.5
Occupa ional
s a e
I
6
6.7
4
8.3
0.045
a
II
57
64.1
26
54.2
III
0
0.0
1
2.1
IV
13
14.6
4
8.3
V
13
14.6
13
27.1
PRE-GEST
BMI
(kg/m
2
)
<=18.5
2
2.2
7
14.6
0.021
a
18.6–24.9
62
69.7
33
68.8
25.0–29.9
22
24.7
8
16.7
30.0+
3
3.4
0
0.0
Newbo n
gende
Male
48
53.9
23
47.9
0.501
a
Female
41
46.1
25
52.1
Pa i y
0
43
48.3
29
60.4
0.176
a
>=1
46
51.7
19
39.6
Bi h
weigh
(g)
>=3000
69
77.5
26
54.2
0.005
a
<3000
20
22.5
22
45.8
I:
sel -employed,
manage ial
o
highe
p o essions;
II:
employees;
III:
s uden ;
IV:
s ay
a
home
mo he s;
V:
unemployed.
PRE-GEST
BMI:
p e-ges a ional
Body
Mass
Index.
a
p-Value:
ob ained
h ough
Chi-squa e
es
o
di e en
ca ego ies
o
a iables.
Table
2
Dis ibu ion
o
obs e ics
and
neona al
a iables,
ca ego ised
acco ding
o
obacco
use
du ing
p egnancy.
Smoking
s a us
Non-smoke s
(n
=
89.
65%)
Smoke s
(n
=
48.
35%)
Mean
(CI
95%)
Mean
(CI
95%)
Bi h
weigh
(g)
3339
(3236.7–3441.2)
3104
(2976.2–3231.7)
0.006
a
Ges a ional
age
278.6
(276.9–280.3)
278.1
(275.1–281.0)
0.742
a
Ges a ional
weigh
gain
(kg)
14.0
(13.0–15.1)
15.2
(14.0–16.4)
0.178
a
P e-p egnancy
smoke
(cig/day)
0
14.5
(12.2–16.9)
Ciga e es
pe
day
1T
0
5.0
(3.8–6.2)
<0.001
b
Ciga e es
pe
day
2T
0
4.58
(3.2–5.9)
<0.001
b
Ciga e es
pe
day
3T
0
4.3
(3.0–5.6)
<0.001
b
1T:
fi s
imes e ;
2T:
second
imes e ;
3T:
hi d
imes e .
a
p-Value:
ob ained
h ough
ANOVA
( ac o :
smoke ).
b
p-Value:
ob ained
h ough
S uden
- es
o
a e ages
ela ed
o
p e-ges a ional
smoking
s a us.
R.
Vila
Candel
e
al.
/
Women
and
Bi h
28
(2015)
e134–e139
e136
weigh
a e
adjus ing
o
ges a ional
age
(pa ial
R
=
0.404,
p
<
0.001)
included
ma e nal
BMI
(pa ial
R
=
0.281,
p
=
0.006).
The
final
model
included
3
a iables
and
explained
27%
o
he
a iabili y
in
newbo n
bi h
weigh .
4.
Discussion
Ou
p ospec i e
obse a ional
s udy
included
137
expec an
mo he s
in
Spain,
who
we e
classified
in o
g oups
acco ding
o
hei
ges a ional
obacco
use.
In
ou
esul s,
p e-ges a ional
ma e nal
BMI
is
posi i ely
ela ed
o
bi h
weigh ,
independen ly
o
all
o he
pa ame e s
examined,
and
in
ag eemen
wi h
o he
s udies.
2,3,18
In
he
Spanish
heal h
ca e
sys em,
midwi es
a e
he
main
poin
o
con ac
o
women
du ing
p egnancy.
Na ional
guidelines
indica e
ha
midwi es
should
ask
abou
women’s
smoking
s a us
a
he
fi s
an ena al
appoin men
(usually
be ween
8
and
12
weeks),
and
p o ide
smoking
cessa ion
ad ice
and
e e al
i
wa an ed.
