Making a difference in infant survival: evidence-based actions to reduce tobacco exposure during pregnancy and infancy in North Carolina

North Carolina faces major challenges in dealing with smoking and its consequences during pregnancy and infancy. Evidence-based strategies exist to help pregnant and parenting smokers to quit, to discourage young people from becoming smokers and to reduce exposure of infants to SHS. North Carolina is making progress in implementing these strategies, but more infant lives could be saved each year if the state adopted a more comprehensive approach to addressing tobacco use by improving cessation services for pregnant and parenting smokers, reimbursing clinicians for providing cessation services, increasing state excise taxes on tobacco products, establishing statewide help or quitline services and adopting tobacco-free school policies. These proven strategies can make a difference.     

What physicians can do about the tobacco problem: best practice interventions for your practice and office

This article is the first in a series of four providing up-to-date information about the tobacco problem and how physicians can effectively intervene. Three of the four articles are accredited for free continuing medical education (CME) credit for physicians. The CME credit is being provided free of charge by Nemours via the Web site www.pedseducation.org. Physicians may obtain credit by logging on to this site, registering, and completing the post-test and evaluation materials. This article reviews the best evidence-based approaches for tobacco intervention in the busy office. It discusses the implementation of the following components of a tobacco-control program to effectively and efficiently address the tobacco problem: 1) physician counseling to promote smoking cessation, 2) strategies to promote abstinence from smoking, 3) strategies to minimize environmental tobacco smoke exposure, 4) strategies to encourage tobacco use cessation, and 5) office-based interventions. By reading the article and completing the post-test, it is anticipated that the following learning objectives will be met: 1) physicians will become familiar with best practice interventions for tobacco counseling and limiting secondhand smoke exposure, and 2) physicians will become familiar with office based strategies to promote a strong anti-smoking message.     

孕期吸烟与被动吸烟影响妊娠结局的研究进展

吸烟会带来一系列的健康问题,而孕期吸烟或者被动吸烟的危害更大。国内外的专家采用了多种研究方法,证实烟草中的化合物对孕妇和胎儿均有害。接触烟雾的孕妇在妊娠期间早产、流产和死胎的风险及各种并发症的风险将大大增加,且对妊娠结局产生较大影响。今后应加强针对孕妇的有关香烟烟雾危害的健康教育工作,从而使孕妇最终能够有效回避香烟烟雾的危害。     

'Common courtesy' and the elimination of passive smoking. Results of the 1987 National Health Interview Survey

The tobacco industry recommends "common courtesy" as the solution to potential conflicts over smoking in public places and as an alternative to policies that restrict or ban smoking. Specifically, the industry suggests that nonsmokers "mention annoyances in a pleasant and friendly manner" and that smokers ask others, "Do you mind if I smoke?" We analyzed data for 22,000 adults who responded to the 1987 National Health Interview Survey of Cancer Epidemiology and Control to determine if common courtesy is being used in passive-smoking situations. Almost half (47%) of smokers said they light up inside public places without asking if others mind. When someone lights up a cigarette inside a public place, only 4% of nonsmokers ask the person not to smoke despite the fact that most nonsmokers consider secondhand smoke harmful and annoying. We compared these data with similar data collected by the Roper Organization in the 1970s and found that smokers today are less likely to smoke inside public places. However, nonsmokers' actions in response to secondhand smoke have changed very little. These findings show that the common courtesy approach endorsed by the tobacco industry is unlikely, by itself, to eliminate exposure to environmental tobacco smoke. Though no one would oppose the use of common courtesy, we conclude that legislative or administrative mechanisms are the only effective strategies to eliminate passive smoking.     

