Exposure to active and passive smoking among Greek pregnant women

Eliminating active and passive maternal tobacco smoking during pregnancy are among the most important interventions to reduce the risk of adverse birth outcomes [1‐5]. Previous studies have reported that tobacco smoking during pregnancy is significantly associated with increased risks of intrauterine growth retardation, preterm birth, low birth weight, miscarriage, stillbirth, congenital malformation, sudden infant death syndrome, genetic-related hereditary diseases, perinatal mortality and morbidity, short stature, cognitive delays, and neurologic disorders [2‐9]. Pregnant women who smoke place themselves and their infants in a high-risk situation [2]. However, more than a third of women smokers will continue to smoke during pregnancy, despite being aware of many of the imminent risks to their infants [10].

Previous studies have demonstrated that pregnant smokers usually have partners who actively smoked during pregnancy [8, 11, 12]. The health of pregnant women and their fetuses’ is inherently threatened by both the active and passive smoking of the pregnant women’s partners or families [2, 12]. However, the effect of passive maternal smoking is not explicit enough and has not been extensively studied [9, 13, 14]. The perceptions of pregnant smokers regarding the health risks of smoking and the need to abstain from passive smoking have been described as important factors influencing a smoke-free behavior [2, 8]. A partner who continues using tobacco throughout a woman’s pregnancy is a significant prognostic factor of the current smoking status of the pregnant woman [2, 11, 15].

Recent studies have generally highlighted the need to conduct further research on the types of interventions which could be employed in order to set goals for reducing smoking in pregnancy and promote smoke-free environments, as a potential benchmark of an effective primary care system [16]. Midwives and other community health professionals need to educate, and offer support to pregnant women to stop smoking and avoid postnatal relapse among woman who have quit smoking during their pregnancy [17]. Despite the fact that pregnancy provides a ‘window of opportunity’ to encourage positive behavior change, encouraging pregnant smokers to change their health behavior may be challenging [3].

The aim of this study was to explore the perceptions, attitudes and behaviors towards active and passive maternal smoking during pregnancy of smokers, non-smokers and recent quitters in Athens, Greece. Our specific objectives were to: i) assess the proportion of women who were active smokers and exposed to second-hand smoking during pregnancy; ii) compare pregnant smokers and non-smokers in regards to postnatal depressive and anxiety symptomatology, neonatal problems, partner smoking habits and other sources of passive smoking (work, social places, car etc.); and iii) explore women’s perceptions and attitudes towards smoking during the perinatal period.

Statistical analysis was performed using IBM SPSS Statistics version 20.0 and LISREL (Linear Structural Relations). The descriptive characteristics were calculated for the socio-demographic variables. The assumptions of normality, homogeneity and independent cases of the sample were checked. We used chi-square tests to investigate whether significant differences existed in maternal beliefs and attitudes toward smoking during pregnancy between groups of quitters and smokers. T-tests were carried out to compare the descriptive variables, risk perception, attitudes to smoking, smoking behaviors women who smoked during pregnancy. Reliability coefficients, as measured by Cronbach’s alpha, were calculated for the smoking questionnaire in order to assess reproducibility and consistency of the instrument; and the internal consistency of the questionnaire was also tested using Guttman split-half coefficients.

Our study has identified that the initial rate of tobacco use among pregnant women sampled was higher than that of the general population of women in Greece in the same age range (3.7 % of women aged 18–34 smoke in Greece as reported in recent studies) [4, 5]. Addressing smoking in women who are considering pregnancy and targeting women in early pregnancy is a key public health priority for Greece if maternal and infant health outcomes are to be improved. Based on our findings, approximately 73.7 % of women chose not to smoke during pregnancy with 21.7 % reporting quitting in association with their pregnancy. Among woman who continued to smoke during pregnancy, just over half were unable to stop smoking, a quarter did not want to and a small number of women contended they did not believe it was essential, with significant differences in terms of impact of smoking on development of fetal health issues and newborn health problems.