Howe e ,
he e
is
s ill
a
pauci y
o
da a
ega ding
he
impac
o
smoking
cessa ion
ad ice
on
smoking
s a us.
The
p opo ion
o
smoke s
dec eased
p og essi ely
om
he
fi s
o
he
hi d
imes e ,
which
is
also
consis en
wi h
p e ious
s udies.
6,7,10,11,13,19
In
ou
s udy,
we
obse ed
s a is ically
signifi-
can
di e ences
be ween
ciga e e
consump ion
and
ma e nal
age,
educa ional
le el
and
occupa ional
s a e.
20
Ou
da a
sugges
ha ,
aking
in o
conside a ion
al eady
known
ac o s
ha
influence
on
bi h
weigh ,
a
linea
ela ion
pe sis s
be ween
sel - epo ed
consump ion
o
ciga e es
in
he
hi d
imes e
and
neona al
bi h
weigh ,
as
p e iously
epo ed.
17
Howe e ,
o he
s udies
ha e
pos ula ed
sa e
le els
o
obacco
consump ion.
15,21,22
The
obse able
e ec
o
ma e nal
smoking
Table
3
Associa ion
be ween
smoking
s a us
du ing
p egnancy
and
bi h
weigh ,
acco ding
o
ma e nal
p e-ges a ional
BMI
(kg/m
2
;
n
=
137).
PRE-GEST
BMI
Mean
cig/day
Bi h
weigh
(g)
n
(%)
R
p-Value
(CI
95%)
Mean
(CI
95%)
<=18.5
kg/m
2
(n
=
9)
PRE-PREG
non-smoke
0
3065.0
(333.1–5796.8)
2
(22.2)
0.034
0.93
a
PRE-PREG
smoke
10.7
(4.5–16.7)
3095.3
(2702.0–3487.9)
7
(77.8)
Non-smoke
1T
0
3104.1
(2796.7–3411.5)
6
(66.6)
0.062
0.874
a
Smoke
1T
4.3
(2.9–8.7)
3056.6
(1542.0–4571.2)
3
(33.3)
Non-smoke
2T
0
3104.1
(2796.7–3411.5)
6
(66.6)
0.062
0.874
a
Smoke
2T
7.3
(3.0–9.6)
3056.6
(1542.0–4571.2)
3
(33.3)
Non-smoke
3T
0
3104.1
(2796.7–3411.5)
6
(66.6)
0.062
0.874
a
Smoke
3T
5.0
(4.5–7.9)
3056.6
(1542.0–4571.2)
3
(33.3)
18.6–24.9
kg/m
2
(n
=
95)
PRE-PREG
non-smoke
0
3297.8
(3187.6–3408.0)
61
(64.3)
0.243
0.018
a
PRE-PREG
smoke
5.5
(3.7–7.3)
3070.1
(2910.4–3229.8)
33
(34.7)
Non-smoke
1T
0
3265.6
(3158.6–3372.6)
68
(71.6)
0.174
0.091
a
Smoke
1T
7.3
(3.4–9.2)
3092.2
(2910.5–3273.9)
27
(28.4)
Non-smoke
2T
0
3284.3
(3179.8–3388.9)
73
(76.8)
0.276
0.007
a
Smoke
2T
7.7
(4.2–8.5)
2990.6
(2816.7–3164.5)
22
(23.2)
Non-smoke
3T
0
3289.0
(3185.5–3392.6)
74
(77.9)
0.304
0.003
a
Smoke
3T
4.5
(3.4–9.4)
2960.2
(2789.8–3130.6)
21
(22.1)
25.0–29.9
kg/m
2
(n
=
30)
PRE-PREG
non-smoke
0
3380.2
(3134–3625.9)
22
(73.3)
0.121
0.523
a
PRE-PREG
smoke
3.1
(0.7–5.5)
3243.1
(2941.4–3544.7)
8
(26.7)
Non-smoke
1T
0
3386.5
(3151.9–3621.0)
23
(76.6)
0.156
0.411
a
Smoke
1T
4.4
(2.2–7.4)
3202.8
(2860.8–3544.8)
7
(23.3)
Non-smoke
2T
0
3388.8
(3174.3–3603.2)
25
(83.3)
0.202
0.284
a
Smoke
2T
5.4
(1.1–8.3)
3118.0
(2601.5–3634.5)
5
(16.7)
Non-smoke
3T
0
3388.8
(3174.3–3603.2)
25
(83.3)
0.202
0.284
a
Smoke
3T
6.2
(1.6–8.2)
3118.0
(2601.5–3634.5)
5
(16.7)
>30.0
kg/m
2
(n
=
3)
PRE-PREG
non-smoke
0
4166.6
(2781.0–5552.2)
3
(100.0)
PRE-GEST
BMI:
p e-ges a ional
Body
Mass
Index;
PRE-PREG:
p e-p egnancy;
1T:
fi s
imes e ;
2T:
second
imes e ;
3T:
hi d
imes e ;
CI
95%:
confidence
in e al
95%;
R:
Pea son’s
co ela ion;
p- alue:
ob ained
h ough
ANOVA.