The pharmacotherapy of smoking cessation

1. The great majority of smokers are chronically dependent on tobacco. This dependence arises from the rituals and sensory associations of smoking that are reinforced, within seconds, by a rapid burst of nicotine from the cigarette. 2. All forms of nicotine replacement therapy (NRT) -- gum, patches and inhaler -- and bupropion are safe and effective for increasing smoking cessation rates in the short and long terms. 3. Other than those who are minimally dependent, all patients willing to quit should be offered one of these therapies unless contraindications exist. The effectiveness of drug treatments is multiplied when associated with effective counselling or behavioural treatments. 4. While NRT is not recommended during pregnancy or in patients with cardiac disease, if the alternative is smoking NRT is almost certainly safe. 5. Combination NRT (more than one therapy) may be indicated in patients who have failed monotherapy in association with withdrawal symptoms. 6. There are some specific contraindications to the use of bupropion. Its subsidised availability should not influence prescribers to ignore these.     

Second-hand tobacco smoke in Oklahoma: a preventable cause of morbidity and mortality and means of reducing exposure

Evidence has mounted in recent years establishing second-hand tobacco smoke exposure as a cause of morbidity and mortality in nonsmokers. The ratio of deaths is approximately one nonsmoker dying from illness caused by second-hand smoke exposure for every eight smokers who die from diseases caused by tobacco use. This is equivalent to about 750 nonsmoker deaths each year in Oklahoma caused by exposure to second-hand smoke. This article reviews the components of second-hand smoke, its health effects, its prevalence in Oklahoma, and the means of protecting children and nonsmoking adults from exposure. Oklahoma physicians are encouraged to advise their patients about the harmful effects of second-hand smoke and to actively support public policies that decrease exposure to second-hand smoke in public places and workplaces.     

The cost-effectiveness of counseling smokers to quit

Cigarette smoking is the most important preventable cause of death in the United States. Surveys of patients, however, suggest that many physicians do not routinely counsel smokers to quit. Because physicians may not consider counseling against smoking to be as worthwhile as other medical practices, we examined its cost-effectiveness. We based our estimates of the effectiveness of physician counseling on published reports of randomized trials and our estimates of its cost on average charges for physician office visits. Our results indicate that the cost-effectiveness of brief advice during routine office visits ranges from $705 to $988 per year of life saved for men and from $1204 to $2058 for women. Follow-up visits about smoking appear to be similarly cost-effective. Physician counseling against smoking, therefore, is at least as cost-effective as several other preventive medical practices and should be a routine part of health care for patients who smoke.     

Awareness of tobacco-related health hazards among adults in China

Objective To determine the level of awareness of the hazards of tobacco smoking and secondhand smoke inhalation among adults in China. Methods Household surveys were conducted with a total of 13 354 respondents aged 15 years or over from 100 counties of 28 Chinese provinces using a stratified multi-stage geographically clustered sample design. Results The findings revealed that 81.8% of the population was aware that smoking causes serious diseases, and 27.2% and 38.7% were aware that smoking causes stroke and heart attack, respectively. Only 64.3% of respondents were aware that secondhand smoke can cause serious diseases, and 27.5%, 51.0%, and 52.6% were aware that secondhand smoke causes heart disease in adults, lung disease in children and lung cancer in adults, respectively. Awareness regarding smoking-related hazards across all participants was significantly associated with several factors, including gender, smoking status, urban/rural residency, education level and exposure to tobacco control publicity in the last 30 days. Awareness regarding tobacco-related hazards in smokers was significantly associated with urban/rural residency, education level, exposure to tobacco control publicity in the last 30 days, and physician＇s advice. Awareness relating to the hazards of inhaling secondhand smoke was associated with smoking status, urban/rural residency, age, education level, and exposure to tobacco control publicity in the last 30 days. Medical professionals were found to know more about the health hazards of tobacco compared with people in other types of employment. Conclusions Overall awareness of the health hazards of tobacco has improved in the last 15 years in China, but is still relatively poor. Improved means of communicating information and more effective warning labels on cigarette packaging are necessary for increasing public awareness of tobacco hazards, particularly among rural residents and people with less education.     

