Smoking during pregnancy: a retrospective analysis of West Virginia adolescents.
Article Type: Report
Subject: Smoking (Health aspects)
Smoking (Research)
Smoking (Control)
Teenage pregnancy (Research)
Teenage pregnancy (Health aspects)
Teenage pregnancy (Prevention)
Social problems (Research)
Social problems (Health aspects)
Social problems (Prevention)
Authors: McCave, Emily L.
Shiflet, Ashlea
Pub Date: 07/01/2012
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: July-August, 2012 Source Volume: 108 Source Issue: 4
Topic: Event Code: 310 Science & research
Product: Product Code: 9105263 Teenage Pregnancy NAICS Code: 92312 Administration of Public Health Programs
Organization: Government Agency: United States. Department of Health and Human Services
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 310150683
Full Text: Introduction

The issue of teen pregnancy is an ongoing national social problem, as is the issue of tobacco use during adolescence. There is clear evidence of negative economic and health outcomes associated with each of these issues. (1,2) These two social problems warrant significant resources for research and intervention. An area that is equally important is where these two social problems meet, that is the issue of pregnant teenagers smoking during pregnancy. This is one population that especially should be the focus of research and intervention work.

The percent of pregnant teens who report smoking tobacco varies, as do their reasons for smoking during pregnancy. Kaiser and Hays (2005) found that 27% (n = 145) of adolescent pregnant females between the ages of 15 and 18 smoked during pregnancy. (3) In another study, 45% of mothers under the age of 20 reported smoking during their pregnancy compared to 15% of mothers who were between the ages of 30 and 44. (4) One reason that more pregnant teens may smoke compared to adult pregnant women is because of their developmental stage. Peer conformity and acceptance is extremely important to adolescents and those who are pregnant report trying to reduce weight gain during pregnancy to avoid criticism from friends and dating partners. (5-6) Additionally, smoking cigarettes reportedly helps pregnant teens manage daily stress in their lives, particularly when family life is chaotic. (6) Pregnant adolescents' higher rates of smoking have also been attributed to their concern of delivery pain; authors have found that pregnant teens believe they will experience less pain during the delivery if they smoke cigarettes because their infants will be smaller. (7) Their hope for a smaller infant does typically come to fruition for these pregnant teens, as smoking has in fact been linked to low birth weight. (5) It is not surprising then that mothers who had a first pregnancy that resulted in low birth weight are more likely to be recurrent smokers in subsequent pregnancies. (8-9)

Authors have found that adolescents will decrease their level of smoking during the first trimester but will increase again in the third trimester. (9-10) One such study reported that 52% of teenage mothers smoked the year prior to their pregnancy. Of these same mothers, 46% of them smoked during their first trimester while 58% of them reported smoking during their third trimester. (10) A second study looked at 310 pregnant adolescents and found that 59% smoked prior to pregnancy. The percent of pregnant adolescents who reported smoking decreased to 51% during the first trimester. However, the rate of pregnant adolescents smoking increased to 62% in the second and third trimesters. (9)

There are numerous predictive factors of adolescent smoking during pregnancy. These risk factors include: race--specifically, Non-Hispanic Caucasian females are more likely to smoke during pregnancy; socioeconomic status--particularly those living in low-income families and communities, especially rural communities; as well as lower educational attainment. (3,5,8,10,11-18) Other factors that increase the likelihood of smoking during pregnancy include having a limited support system, as well as having peers or significant others who smoke or concurrently use marijuana or alcohol. (10,12,15,18-19)

Consequences of smoking during pregnancy include the risk of complications such as placenta previa, and abruptio placenta along with an increased risk for a miscarriage. (7,16,19-20) Likewise, the negative health outcomes of smoking during pregnancy on fetuses are well documented in the literature. The major risk is that the infant will be born prematurely or with a low birth weight. (7-8,16,21-23) Fetuses exposed to cigarette smoke in utero are also at a greater risk for being placed in the neo-natal care unit after birth and have higher infant mortality rates from Sudden Infant Death Syndrome (SIDS). (7-8,11) Finally, long term effects include developmental and intellectual delays, asthma, as well as other medical illnesses such as bronchitis and pneumonia. (3,7,10,20-22)

Given that West Virginia ranks 45th in the nation for the percent of adolescent smokers ages 12-17, (24) this researcher used retrospective statewide data to examine the prevalence of smoking among pregnant teens in West Virginia. The study aim included identifying the demographic and health characteristics of those teens in West Virginia who did report smoking during pregnancy and their infants.