Table
4
Logis ical
eg ession
be ween
smoking
s a us
du ing
p egnancy
and
ca ego ised
bi h
weigh .
Va iables
Bi h
weigh
(<3000,
3000
g)
G oss
OR
(IC
95%)
p-Value
Adjus ed
OR
*
(CI
95%)
p-Value
PRE-PREG
smoke
2.77
(1.30–5.87)
0.008
3.77
(1.42–9.99)
0.007
Ciga e es/day
1T
3.00
(1.36–6.61)
0.007
4.90
(1.70–14.14)
0.003
Ciga e es/day
2T
4.29
(1.83–10.03)
0.001
5.34
(1.79–15.92)
0.003
Ciga e es/day
3T
4.70
(1.98–11.15)
<0.001
5.94
(1.94–18.16)
0.002
PRE-PREG:
p e-p egnancy;
1T:
fi s
imes e ;
2T:
second
imes e ;
3T:
hi d
imes e .
*
OR
adjus ed
o :
p e-ges a ional
BMI
(no mal
weigh
ca ego y)
and
ges a ional
age
a
bi h
(days).
Table
5
Mul i a ia e
linea
eg ession
analysis
p edic ing
bi h
weigh .
Independen
a iable
Coe ficien
Pa ial
R
Pa ial
R
2
p-Value
Cons an
3079.464
Ges a ional
age
(days)
20.673
0.404
0.186
<0.001
3 d
imes e
ciga e es/days
32.061
0.253
0.232
0.003
P e-ges a ional
BMI
27.387
0.236
0.269
0.006
BMI:
body
mass
index.
R.
Vila
Candel
e
al.
/
Women
and
Bi h
28
(2015)
e134–e139
e137
la e
in
p egnancy
sugges s
ha
e e y
addi ional
ciga e e
consumed
pe
day
in
he
hi d- imes e
esul s
in
a
educ ion
o
app oxima ely
32
g
in
he
bi h
weigh
o
he
newbo n.
Such
e ec
appea s
o
be
g ea e
han
he
p e iously
epo ed
by
Be ns ein
e
al.,
16
Ma hai
e
al.
23
o
England
e
al.
15
who
no ed
be ween
12
and
27
g.
O e all,
ou
esul s
p opose
a
o al
weigh
educ ion
o
137.6
g
(32
g/ciga e e

4.3
ciga e es/day),
wi hin
he
ange
de e mined
by
o he
au ho s
20,24,25
epo ing
a
weigh
all
be ween
114
and
170
g
amongs
smoke s.
The
g ea e
pe -
ciga e e
influence
on
bi h
weigh
in
ou
da a
can
be
explained
by
he
con inuous
linea
ela ionship
we
obse ed.
Thus,
we
disag ee
wi h
he
no ion
o
a
minimum
secu e
le el
on
ciga e e
consump ion
a he
han
a
con inuous
e ec .
A
alid
es ima ion
o
he
isks
associa ed
wi h
obacco
exposu e
would
depend
on
accu a e
measu emen s.
