Full length articleSmoking during pregnancy in the United States, 2005–2014: The role of depression
Introduction
Prenatal exposure to maternal cigarette smoking during pregnancy is associated with a wide variety of adverse outcomes in neonates and infants that span the life course. Compared with unexposed infants, those who are exposed have an elevated risk for sudden infant death (Hutchison et al., 2006), intrauterine growth retardation (Andres and Day, 2000), a 180–250 g decrement in birth weight (Visscher et al., 2003), neurological and language problems (Fried, 1993), difficult temperament (Brook et al., 1998), aggression (Tremblay et al., 2004), behavioral and conduct problems (Monuteaux et al., 2006), deficit in attention and cognitive function (Naeye and Peters, 1984), attention deficit disorder (Button et al., 2005), early onset delinquent/antisocial problems (Wakschlag et al., 2003), later cigarette use (Buka et al., 2003), and increased substance use (Fergusson et al., 1998). Depression is strongly linked with cigarette use and nicotine dependence in the general population (Goodwin et al., 2011, Goodwin et al., 2012, Weinberger et al., 2016) and adults with depression have smoking rates up to 2–3 times higher than those without depression (Zvolensky et al., 2015). A number of studies have recently suggested that smoking both during pregnancy and postnatally (Grover et al., 2012) are higher among women with mental health conditions compared to women without mental health problems (Goodwin et al., 2007). Recent studies also suggest that maternal depression during pregnancy is independently associated with risks to mental and physical health outcomes in offspring (Latendresse et al., 2015, Nkansah-Amankra and Tettey, 2015, Plant et al., 2016, Plant et al., 2015). Pregnant women with depression are also more likely to continue smoking in pregnancy than those without depression (Smedberg et al., 2014). Fewer than half of pregnant women are routinely screened for depression (Venkatesh et al., 2016b), although depression can be screened and treated effectively during pregnancy. If pregnant women with depression have higher levels of prenatal smoking, they would constitute an important high-risk group to identify early in prenatal care to reduce long-term smoking-related adverse maternal and infant outcomes. As such, understanding the relationship between depression and prenatal smoking has tremendous clinical and public health implications to improve overall health.
Despite success of public health-oriented tobacco control programs that have led to substantial declines in smoking prevalence over the past several decades, whether similar reductions in smoking have been experienced among pregnant women is unclear. Recent analyses suggest that declines in smoking have not been distributed equally among subgroups of the population. At least two recent studies found that individuals with mental health problems may not have experienced as steep declines in smoking as the general population (Cook et al., 2014, Lawrence and Williams, 2016). The extent to which public tobacco control programs have had similar reductions in smoking among pregnant women, with and without depression, is unknown.
Pregnant women with depression may be a particularly vulnerable group, especially in need of smoking cessation interventions. There is evidence that smoking during pregnancy is more common among particular groups of women including younger women and women with lower SES profiles (Sirvinskiene et al., 2016). The extent to which these vulnerabilities, depression and low SES, may contribute jointly to an increase in prenatal smoking is not known. There is a need to examine subgroups of pregnant women to identify high-risk groups and determine modifiable risk factors to develop targeted smoking cessation intervention messages.
Depression is a prevalent but very treatable condition and has deleterious effects particularly for both pregnant women and their infants (Grote et al., 2010). Despite the public health significance, depression during pregnancy has received very little public health attention, and although the American College of Obstetrics and Gynecology promote depression screening during pregnancy, very few pregnant women are routinely screened (SAMHSA, 2005). The current study begins to address the gap in understanding the role of depression in smoking during pregnancy. The goals of this study are fourfold. First, we investigate the relationship between depression and cigarette smoking among pregnant women in the United States. Second, we estimate the prevalence of smoking among pregnant women with and without depression from 2005 to 2014. Third, we examine the change in the prevalence of smoking among pregnant women who are depressed, compared with those not depressed, from 2005 to 2014. Fourth, we explore the relationship between depression and cigarette smoking, by important demographic characteristics, among pregnant women in the United States.
Section snippets
Data and population
Data were drawn from the public-use data files from the National Survey on Drug Use and Health (NSDUH) years 2005–2014. The National Survey on Drug Use and Health (NSDUH) provides annual cross-sectional national data on the use of tobacco, other substances, and mental health in the U.S., as described elsewhere (SAMHSA, 2014). For this study, analyses were restricted to female respondents who reported being pregnant at the time of the interview (N = 8721). Of these, 208 (2.4%) were excluded based
Major depressive episode and smoking among pregnant women in the United States
Among pregnant women, 6.7% (95% CI = 6.0–7.5) were categorized as having an MDE. Pregnant women with MDE were more than twice as likely to be smokers during pregnancy than those without MDE (32.5% vs. 13.0%; covariate adjusted OR = 2.50 (1.85, 3.40)).