Cigarette smoking in pregnancy

It is likely that the most important example of passive smoking is that which is imposed on the fetus. An article in the April 18, 1988, issue of the "Medical Journal of Australia" makes it clear (Condon and Hilton) that great difficulties will be faced in dealing with the effects of smoking during pregnancy. Gritz (1980) examined the evidence for fetal toxicity from tobacco smoke and the risk ratios for the various hazards. The risk of spontaneous abortion is increased by a factor of 1.8, low birth weight by a factor of 2.0, and perinatal mortality by a factor of 1.35. These increases come as no surprise given what is known regarding the pathophysiology of tobacco's effect on the fetus and the placenta. Condon and Hilton report on the observation that pregnant women find it much easier to stop drinking alcohol than to quit smoking cigarettes. Women who reported positive feelings about their pregnancy also indicated that their concern about, and attachment to, their unborn child provided insufficient motivation to stop using nicotine. It is assumed that the women described in this article were aware of the risks to the fetus from smoking in that such information is available almost as a routine part of antenatal care, and all but 1 of the smokers did try to reduce or to stop their use of nicotine. Yet, 14 of the 35 smokers failed in their efforts to reduce their smoking; another 7 smokers could manage only a small reduction. The 23,000 tobacco-associated deaths/year support the importance of developing a strategy to deal with nicotine dependence, particularly in situations of high risk such as pregnancy. The most reasonable and potentially effective approach would be to expend energy on preventing or dissuading young women from smoking in the 1st place. Over the past decade there have been numerous efforts at mass-media and educational campaigns to dissuade women from smoking, but these efforts have been overwhelmed totally by the determined drive on the part of tobacco companies to recruit female smokers.     

Teenage smoking in pregnancy and birthweight: a population study, 2001-2004

OBJECTIVE: To determine the association between smoking in pregnant teenagers and baby birthweight. DESIGN, SETTING AND PARTICIPANTS: A retrospective population-based study of women aged < 20 years who gave birth to liveborn singletons in Australia between January 2001 and December 2004. Data were drawn from the National Perinatal Data Collection. MAIN OUTCOME MEASURES: Maternal smoking, birthweight, low birthweight (LBW). RESULTS: The prevalence of LBW in babies born to teenage smokers was 9.9%, compared with 6.0% in babies born to teenage non-smokers (odds ratio [OR], 1.72 [95% CI, 1.57-1.90]). On average, babies born to teenage smokers were 179.8 g lower in birthweight than babies born to teenage non-smokers (95% CI, 165.5 -194.1 g; t = 24.6, P < 0.001). Smoking, Indigenous status, Socio-Economic Indexes for Areas category and parity were independently associated with LBW (all ORs > 1.3; P < 0.001) after adjusting for maternal age group. Teenagers smoking > 10 cigarettes a day had babies with lower birthweight that those who smoked < or = 10 cigarettes a day, demonstrating a dose-response relationship. The babies of teenage smokers who stopped smoking before 20 weeks' gestation had birthweights similar to those of babies born to teenage non-smokers. One in 15 teenage smokers stopped smoking during pregnancy. CONCLUSION: Babies whose mothers smoked during pregnancy were more likely to have LBW than babies whose mothers did not smoke. Mothers who continue to smoke in the second half of pregnancy increase their baby's risk of LBW. There is significant scope to improve the quitting rate, and health professionals need to target smoking cessation at all contacts with pregnant women who continue to smoke.     

Does breathing other people's tobacco smoke cause lung cancer?

The available epidemiological studies of lung cancer and exposure to other people's tobacco smoke, in which exposure was assessed by whether or not a person classified as a non-smoker lived with a smoker, were identified and the results combined. There were 10 case-control studies and three prospective studies. Overall, there was a highly significant 35% increase in the risk of lung cancer among non-smokers living with smokers compared with non-smokers living with non-smokers (relative risk 1.35, 95% confidence interval 1.19 to 1.54). Part of this increase was almost certainly caused by the misclassification of some smokers as non-smokers. As smokers, who are more likely to get lung cancer than non-smokers, tend to live with smokers this misclassification probably exaggerated the estimated increase in risk. Adjustment for this error reduced the estimate to 30% (relative risk 1.30), but as people who live with non-smokers may still be exposed to other people's smoke this estimate was revised again to allow for the fact that a truly unexposed reference group was not used. The increase in risk among non-smokers living with smokers compared with a completely unexposed group was thus estimated as 53% (relative risk of 1.53). This analysis, and the fact that non-smokers breathe environmental tobacco smoke, which contains carcinogens, into their lungs and that the generally accepted view is that there is no safe threshold for the effect of carcinogens, leads to the conclusion that breathing other people's tobacco smoke is a cause of lung cancer. About a third of the cases of lung cancer in non-smokers who live with smokers, and about a quarter of the cases in non-smokers in general, may be attributed to such exposure.     