Howe e ,
some
indi iduals
may
be
mo e
eluc an
han
o he s
o
disclose
hei
smoking
s a us
and
exposu e
o
obacco.
This
can
be
pa icula ly
ue
o
p egnan
women,
o
whom
smoking
may
be
ega ded
as
socially
unaccep able.
Thus,
es ima es
based
on
sel - epo ed
in o ma ion
a e
likely
o
unde es ima e
he
eal
p opo ion
o
obacco
use.
Exposu e
o
obacco
can
be
analysed
by
measu ing
smoke
componen s
in
he
ai ,
sel - epo ed
indica o s
o
exposu e
h ough
in e iews
o
measu ing
smoke
componen s
concen a-
ions
wi h
bioma ke s.
26
The
fi s
app oach
is
subop imal
as
moni o s
can
only
be
used
o
sho
pe iods
o
ime,
which
a e
unlikely
o
be
eflec i e
o
o e all
exposu e.
In
e ms
o
sel -
epo ed
smoking
beha iou s,
a
ecen
me a-analysis
27
sugges ed
ha
in
mos
s udies
i
could
be
an
accep able
me hodology
o
es ima ing
obacco
consump ion,
i
alida ed
wi h
biochemical
measu emen s.
Howe e ,
he
au ho s
excluded
s udies
which
included
p egnan
women.
O he
au ho s
ha e
concluded
ha
alida ion
wi h
bioma ke s
should
also
be
conside ed
in
s udies
wi h
s uden s
and
in e en ion
s udies.
28,29
Despi e
hese
ad an-
ages,
sel - epo ed
ques ionnai es
p esen
a ious
conce ns
ela ed
o
hei
alidi y
as
ools
o
da a
collec ion,
a
lack
o
alida ion
and
s anda disa ion
as
well
as
misclassifica ion
o
exposu e
amongs
he
mos
se ious
d awbacks.
These
may
o igina e
om
pa icipan s’
ailu e
o
accu a ely
ecall
exposu e,
lack
o
knowledge,
in en ional
alse
epo ing,
biased
ecall,
o
memo y
ailu e.
28
Bias
may
be
mo e
common
whene e
social
desi abili y
is
g ea e .
11
Fu he mo e,
he
quan i y
o
inhaled
and
abso bed
smoking
p oduc s
a ies
wi h
he
manne
o
smoking,
which
may
be
di ficul
o
exp ess
and
quan i y
in
a
ques ionnai e.
25
Unde epo ing
was
ound
in
4–12%
o
p egnan
women
who
demons a ed
alues
inconsis en
wi h
hei
sel - epo .
26
O he
in es iga o s
ha e
iden ified
a
poo
co ela ion
o
sel -
epo ed
ma e nal
ciga e e
consump ion
wi h
bioma ke s
like
u ina y
co inine.
They
ha e
epo ed
an
in e sely
p opo ional
ela ionship
o
u ina y
nico ine
o
bi h
weigh .
15,30
Some
me hodological
conside a ions
should
be
no ed
wi h
ega d
o
ou
s udy.
Fi s ,
ou
esul s
ely
on
he
alidi y
o
esponses
o
he
sel - epo ed
ques ionnai e.
Consequen ly,
he
smoking
a e
we
obse ed
may
e ec i ely
be
an
unde es ima ion
o
he
ue
p opo ion,
due
o
he
po en ial
o
socially
desi able
esponses
o e ed
by
ou
pa icipan s.
The
ac o s
mos
closely
ela ed
o
concealing
an
indi idual’s
smoking
s a us
ha e
o
do
wi h
he
iming
and
he
quan i y
o
obacco
consumed.
9,12,31,32
We
acknowledge
ha
in
op imal
ci cums ances,
midwi es
ca ing
o
pa icipan s
may
no
be
he
ideal
ec ui e s
o
indi iduals
on o
a
s udy.
As
an
addi ional
limi a ion
in
ou
s udy,
we
had
a
educed
numbe
o
pa icipan s
wi hin
he
unde weigh
and
obese
ca ego ies,
al hough
his
was
due
o
he
na u e
o
he
sampling.