Demographic characteristics among pregnant women with and without MDE in 2005–2014
Pregnant women with MDE were younger (p < 0.0001), more likely to be widowed, separated, divorced or never married (p < 0.0001), had lower levels of formal education (p = 0.0009), lower income (p = 0.06) and were more likely to be White (p = 0.0015) than
Discussion
These findings suggest that, in the United States, pregnant women experiencing a major depressive episode within the past year have adjusted smoking rates nearly three times higher than those who have not experienced a past-year MDE. This disparity has increased significantly over the past 10 years–moving in the opposite direction from both national smoking trends and smoking trends among pregnant women without MDE. In 2014, nearly 40% of pregnant women with MDE smoked during pregnancy,
Public health implications
Pregnant women are a vulnerable population. In this large longitudinal national sample of pregnant women, we found a significant relationship between depression and cigarette smoking, with a dramatic increase over time in the prevalence of smoking among pregnant women with depression. Given these findings, large-scale and targeted smoking cessation initiatives for pregnant women with mental health problems are needed. Importantly, women with the highest levels of smoking (low education, low
Role of funding source
This work was supported by a grant from NIDA/NIH to Dr. Goodwin (#DA02892). The funding source played no role in the analysis or interpretation of results.
Contributors
RDG conceived of the study question and drafted the manuscript. MMW designed the statistical analyses. KCP conducted the analyses. DN, YN, DSH, PS and SG made critical contributions to the interpretation of results and co-writing the manuscript. All authors approved of the final manuscript.
Conflict of interest
No conflict declared.
References (42)
- et al.
Perinatal complications associated with maternal tobacco use
Seminars in Neonatology
(2000) - et al.
Longitudinal study of co-occurring psychiatric disorders and substance use
J. Am. Acad. Child Adolesc. Psychiatry
(1998) - et al.
Predictors of persistent nicotine dependence among adults in the United States
Drug Alcohol Depend.
(2011) - et al.
Does quitting smoking during pregnancy have a long-term impact on smoking status?
Drug Alcohol Depend.
(2012) - et al.
Association between depressive symptoms in adolescence and birth outcomes in early adulthood using a population-based sample
Prev. Med. Rep.
(2015) - et al.
Smoking during pregnancy in association with maternal emotional well-being
Medicina (Kaunas Lithuania)
(2016) - et al.
Implementation of universal screening for depression during pregnancy: feasibility and impact on obstetric care
Am. J. Obstet. gynecol.
(2016) - et al.
Pregnant smokers who quit, pregnant smokers who don’t: does history of problem behavior make a difference?
Soc. Sci. Med.
(2003) - et al.
Major depressive disorder and smoking relapse among adults in the United States: a 10-year: prospective investigation
Psychiatry Res.
(2015) Diagnostic and Statistical Manual of Mental Disorders
(1994)
Analysis of effects of 2008 NSDUH questionnaire cahnges: methods to adjust adult MDE and SPD estimates and to estimate SMI in the 2005–2009 surveys.
2010 National Survey on Drug Use and Health
Elevated risk of tobacco dependence among offspring of mothers who smoked during pregnancy: a 30-year prospective study
Am. J. Psychiatry
Relationship between antisocial behaviour, attention-deficit hyperactivity disorder and maternal prenatal smoking
Br. J. Psychiatry
Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation
JAMA
Estimates of nondisclosure of cigarette smoking among pregnant and nonpregnant women of reproductive age in the United States
Am. J. Epidemiol.
Maternal smoking during pregnancy and psychiatric adjustment in late adolescence
Arch. Gen. Psychiatry
Prenatal exposure to tobacco and marijuana: effects during pregnancy, infancy, and early childhood
J. Clin. Gynecol. Obstet.
Lessons learned from the London Exercise and Pregnant (LEAP) Smokers randomised controlled trial process evaluation: implications for the design of physical activity for smoking cessation interventions during pregnancy
BMC Public Health
Mental disorders and nicotine dependence among pregnant women in the United States
Obstet. Gynecol.
Mental disorders and cigarette use among adults in the United States
Am. J. Addict.
A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction
Arch. Gen. Psychiatry
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