November 2002, (Vol. 3, No. 6)
Addressing High Rates of Smoking During Pregnancy in Wisconsin
By: Vanessa Newburn, Patrick Remington, Paul Peppard

Maternal smoking during pregnancy is a serious public health problem in the U.S. and in Wisconsin. Adverse health effects of smoking during pregnancy include increased risk of spontaneous abortion, delayed fetal growth, low birth weight and pre-term deliveries, infant mortality, and perinatal morbidity such as reduced lung function and cognitive development1. In addition to health consequences, direct health care costs in the U.S. associated just with the birth complications associated with first or secondhand smoking exposure during pregnancy have been estimated to be as high as $2 billion annually2.

There is considerable geographic variation in the prevalence of smoking during pregnancy in the U.S. Nationally, approximately 13% of pregnant women smoke3. Though prevalence declined nearly one-third in the 1990s, this rate still represents nearly 500,000 annual births. Compared to other states, Wisconsin has consistently had relatively high prevalence of smoking during pregnancy, ranking 11th highest in 1998 with a prevalence of 18%. This excess prevalence cannot be explained by a difference in distribution of maternal age, education, or race/ethnicity4.

Analyses of Wisconsin birth certificate data indicate considerable variation among Wisconsin counties in prevalence of smoking during pregnancy. In 2000, county prevalences ranged from 8% to 54% (Figure 1).
Figure 1:  Distribution of prevalence of smoking during pregnancy across Wisconsin counties

In addition, temporal trends in prevalence at the county level over the past ten years varied from steep declines (up to 6% annual relative decreases in prevalence) to stagnant or slightly increasing trends (up to 2% annual relative increases in prevalence) (Figure 2).
Figure 2:  Distribution of prevalence of smoking during pregnancy across Wisconsin counties, 1990-2000

The state average trend in smoking during pregnancy over the previous decade has been an approximately 3% annual relative decline.

Nationally, several subgroups in the population appear to be at higher risk for smoking during pregnancy. Particularly at-risk subgroups include younger women, American Indian5, less educated mothers, unmarried women, and women with late or no prenatal care3. Wisconsin has higher prevalences of women who smoked during their pregnancy than the national averages across most major demographic sectors4. Reducing rates of smoking during pregnancy is an important health priority in the U.S.6 One goal of Healthy People 2010 national objectives is to reduce the percentage of women who smoke during pregnancy to less than 2%. To help achieve that goal, Wisconsin will need to show dramatic improvement from its 2000 prevalence of 16%. Because of the substantial geographic variation among Wisconsin counties in prevalence and trends in prevalence, county-specific tobacco control objectives for reducing rates of smoking during pregnancy may be preferable to a single goal applied to all counties. Additionally, tobacco use interventions should be culturally sensitive and tailored to high-risk populations.

Effective program and policy options for reducing the rates of smoking during pregnancy are well-documented, and emphasize the need to support local grassroots community efforts to achieve overall reductions in tobacco use. Data from programs in such states as California, Massachusetts, Oregon, and Florida, show that a decentralized approach which focuses on multi-faceted community-based programs is most successful in reducing overall rates of smoking7.

The Center for Disease Control (CDC), in Best Practices for Comprehensive Tobacco Control Programs, emphasizes policy development, health promotion, health protection, and community empowerment as key components to community tobacco use reduction programs8. These activities include developing partnerships with local organizations, conducting educational programs, and encouraging policies that support tobacco use prevention and cessation. Primary health care provider reminders to discuss tobacco use and quitting with patients, provider education on effective methods for quitting, and patient education using tailored self-help materials are effective community-based interventions9.

Over the past 15 years intervention research has established that brief (5-15 minutes) sessions of quitting advice and counseling combined with pregnancy-tailored self-help material provided in the course of routine prenatal care produces quit rates that are higher than those achieved with usual care10-13. Further, both the World Health Organization and the US Agency for Health Care Policy and Research, through a clinical practice guideline published in 199614, recommend that self-help guides be the standard patient education procedure for pregnant smokers15. In 2000, the Wisconsin Tobacco Control Board initiated the pilot program, First Breath, which offers intense smoking cessation counseling along with tailored self-help materials for pregnant women attending Prenatal Care Coordination (PNCC) and Women, Infants, and Children (WIC) appointments in 8 communities.

Given the substantial savings associated with averting low birth weight deliveries, these "best practice" interventions have also proven highly cost-effective. It is estimated that for every $1 invested in these interventions, about $6 are saved, with the result that the current "best practice" for brief cessation counseling in pregnancy is likely, for smokers, to be more cost-effective than all the rest of prenatal care12, 16-19. More comprehensive intervention efforts might include promoting cessation among women considering childbearing, reaching the pregnant smoker as soon as possible, maintaining postpartum cessation, developing different interventions for the continuing smoker, and focusing on the pregnant smoker's partner20.

Marked improvements in the health of Wisconsin women and children populations can be expected with a substantial commitment of resources to support community-based approaches to reduce rates of smoking during pregnancy. Adequate funding is critical to the success of community programs, since there is a relationship between the level of investment in effective tobacco control programs and the degree of decline in cigarette consumption21. A range of $0.70-$2.00 per capita per year is recommended for local governments and organizations8. With the recent reallocation of Wisconsin's Tobacco Settlement funds from the Tobacco Control Board to reduce the state budget deficit, finding funding alternatives for tobacco use prevention is a clear public health priority for the state of Wisconsin.


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