Smoking cessation during pregnancy

Smoking during pregnancy is associated with maternal, fetal, and infant morbidity and mortality. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment has been proven to increase quit rates. For pregnant women who smoke less than 20 cigarettes per day, the provision of a 5-15 minute, five-step counseling session and pregnancy-specific educational materials increases cessation by 30-70%. This bulletin outlines this office-based intervention and addresses treatment issues pertaining to pregnant women who smoke heavily, smoking reduction, pharmacotherapy, healthcare support systems, and coding.     

乌鲁木齐市汉族孕妇营养知识、态度及行为调查与分析

目的了解乌鲁木齐市汉族孕妇营养知识、态度及饮食行为现状及其影响因素,为孕妇营养教育工作提供科学依据。方法采用问卷调查法,对2011年5-11月在乌鲁木齐市妇幼保健院定期行产前检查的汉族孕妇共600例(孕早、中、晚期各200例)进行营养知识、态度、行为的问卷调查,并对结果进行分析。结果乌鲁木齐市汉族孕妇营养知识掌握情况欠佳,营养态度普遍较好。62.8%的孕妇有挑食、偏食现象,66.7%的孕妇不吃保健品,97.8%孕妇不吸烟,但是61.5%的孕妇受被动吸烟,1.3%孕妇在孕期偶尔饮酒,96.8%孕妇不知道如何安排孕期的饮食。孕妇营养知识水平与年龄、文化程度间差异有统计学意义(P<0.01),与职业间差异无统计学意义(P>0.05)。结论乌鲁木齐市汉族孕妇的营养知识水平和饮食行为有待改善,建议提高医护人员的营养知识水平,加强孕妇及家人的营养教育,以促进母子健康。     

Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation

Context  Successful smoking cessation is a major public health goal. In controlled clinical trials, nicotine replacement therapy (NRT) and the antidepressant bupropion have been shown to significantly increase cessation rates only for moderate to heavy smokers (15 cigarettes/d). Nicotine replacement therapy is heavily promoted to the general population by both the pharmaceutical industry and tobacco control advocates. Objective  To examine trends in smoking cessation, pharmaceutical cessation aid use, and success in cessation in the general California population. Design, Setting, and Participants  The large population-based California Tobacco Surveys of 1992, 1996, and 1999, including 5247 (71.3% response rate), 9725 (72.9% response rate), and 6412 (68.4% response rate) respondents, respectively. Main Outcome Measures  Rates of cessation attempts (1 day) among smokers in the last year, use of pharmaceutical aids (mostly over-the-counter products since 1996), and cessation success. Results  Between 1992 and 1999, cessation attempts among California smokers increased 61.4% (from 38.1% to 61.5%), and NRT use among quitters increased 50.5% (from 9.3% to 14.0%). A total of 17.2% of quitters used NRT, an antidepressant, or both as an aid to cessation in 1999. In 1996 and 1999, the median duration of aid use (14 days) was much less than recommended, and only about 20% of users had adjuvant one-on-one or group behavioral counseling. Use of NRT increased short-term cessation success in moderate to heavy smokers in each survey year. However, a long-term cessation advantage was only observed before NRT became widely available over-the-counter (August 1996). In 1999, no advantage for pharmaceutical aid users was observed in either the short or long term for the nearly 60% of California smokers classified as light smokers (<15 cigarettes/d). Conclusion  Since becoming available over the counter, NRT appears no longer effective in increasing long-term successful cessation in California smokers.      