Another criterion that we took into account and on which there was also a statistically significant difference, was the smoking status of the partner [2, 8, 23]. Previous studies which have investigated smoking in pregnancy have also reported that women who did not quit smoking during their pregnancy typically had family members, who were smokers, had partners who smoked, or lived with relatives who smoked [2, 11, 12]. Partners play an important role in influencing women’s smoking behaviour in the perinatal period, and their support (or lack of support) can be an important barrier or facilitator to quitting [2, 8, 23]. A partner who continues using tobacco throughout a woman’s pregnancy is a significant predictor of the current smoking status of the pregnant woman [2, 8, 23]. Moreover, maternal passive smoke exposure during pregnancy has also been shown to have adverse effects on fetal health [8]. Second hand smoke (SHS) exposure during pregnancy is associated with multiple health concerns in the perinatal period including preterm birth, bronchopulmonary dysplasia, wheezing and asthma [8, 23‐26].

In our study, despite the high level of awareness that pregnant smokers generally demonstrated about risks to the health of their infants as a consequence of their reluctance to quit smoking, only one third of participants were successful in quitting [2]. Based on our findings, even in cases where women managed to quit smoking or reduce their smoking in pregnancy, they continued to be exposed to passive smoke. Moreover, this occurred either as a consequence of the smoking behavior of their partners and other family members, or as a result of being in social places, such as restaurants [2, 8, 23‐26]. In line with previous study findings, our study also found that the two most prominent factors influencing the exposure of women to passive smoking were dining at restaurants (41.6 %) and having a partner who smoked (35.9 %) [2, 8, 23‐26]. Having a partner who does not smoke or who quits when the woman becomes pregnant is clearly of benefit to support a pregnant women’s attempts to avoiding contact with passive smoking [2, 8, 23‐26].

Although in our study benefits to infant health did not appear to be a motivating factor for other family members to quit smoking, infant health was the most critical reason for pregnant women to quit. Specifically, most of the quitters in our study stopped smoking as soon as their pregnancy was confirmed. It has previously been found that specific psychosocial interventions targeting smoking cessation can increase the number of women who stop smoking in pregnancy, and subsequently reduce low birth weight and preterm births [27]. It is therefore essential that pregnant women, their partners and close relatives are educated on the health risks of active and passive smoking and how these could affect fetal and infant health as well as their own health [2, 8, 23‐26, 28]. Moreover, the parents’ social support network, including close family members should be involved in supporting smoke-free environments in spaces shared by the newborn. Strategies for successfully engaging families during the perinatal period should be adopted by community based health professionals including community midwives. Health workers should assist women and their families with addressing SHS exposure during the perinatal period by supporting home smoking bans and reducing infant contact with smokers.

In the current study, most pregnant smokers claimed to have actively tried to quit during their pregnancy but unfortunately just over half did not succeed. A possible reason could be that compared to other quitters, pregnant smokers generally had a longer history of smoking [2, 27]. Furthermore, when advising on quitting, motivational and behavioral support should be provided in parallel with easy access to smoking cessation clinics [27]. It would be also beneficial if this service could be provided in the same maternity hospital or in the community health center.

Whether or not a pregnancy was desired and planned, was also a factor that seemed to affect the willingness of pregnant smokers to quit in our study. Women with planned pregnancies were half as likely to be smokers just before pregnancy, and more likely to give up or reduce the volume of cigarettes as pregnancy progressed. However, unplanned pregnancies had 24 % increased odds of low birth weight and prematurity, compared to planned pregnancies independent of smoking status [17].

Recent studies have reported a number of psychosocial differences between smokers and non-smokers during pregnancy and the postnatal period [29‐31]. In our study, women who smoked had significantly higher levels of depressive/anxiety symptoms (Fig. 2) than non-smokers as assessed using the EPDS scale, although caution should be applied to these findings which could reflect women’s experiences of transitory psychological symptoms and/or changes in their functioning and mental state as a normal response to the pregnancy and birth experience. Maternal anxiety and stress may inhibit smoking cessation during pregnancy and promote a relapse after pregnancy in women who have achieved abstinence [30]. Smoking cessation is correlated with depressive symptomatology and should be supported under medical guidance among those smokers who are identified as having mental health symptoms. Community midwives were most likely to provide smoking cessation advice in the study by McCurry et al. 2002 [32]. Moreover, counseling by midwives and healthcare staff were found to significantly reduce the volume of smoking during pregnancy and consequently boost an increase in birth weight [1, 27]. Thus, specific training of community midwives in smoking cessation interventions is needed in order to develop their capability and capacity to provide appropriate and tailored support to pregnant smokers and reduce relapse rates during the postnatal period. In a study from the west of Scotland the development of a home-based midwifery intervention program to support young pregnant smokers to quit was found to be a promising approach to engage young pregnant smokers to help them quit. Local obstetricians and midwives were found to be very willing to support this approach [33].

