Depression and smoking during pregnancy
Introduction
Maternal smoking during pregnancy is associated with increased risk for spontaneous abortions, low birthweight, premature delivery, and fetal death Castles et al., 1999, Cnattingius et al., 1988, Tuthill et al., 1999, Ventura et al., 1998, Walsh, 1994. Most pregnant women seem to be aware of the potential negative consequences of smoking and are in fact concerned about their tobacco use Dunn et al., 1998, MacCorquodale & Ballweg, 1991, Walsh et al., 1997. However, only about 30% of those who smoke manage to quit after learning that they are pregnant Floyd et al., 1993, LeClere & Wilson, 1997, Severson et al., 1995; the rest continue to smoke throughout pregnancy. There is certainly a need to better understand what prevents the majority of expectant mothers from quitting smoking.
Studies have found that multiple factors predict smoking during pregnancy. Women who do not have a positive attitude towards pregnancy are more likely to continue to smoke after they learn about their pregnancy Hanna et al., 1994, LeClere & Wilson, 1997. Heavy smokers have more difficulty in quitting and thus are more likely to remain smokers during pregnancy Hakansson et al., 1999, Severson et al., 1995. Those who have other smokers in the same household are more likely to remain smokers throughout pregnancy LeClere & Wilson, 1997, Severson et al., 1995. Low education, as well as the status of not being married, are also found to predict continued smoking among pregnant women LeClere & Wilson, 1997, Severson et al., 1995, Ventura et al., 1998, Williamson et al., 1989.
One factor that has not received sufficient attention in previous studies is the role of depression in smoking during pregnancy. The association between depression and smoking has been investigated with those who are not pregnant (Borrelli, Bock, King, Pinto, & Marcus, 1996). Smokers who are nicotine dependent have higher scores on symptomatic measures of depression compared with nonsmokers (Breslau, Kilbey, & Andreski, 1993). Among current smokers, persons with a history of major depression report more withdrawal symptoms during unsuccessful quit attempts or attempts to cut down than persons without a history of depression (Breslau, Kilbey, & Andreski, 1992). Depressed smokers are more likely to relapse (Anda et al., 1990) and less likely to adhere to a smoking cessation program (Ginsberg et al., 1997). Depression is also found to predict a lower quit rate in adolescent smokers (Zhu, Sun, Billings, Choi, & Malarcher, 1999). However, only one study has dealt with smoking and the development of depression in pregnancy (Pritchard, 1994). Pritchard found that depression increased as the pregnancy progressed from 20 to 30 weeks for all the women and that smokers had a higher rate of depression than nonsmokers at both 20 and 30 weeks. However, because the study focused on depression as the outcome variable, it did not examine if depression predicts smoking when the effects of other known predictors of smoking in pregnancy are controlled.
The present study intends to examine if depression contributes to continued smoking during pregnancy after controlling for other predictors of smoking identified in previous studies. Thus, this study will measure depressive symptoms of pregnant women along with other predictors of smoking such as attitudes towards the pregnancy, the presence of other smokers in the same household, and educational level. Furthermore, besides comparing current smokers with never smokers, this study will also compare current smokers with former smokers, and former smokers with never smokers, for depressive symptoms. Previous analyses of depression and smoking often group former smokers with never smokers as one category (nonsmokers). However, it is not clear whether former smokers are indeed just like never smokers now that they are no longer smoking. Given that pregnancy is a time that smokers are quitting at a greater rate than usual (Brenner & Mielck, 1993), it will be interesting to see how these former smokers compare to those who currently smoke and those who have never smoked in terms of experience of depressive symptoms.
Section snippets
Survey sample
Participants in this study were pregnant women enrolled from two Norwegian hospitals, Bærum and Lillehammer, both county hospitals outside Oslo. The pregnancy care system in Norway is organized in such a way that all low risk pregnancies are taken care of by general practitioners (and their employed midwives), while high risk pregnancies are referred to specialists (obstetricians). All pregnancy care is free of charge. In addition to the routine care, every woman is offered an ultrasound
Results
Overall, 13.1% of the participants were current smokers, another 35.9% were former smokers, and the rest of them had never smoked. Table 1 presents the characteristics of these women by their smoking status.
The participants' ages ranged from 17 to 44, with a mean age of 29.2 (S.D.=4.6). There was no significant difference in the age distribution regardless of smoking status. However, current smokers were much less educated than never smokers. Only 18.8% of current smokers had 12 or more years
Discussion
The data from this study indicate that there is a strong link between depression and smoking: depression not only predicts current smoking behavior, but it also predicts past smoking behavior. This remains true after the effects of other known predictors, education and presence of other smokers, are controlled in the analysis.
There are several possible underlying mechanisms that can make a depressed person more prone to continuing smoking in pregnancy. One is the self-medication hypothesis,
Acknowledgements
This work is supported in part by The Norwegian Cancer Society and was initiated during Dr. Valbø's sabbatical visit to the University of California, San Diego. The data analysis and writing were supported by NCI 5 P01-CA72092. The authors wish to thank Michael Byrd and Kendal Manning for assistance in questionnaire construction, and Drs. Toril Kolås, Jichao Sun, Sharon Cummins, and Ann Heyen for their assistance in data collection, statistical analysis, and preparation of an earlier draft of
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