Considerations for smoking advice in pregnancy

Cigarette smoking in pregnancy was the single most important preventable factor identified when determinants of birth weight were studied in 375 pregnancies. Current professional intervention was not effective in reducing cigarette consumption in pregnancy in these mothers in Londonderry, of whom only 19 (5%) became ex-smokers. Present health education, which emphasises impaired fetal growth and wellbeing, had its greatest effect amongst primigravid smokers of whom 32% made some reduction in cigarette consumption. Maternal expectation of birth weight differed significantly between non-smokers, light to moderate, and heavy smokers (8.2 lb, 7.9 lb, 7.3 lb respectively). 54% of multiparous smokers expected the birth weight to be similar to the birth weight in previous pregnancies. Of the women who reduced smoking, 57% did so for the baby, 23% because they found the habit less pleasurable during pregnancy and 13% because of professional advice. Maternal expectation of birth weight is one factor which negates the slant of current health education advice in pregnancy. An anti-smoking programme aimed at protecting the fetus from the harmful effects of cigarettes may produce optimal results when targeted at primary school-aged children in whom the smoking habit is less firmly established.     

南昌市部分公共场所二手烟暴露现况调查

目的了解南昌市部分公共场所的二手烟暴露情况。方法对南昌市医院、学校、政府机构、疾控机构和公共交通场所共101家场所进行现场观察,对场所内的1 870名工作人员和来访者进行问卷调查,并监测市区场所室内空气中的PM2.5浓度。结果被调查的101个场所中,15.8%为全面禁烟场所,20.8%有禁烟标志,18.8%有控烟宣传栏,但在公共场所吸烟现象仍比较普遍。非吸烟工作人员中,有37.1%在工作场所受到二手烟的侵害,不同类型场所的工作人员二手烟暴露率间差异有统计学意义(P<0.001)。不同场所类型空气中PM2.5的平均浓度不同,差异有统计学意义(P=0.023),其中公共交通场所室内空气中PM2.5的浓度最高,其值高达122.98μg/m3;学校、政府和疾控机构相对较低。影响室内PM2.5浓度的因素包括室内吸烟人数和场所1公里内有工地,其中室内吸烟人数影响较大。结论公共场所吸烟现象严重,二手烟暴露率高,禁烟措施不完善,执行力度不够。需要加强宣传教育,同时出台符合《烟草控制框架公约》的地方法规。     

环境烟草烟雾与儿童哮喘

支气管哮喘是儿童时期常见的慢性呼吸道疾病,环境烟草烟雾已经成为诱发儿童哮喘的主要危险因素之一,可导致发生儿童哮喘的风险上升。对于已经发展为哮喘的儿童,环境烟草烟雾会影响哮喘控制,包括加重现有哮喘症状,诱发哮喘发作,降低生活质量,影响药物治疗。在此就环境烟草烟雾暴露对儿童哮喘的影响及可能机制予以综述。     

Trends in pregnancy-related smoking rates in the United States, 1987-1996

CONTEXT: Rates of smoking are increasing among adolescents and young adults, but trends in smoking among pregnant women have not been studied. OBJECTIVE: To assess pregnancy-related variations in smoking behaviors and their determinants among women of childbearing age in the United States. DESIGN: Analysis of data collected between 1987-1996 from the Behavioral Risk Factor Surveillance System survey. SETTING AND SUBJECTS: A total of 187302 (178499 nonpregnant and 8803 pregnant) noninstitutionalized women aged 18 to 44 years from 33 states. MAIN OUTCOME MEASURES: Prevalence rates of smoking initiation and current smoking, median number of cigarettes smoked, and adjusted odds ratios for smoking stratified by pregnancy status; prevalence rate ratio for current smoking comparing pregnant with nonpregnant women. RESULTS: The overall percentage of women who had ever initiated smoking decreased significantly from 44.1% in 1987 to 38.2% in 1996. During that 10-year period, the prevalence of current smoking also decreased significantly among both pregnant women (16.3% to 11.8%) and nonpregnant women (26.7% to 23.6%). Overall, pregnant women were about half (54%) as likely as nonpregnant women to be current smokers during 1987-1996. Over time, the median number of cigarettes smoked per day by pregnant smokers remained at 10, whereas among nonpregnant smokers it decreased from 19 to 15 (P<.05 for trend). In the same period, among young women (aged 18-20 years), prevalence rates of smoking initiation and current smoking increased slightly. Sociodemographic subgroups of women at increased risk for current smoking were the same for pregnant and nonpregnant women (ie, those with a completed high school education or less, whites, and those who were unmarried). CONCLUSIONS: In this analysis, the decline in smoking over time among pregnant women was primarily due to the overall decline in smoking initiation rates among women of childbearing age, not to an increased rate of smoking cessation related to pregnancy. To foster effective perinatal tobacco control, efforts are needed to further reduce the number of young women who begin smoking. Clinicians should query all pregnant women and women of childbearing age about smoking and provide cessation and relapse interventions to each smoker.     