Methodology

This researcher utilized retrospective data from the West Virginia Birth Score program. The statewide Birth Score program is unique to West Virginia; it was designed to screen newborns for risk of infant death within the first year and provides a mechanism for early referral to services. (25) Since 1998, all West Virginia hospitals and facilities that provide birthing services are required by law to participate in the program. The statewide data that is collected is managed at West Virginia University School of Medicine. Answers on the Birth Score screen add up to a total score and those with a "high birth score" (scores over 99) are automatically referred to services, either through Medicaid funded services or private community services. In addition to the Birth Score screen, mothers are asked additional questions during the birth hospitalization when they obtain the Birth Certificate for their child.

The cases from the dataset that were selected included adolescent girls between the ages of 12 and 18 who gave birth in West Virginia between the years of 2003 and 2008. Cases with missing data were excluded from the analysis. Additionally, frequency distributions were examined for each variable. These distributions were used to identify the cases that had extreme values outside of the normal distribution, otherwise known as outliers. An example of this would be a case in which the gestational period for a teen was 45 weeks or her weight gain during pregnancy was 55lbs. Extreme values that are outside the norm of the population have a greater impact on the data analysis and may lead to biased results. One way to prevent this is to delete the cases. The variables included in this study included 1) smoking status, 2) maternal education level, 3) year infant was born, 4) prior living births, 5) race, 6) trimester teen accessed prenatal care, and 7) birth score. Descriptive and bivariate analyses were conducted.

The University Institutional Review Board approved this study.

Results

There were 6,922 teens who remained in this sample after cases with missing data and outliers were deleted. From this sample, 34.1% (n = 2,359) of teens reported smoking during pregnancy. A breakdown of the descriptive and bivariate results by variables is provided below.

Tobacco Use During Pregnancy and Educational Level

Looking within each educational level, a higher percent of pregnant teens with lower educational levels reported tobacco use during pregnancy. Comparing teens across educational levels, 46.5% (n = 277) of those with an educational level of Kindergarten through 8th grade reported smoking in pregnancy. This compared to 45.8% (n = 559) with a 9th grade educational level, followed by 35.9% (n = 603) with a 10th grade educational level. For those with an 11th grade educational level, 27.8% (n = 425) reported smoking during pregnancy, followed by 26.8% (n = 481) of those with a 12th grade educational level. The lowest percent of teens who reported smoking during pregnancy were those teens with some college or above, with 13.9% (n = 14). A Chi-square analysis showed a significant relationship between educational level and smoking during pregnancy ([chi square](5) = 205.5, p = .000). The effect size was .172 for this analysis, which is considered a small effect size according to Cohen (1992). (26)

Tobacco Use During Pregnancy and Infant Birth Weight

An independent t-test was conducted to determine whether there was a significant relationship between tobacco use during pregnancy and infant birth weight. The results indicated that those teens who smoked tobacco during pregnancy gave birth to infants with significantly lower birth weights than those who did not smoke during pregnancy (t (6920) = 11.903, p = .000). Infants born to teen mothers who smoked weighed on average 3070.39 grams (SD = 511.20). This is compared to 3225.97 grams for infants born to those who did not smoke during pregnancy (SD = 517.58). Levene's test for equal variances was not significant (p =.649), indicating that the necessary assumption that the two groups (smoking and non-smoking) have approximately equal variance on the dependent variable (infant birth weight) was met.

Tobacco Use During Pregnancy and Prior Births

A small number of teens reported a prior birth (n = 839) compared with those who did not have a prior birth (n = 6,083). When examining smoking status of these two groups, a larger percent of those who did have a prior birth smoked during pregnancy (45.5%, n = 382). This compares to 32.5% (n =1,977) of teens who smoked during pregnancy and did not have a prior birth. A Chi-square analysis showed a significant relationship between prior births and smoking during pregnancy ([chi square](1) = 55.72, p = .000), however the effect size was small (.090) for this analysis.