Smoking during pregnancy not only impacts on the woman’s health, but also on the health of her unborn child. Partners and families of pregnant women should be made aware of this risk and encouraged to participate in smoking cessation programs in order to enhance efforts and quitting results. There is evidence that stopping smoking as early as possible during the pregnancy can reduce the above mentioned risks [34, 35]. Group interventions that include health education information about the risks of smoking and advice to quit, are highly recommended during the perinatal period for smoking cessation support or advice on how to make this change [27]. Women who have had a smoke free pregnancy should be offered help to remain smoke free after birth [34, 35], given that women who quit smoking during pregnancy remain a high-risk group for smoking relapse during the postpartum period [36].

This study had limitations which should be considered. First, maternal smoking status was assessed based on retrospective self-report and without any further clinical assessment. Secondly, we did not follow women up beyond the first 3 days postnatally to assess if pregnant quitters returned to active smoking and women were not routinely asked in early pregnancy about their smoking status in both maternity settings. Moreover, only women who lived in urban areas were able to access the limited free smoking cessation support services offered (mostly in teaching hospitals), if they wanted to quit. As this was a study relevant to perinatal smoking cessation services in Greece, findings may not be not applicable for countries where perinatal smoking cessation services have already been implemented.

Nevertheless, smoking cessation services provided by qualified personnel should be routinely offered in maternity units in Greece. It was apparent in our population that although advice was offered, most pregnant women were unaware or did not know how to access the smoking cessation clinics, which were based in the general hospitals. Although in Greece smoking is banned in public places, there are currently no effective ways of implementing the law. Significant aspects of exposure to passive smoking, such as smoking in cars when children are present, are underestimated and not banned.

The study sample only included participants who gave birth in a public hospital and excluded women who gave birth in private hospitals or at home. However, efforts were made to recruit a representative sample although it should be noted that the rapid socio-economic changes over the last three decades in Greece, have resulted in a relatively homogenous maternal population. Of note is that the majority of women who use public maternity hospitals are routinely transferred to units in Athens for the birth and more specifically to the two large metropolitan university hospitals included in our study. Despite these limitations our sample size is considered satisfactory for statistical analysis.

Other study limitations included the lack of blinding of the midwife researcher to the smoking status of participants which could have potentially resulted in observer bias. Furthermore, there were inherent difficulties due to the low literacy level of women in using a Likert response format. It is possible that other characteristics of maternal smoking behavior corresponded to the differences in risk perceptions and smoking attitudes between smokers and quitters. In this study, we relied on retrospective maternal reports of smoking behavior and recall bias may also have impacted our findings.

The study focused primarily on a potential association between depressive and anxiety symptoms as assessed using the EPDS and maternal active and passive smoking. The EPDS was used in this study because it is a widely administered research tool and no other validated tools are currently available for screening maternal depressive and anxiety symptomology in the Greek language. An EPDS cut-off point of 8/9 was used for screening purposes, in which sensitivity is higher than specificity, in order to detect more potential cases [22].

As only sociodemographic and perinatal variables were assessed as potential confounding factors it is possible that there are other biological and environmental confounding variables which were not detected in this study.

In this study considerably high rates of tobacco use were reported in the first trimester of pregnancy. Most women chose to stop smoking although there were high levels of exposure to passive smoking. Perceptions of fetal health risks and attitudes towards smoking during pregnancy were critical prognostic factors of the anti-smoking behaviors of pregnant women in the study sample. Our data supports the importance of ensuring that pregnant women, their partners and close relatives are educated on the health risks of active and passive smoking and how these could have an adverse effect on birth and other health outcomes of women infants. Smoke-free environments are necessary to promote perinatal maternal and infant health. There is an emerging need to highlight the international aspects of this critical public health issue.