吸烟对大鼠免疫系统功能的影响

目的 探讨吸烟对大鼠血清CD3、CD4、CD8 T淋巴细胞和IgA、IgG、IgM及补体含量影响的时间效应.方法 雄性健康清洁级Wistar大鼠30只,随机分为对照组和烟草烟雾暴露组,每组15只大鼠.对照组暴露于正常饲养环境,烟草烟雾暴露组每日暴露于烟草烟雾环境30 min,每日2次.两组大鼠分别于烟草烟雾暴露时（T0）、烟草烟雾暴露1个月（T1）、烟草烟雾暴露2个月（T2）、烟草烟雾暴露3个月（T3）、烟草烟雾暴露4个月（T4）、烟草烟雾暴露5个月（T5）和烟草烟雾暴露6个月（T6）时采内眦静脉血,检测血清CD3、CD4、CD8 T淋巴细胞的含量,测定IgA、IgG、IgM、C4、C3含量.结果 烟草烟雾暴露组CD3、CD4T淋巴细胞自T3时逐渐下降（P＜0.05）,CD8 T淋巴细胞自T4时逐渐上升（P＜0.05）,对照组各指标各时点间均无明显差异.与对照组比较,烟草烟雾暴露组T3～T6时CD3和CD4 T淋巴细胞含量均明显减少（P＜0.05）,CD8 T淋巴细胞含量均明显增多（P＜0.05）.T4～T6时,对照组IgG、IgM和C4含量均明显高于烟草烟雾暴露组（P＜0.05）.烟草烟雾暴露组IgG、IgM和C4、C3自T4时逐渐下降;对照组各指标各时间点间均无明显差异.结论 烟草烟雾暴露损伤细胞免疫的时间窗为3个月.短期吸烟对体液免疫功能影响不大,长期可致体液免疫功能逐渐受损,具体机制尚需进一步研究证实.     

Predictors of physician's smoking cessation advice

OBJECTIVES--To determine the percentage of smokers reporting that a physician had ever advised them to smoke less or to stop smoking, and the effect of time, demographics, medical history, and cigarette dependence on the likelihood that respondents would state that a physician had ever advised them to stop smoking. DESIGN AND SETTING--Data were collected from the Stanford Five-City Project, a communitywide health education intervention program. The two treatment and three control cities were located in northern and central California. As there was no significant difference between treatment and control cities regarding cessation advice, data were pooled for these analyses. PARTICIPANTS--There were five cross-sectional, population-based Five-City Project surveys (conducted in 1979-1980, 1981-1982, 1983-1984, 1985-1986, and 1989-1990); these surveys randomly sampled households and included all residents aged 12 to 74 years. MAIN OUTCOME MEASURES--Improved smoking advice rates over time in all towns was an a priori hypothesis. RESULTS--Of the 2710 current smokers, 48.8% stated that their physicians had ever advised them to smoke less or stop smoking. Respondents were more likely to have been so advised if they smoked more cigarettes per day, were surveyed later in the decade, had more office visits in the last year, or were older. In 1979-1980, 44.1% of smokers stated that they had ever been advised to smoke less or to quit by a physician, vs 49.8% of smokers in 1989-1990 (P less than .07). Only 3.6% of 1672 ex-smokers stated that their physicians had helped them to quit. CONCLUSION--These findings suggest that physicians still need to increase smoking cessation counseling to all patients, particularly adolescents and other young smokers, minorities, and those without cigarette-related disease.