Tobacco Use During Pregnancy and Infant Birth Score

A higher percentage of infants with a high birth score were born to teen mothers who smoked tobacco during pregnancy. Of the 1,303 mothers who had an infant with a high birth score, 38.6% reported using tobacco during pregnancy. This compares to 29.8% (n = 1056) of the teens who had a infant with a low birth score and reported smoking during pregnancy.

Tobacco Use During Pregnancy and Race

Differences in race were found when examining those teen mothers who smoked tobacco during pregnancy. Of the 6,414 mothers who were Caucasian, 35.1% (n = 2254) smoked during pregnancy. This compares to 20.4% (n = 74) of the African American mothers who smoked during pregnancy.

Tobacco Use During Pregnancy and Infant Year Born

Tobacco use during pregnancy varied depending on the year the infant was born. There was a decline in the percent of teens reporting tobacco use during pregnancy for those who gave birth in 2007 and 2008 (see Table 1 for breakdown by year).

Tobacco Use During Pregnancy and Prenatal Care

In looking at those teens who started prenatal care in the first trimester, 34.2% (n = 1791) reported smoking during pregnancy. This compared to 34.3% (n = 494) who reported smoking during pregnancy and sought prenatal care during the second trimester. For those who started prenatal care in the third trimester, 29.3% (n = 65) reported smoking during pregnancy. Of the small group of teens who did not access prenatal care, 40.9% (n = 9) reported smoking during pregnancy.

Utilization of prenatal care did not vary by smoking status. In both groups 76% accessed prenatal care in the first trimester, 21% sought care in their second trimester, and 3% first began their prenatal care in their third trimester. Less than 1% of both groups did not utilize prenatal care. Those who reported smoking had a similar number of prenatal visits than those who did not smoke (9.58 visits compared to 9.83 visits, respectively). While this difference was statistically significant (t=2.820, df = 6920, p = .005), clinically this difference is small (less than one visit in difference).

Limitations

This study did not use a randomly selected sample, but rather the entire sampling frame of teens who gave birth in West Virginia during 2003- 2008. This limits the ability to generalize results beyond West Virginia. Additionally, given the very large sample size (n = 6,922), it is not surprising that all of the Chi-square analyses conducted on these variables resulted in significance levels of p [less than or equal to] .01. According to Cohen (199226), in Chi-square analysis, effect sizes are small, medium, and large (.10, .30, and .50, respectively). When looking at effect size, however, none of the relationships that were found to be significant had either a medium or large effect size. Consequently, while additional Chi-square analyses were conducted, only the two Chi-square results with the highest effect sizes were reported, which were still very small in terms of strength of relationship. Thus, the majority of the results of this study should be used primarily for descriptive purposes rather than inferential statements.

Discussion

This study examined retrospective data on all those adolescents who gave birth from 2003-2008 in West Virginia, as it relates to tobacco use during pregnancy. Important information regarding the demographic and health characteristics of adolescents in West Virginia who are pregnant and smoking was found. Implications for future research and interventions are discussed below.

Education Level and Tobacco Use

The highest percent of teens reporting tobacco use during pregnancy were those in the earlier grades (8th grade or less), followed by those in 9th and then 10th grade. While the percentages were lower in the final two grades in high school, there was still over one quarter of the teens who reported smoking during pregnancy. It was only for the small group of teens who had some college level education that the percentages were under 15%. This suggests that school nurses, health teachers, and social workers should target their interventions towards younger teens. This can be done on a larger scale, such as in all health classes, as well as for those students who let school staff know that they are pregnant and planning to move forward with the pregnancy. Additionally, as part of sexual education and/or health classes, it would be beneficial to cover the risk factors associated with smoking during pregnancy. While a majority of teens do get pregnant in the last two years of high school, those who are younger are already at a higher risk medically and thus should have education as to the health benefits of not smoking during pregnancy both for themselves and their infants.

