Elsevier

Drug and Alcohol Dependence

Volume 179, 1 October 2017, Pages 159-166
Drug and Alcohol Dependence

Full length article
Smoking during pregnancy in the United States, 2005–2014: The role of depression

https://doi.org/10.1016/j.drugalcdep.2017.06.021Get rights and content

Highlights

  • The relationship between depression and cigarette smoking in pregnancy is estimated.

  • Logistic regression models in the National Survey on Drug Use and Health were used.

  • Smoking during pregnancy has increased in women with depression from 2005 to 2014.

  • Smoking is four times more common in pregnant women with than without depression.

  • Public health tobacco control programs must better target this demographic.

Abstract

Background

Despite success of public health-oriented tobacco control programs in lowering the smoking prevalence over the past several decades, it is unclear whether similar reductions in smoking have been experienced among pregnant women, especially in vulnerable groups such as those with major depression and/or lower socioeconomic status.

Objectives

The purpose of this study is to examine the relationship between major depressive episode (MDE) and smoking among pregnant women overall, and by demographics and to estimate changes in the prevalence of cigarette smoking among pregnant women with and without MDE from 2005 to 2014.

Study design

Cigarette use among pregnant women with and without MDE was examined using logistic regression models in the National Survey on Drug Use and Health.

Results

Prenatal smoking is more common among pregnant women with, compared to without, MDE (32.5% vs. 13.0%; (adjusted OR = 2.50 (1.85, 3.40)), and greater disparities were revealed when also considering income, education and race. Over time, smoking during pregnancy increased significantly among women with MDE (35.9% to 38.4%; p = 0.02)) and showed a decreasing trend among women without MDE (12.5% to 9.1%; p = 0.07) from 2005 to 2014.

Conclusions

Over the past decade, smoking during pregnancy has increased among women experiencing a major depressive episode and is over four times more common among pregnant women with, than without, MDE. Disparities in smoking during pregnancy by MDE status and socioeconomic subgroups appear substantial. Given the multitude of risks associated with both MDE and smoking during the prenatal period, more work targeting this vulnerable and high-risk group is needed.

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)

  • J. Aldworth et al.

    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

    (2012)
  • S.L. Buka et al.

    Elevated risk of tobacco dependence among offspring of mothers who smoked during pregnancy: a 30-year prospective study

    Am. J. Psychiatry

    (2003)
  • T. Button et al.

    Relationship between antisocial behaviour, attention-deficit hyperactivity disorder and maternal prenatal smoking

    Br. J. Psychiatry

    (2005)
  • B.L. Cook et al.

    Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation

    JAMA

    (2014)
  • P.M. Dietz et al.

    Estimates of nondisclosure of cigarette smoking among pregnant and nonpregnant women of reproductive age in the United States

    Am. J. Epidemiol.

    (2011)
  • D.M. Fergusson et al.

    Maternal smoking during pregnancy and psychiatric adjustment in late adolescence

    Arch. Gen. Psychiatry

    (1998)
  • P.A. Fried

    Prenatal exposure to tobacco and marijuana: effects during pregnancy, infancy, and early childhood

    J. Clin. Gynecol. Obstet.

    (1993)
  • N. Giatras et al.

    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

    (2017)
  • R.D. Goodwin et al.

    Mental disorders and nicotine dependence among pregnant women in the United States

    Obstet. Gynecol.

    (2007)
  • R.D. Goodwin et al.

    Mental disorders and cigarette use among adults in the United States

    Am. J. Addict.

    (2012)
  • N.K. Grote et al.

    A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction

    Arch. Gen. Psychiatry

    (2010)
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