The
s eng hs
o
ou
s udy
a e
he
use
o
p obabili y
sampling
in
he
selec ion
o
he
s udy
popula ion.
In
addi ion,
we
we e
able
o
d aw
a
alid
sample
size
ep esen a i e
o
he
o al
popula ion
o
expec an
mo he s
in
ou
se ing.
Unlike
o he
s udies,
ou
sample
was
ca ego ised
by
p e-ges a ional
ma e nal
BMI,
an
impo an
independen
ac o
in
de e mining
bi h
weigh .
Di e en
s udies
ha e
ied
o
de e mine
he
ela ionship
be ween
ciga e e
smoking
amongs
expec an
mo he s
and
bi h
weigh .
Al hough
he
s udies
ha e
p oduced
he e ogeneous
esul s,
mos
obse e
an
inc eased
isk
o
lowe
bi h
weigh
amongs
smoke s.
1,19–21
Howe e ,
he
s udies
a e
limi ed
by
he
di ficul y
in
quan i ying
ma e nal
exposu e
p ecisely
and
in
adjus ing
o
he
mul iplici y
o
con ounding
ac o s
ha
can
a ec
bi h
weigh .
32,33
In
conclusion,
ou
esul s
on
he
associa ion
o
ac i e
smoking
du ing
p egnancy
wi h
bi h
weigh
indica e
ha
smoking
in
p egnancy
inc eased
he
isk
o
ha ing
lowe
weigh
newbo ns
(<3000
g),
and
ha
his
isk
is
mos
p onounced
o
women
who
smoke
du ing
hei
hi d
imes e ,
ein o cing
he
need
o
encou age
and
suppo
women
o
a oid
smoking
du ing
Fig.
1.
The
ela ionship
be ween
hi d- imes e
ciga e e
consump ion
and
newbo n
bi h
weigh
is
illus a ed
a
he
sample
means
o
ges a ional
age
(days)
and
body
mass
index.
The
e ec
o
each
added
ciga e e
consumed
in
he
hi d
imes e
on
newbo n
bi h
weigh
is
app oxima ely
32
g.
R.
Vila
Candel
e
al.
/
Women
and
Bi h
28
(2015)
e134–e139
e138

p egnancy.
P egnancy
o e s
a
s a egic
oppo uni y
o
heal h
p o essionals
o
p omo e
smoking
cessa ion
and
mo i a e
women
o
gi e
up
obacco
use.
Such
oppo uni y
o
encou age
smoking
cessa ion
in e en ions
should
be
specially
seized
by
midwi es,
as
fi s
poin
o
con ac
o
women
du ing
hei
p egnancy.
E hical
app o al
The
p esen
s udy
was
ca ied
ou
in
acco dance
wi h
he
basic
p inciples
o
all
medical
esea ch,
he
Helsinki
Decla a ion.
The
Commi ee
o
E hics
and
Resea ch
o
he
Uni e si y
Hospi al
o
La
Ribe a
(UHLR)
app o ed
he
s udy
p oposal
in
Janua y
2011
(#11-415).
Acknowledgemen s
and
disclosu es
The
au ho s
would
like
o
hank
all
s udy
pa icipan s.
We
also
acknowledge
he
manage s
o
he
Uni e si y
Hospi al
o
La
Ribe a
o
hei
suppo
du ing
ou
esea ch.
We
would
like
o
hank
Meggan
Ha is,
P o esso
o
P e en i e
Medicine
and
Public
Heal h
a
Uni e si a
de
Vale
`ncia
(Spain)
o
he
ansla ion
o
his
pape
and
eedback.
The
au ho s
ha e
no
conflic s
o
in e es
o
disclose.
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AA,
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CJ,
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JJ.
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ea ly
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Am
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Obs e
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2008;198(6):673.e1–e.
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M,
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JL,
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TI,
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J,
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HA,
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EA,
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L,
e
al.
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C,
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M.
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and
passi e
smoking
du ing
p egnancy
and
ul asound
measu es
o
e al
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LJ,
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JS,
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GJ,
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