Birth Weight and Tobacco Use

The results of this study are consistent with the literature, in that those who smoke tobacco during pregnancy have babies with significantly lower birth weights. This is a major concern, given that low birth weight has been found to be the primary predictor of infant mortality. (25) Also in a recent study using the West Virginia Birth Score data for all women in the state, "the average birth weight of infants born to mothers who smoked was 3039 grams compared to the average birth weight of infants born to mothers who did not smoke of 3289 grams" (p. 18). (25) This is similar to the results found in the West Virginia teen population as well. The main issue at hand here is the desire of teen girls to reduce weight gain and manage stress, as well have a less painful delivery. Currently, using tobacco is a way that these teens can effectively achieve these goals. The next step in research would be to examine the knowledge levels of teen girls in regards to the health impact of low-birth weight on infants and its connection to infant mortality. Future research is needed to thoroughly explore how teens negotiate the decision to use tobacco during pregnancy, specifically considering issues such as their fears about delivery, their knowledge levels of alternative delivery strategies to reduce pain during childbirth, their health concerns for their infants, and the influence of whether the pregnancy was desired or not. It is important to note that any provider developing an intervention in this particular area needs to use a developmental approach, given that the cognitive and socio-emotional maturity level of the teen is certainly a factor in their ability to successfully negotiate this decision-making process.

Birth Score and Tobacco Use

It is not surprising that there was a higher percentage of teen mothers who reported smoking during pregnancy and who also had an infant with a high birth score. Smoking during pregnancy is one of the seven questions on the Birth Score screen and it does add points towards the total score if answered "yes". While not all seven variables that make up the total birth score were examined in this study, four other variables besides smoking during pregnancy were analyzed, including prior pregnancies, birth weight, maternal education, and maternal age. These four variables all showed higher percents of teens who reported smoking during pregnancy as well, indicating that the birth score screen is a valuable tool for identifying those who may need additional education and resources on tobacco cessation.

In another West Virginia study that used the Birth Score data on women of all ages who gave birth between 2001 and 2009, Mullett and colleagues found that 28.5% of the women had reported using tobacco during pregnancy (2010). (25) This is lower than the 34.1% of teens in this study's sample who reported using tobacco during pregnancy. The results of this study confirm what was found in the larger study of all women. Mullett and colleagues found that women who had an infant with a high birth score were more likely to report tobacco use during pregnancy (53.7%) compared with those women who used tobacco during pregnancy and had an infant with a low birth score (23.6%). (25)

Year of Birth and Tobacco Use

While over one third of the sample consistently reported using tobacco during pregnancy during 2003-2007, 2008 was the first year that this percentage dropped to 29%. This may be in part due to efforts to increase statewide surveillance of tobacco use as well as to create evidence-based, comprehensive smoking cessation programs since 2007. (27)

Race and Tobacco Use

Similar to the rest of the country, there was a higher percentage of Caucasian teens who reported smoking during pregnancy, as compared to their African American teen counterparts. Authors have suggested the rates are higher for Caucasian teens because they are more likely to live with someone who smokes, to see a parent or guardian smoke, to have friends who smoke, and lastly, they are less likely to have a smoking ban in their homes than African American teens. (28) Given that smoking rates are higher for teens in West Virginia than the rest of the nation, those engaging in research and interventions in this area should consider that tobacco use might be perceived as normative for adolescents and thus involvement by key stakeholders such as family members, peers, and teachers is critical.

Prenatal Care and Tobacco Use

An important finding is that prenatal care utilization did not vary between smokers and nonsmokers. Using the total number of prenatal care visits and the trimester in which prenatal care was first accessed provides a more complete picture than only using one of these indicators. (29) Three-quarters of the teens in both groups accessed prenatal care in their first trimester. The Healthy People 2020 has a target of 77.9% of the population accessing prenatal care in the first trimester, indicating that West Virginia is close to reaching this goal. (30) Additionally, the American Congress of Obstetricians and Gynecologists (ACOG) recommend at least nine visits for adequate prenatal care. (29) This study's findings indicate that on average both the non-smoking and smoking teens in West Virginia are receiving an adequate number of prenatal visits with just over nine visits for both groups. Given these findings, health providers should have equal opportunities to counsel smoking teens. As mentioned in the introduction, the main obstacle may in fact be less about accessing these teens but rather having an impact in smoking cessation during later trimesters. A limitation with the Birth Score screen at the time of data collection is that the form did not ask specific questions about smoking behavior prior to pregnancy, the amount of smoking during the pregnancy, or about intention to reduce or quit smoking during pregnancy. Consequently, these additional questions remain unanswered. In particular, the question of whether or not there was an increase in reported smoking during the third trimester compared to the first trimester is an important piece of data that could be useful in comparing our teens with those in other states.

While only a small number of the teen mothers reported no prenatal care, this group still had the highest percentage (nearly 41%) of teens who reported tobacco use during pregnancy. This subpopulation of pregnant teens is a group that needs to be a focus of attention for research and intervention. Determining the primary reasons as to why they are not using prenatal care is key; it may be an access issue due to financial or transportation barriers, or it could be that it is normative within their families to not utilize formal health care services, perhaps because of mistrust of physicians or perceived lack of privacy in their rural communities. A majority of the sample sought prenatal care in either the first or second trimester and had similar rates of using tobacco during pregnancy (just over 33%). It is likely that these teens are receiving health education related to tobacco use during pregnancy and assistance for smoking cessation prior to the third trimester, which is when smoking is most harmful to the fetus. (5) Authors can focus future efforts on determining the effect of tobacco health education during these prenatal visits and tracking tobacco use over the course of the pregnancy.

Building on What we Know Works

Interventions can target those teens who have not started smoking yet, those who have recently quit and may start again, and those who are actively using tobacco. For those teens who use tobacco and become pregnant, programs that have demonstrated some evidence of success with teens are "multi session smoking prevention programs with peer support" as they help provide the intervention needed for female adolescents transitioning into motherhood at an early age (p.152). (9) Likewise, these multi session interventions have been found to reduce smoking initiation among teenagers. (9) Intervention programs that involve peer resistance, role modeling and booster sessions can be highly successful and these interventions should occur where large populations of adolescents gather such as schools and health care facilities. (7,9)

Authors have shown that programs that utilize a multidimensional educational framework can be successful in short-term tobacco cessation in adolescents. Ideally programs would result in long-term smoking cessation, however, the critical time period that nicotine interferes with fetal development is during the third trimester. Those who stop smoking by the third trimester have babies with similar health outcomes as compared to babies born to non-smoking mothers. (9,13-14,22) Programs such as The Teen FreshStart program plus Buddy, which was modified from an existing intervention curricula created by the American Cancer Society, should be considered for replication studies. (21) Short term cessation by pregnant teens was reported by those participating in this curriculum.

These cessation interventions should be adapted to serve each unique adolescent mother by encouraging participation of the adolescents' parents, being developmentally appropriate and using educational materials that examine the first-hand as well as environmentally harmful effects of smoking on the fetus and infant. (9) Throughout the intervention, adolescents should receive positive reinforcements for quitting or lowering their cigarette intake. Finally, adolescent peers may also aid in these interventions as they provide real-life experiences for teenagers and can serve as a support system. (3,7,9,21) A collaboration of professionals such as social workers, law enforcement, teachers, nurses, physicians, substance abuse counselors and child protective services workers can also be effective in promoting cessation for the health of the teen mother and infant.

Conclusion

This data reveals that tobacco use among pregnant teens is a statewide concern in West Virginia. Important demographic and health characteristics of the West Virginian teens who gave birth during 2003-2008 were presented. Several ideas were discussed for future research and intervention efforts for better understanding the complexities involved for this population as well as how to address this social problem. Moving forward with evidence-based research and interventions to improve tobacco prevention and cessation is in line with the priorities of the Department of Health and Human Services. According to the Healthy People 2020 plan, there are five objectives that set forth a priority to reduce the prevalence of smoking by adolescents who are pregnant. These objectives include a reduction in: 1) the incidence of infants born low birth weight (LBW) and very low birth weight (VLBW); 2) the incidence of preterm births; 3) the incidence of fetal and infant mortality; 4) the incidence of illness and complications for mothers during pregnancy and delivery; and lastly, 5) increase in the proportion of pregnant women who reach their recommended weight gain during pregnancy. (30) While these may be ambitious goals, West Virginia residents deserve to have these objectives identified as a state priority. The state can become a leader in the country by allocating resources to attract researchers, health providers, state legislators, community leaders, and consumers to share their expertise and work within communities to make these objectives a reality over the next ten years.

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Emily L. McCave, PhD, MSW

Assistant Professor, Division of Social Work, WVU

Ashlea Shiflet, BA, MSW

Student, Division of Social Work, WVU
Table 1. Tobacco Use by Year
Infant Born

                      % (n) of Teens Who
Year Infant Born    Smoked During Pregnancy

2003                      35.9 (409)
2004                      36.2 (375)
2005                      34.1 (391)
2006                      36.2 (446)
2007                      33.1 (414)
2008                      29.0 (324)
Overall                  34.1 (2359)
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