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ORIGINAL RESEARCH |
From the Centers for Disease Control and Prevention, Atlanta, Georgia.
Address reprint requests to: Shahul H. Ebrahim, MD, PhD Centers for Disease Control and Prevention (K-55) Mailstop K-55 4770 Buford Highway NE Atlanta, GA 30341 E-mail: sebrahim{at}cdc.gov
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Abstract |
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Methods: Using behavioral risk factor surveillance system data from 1987 through 1997, we determined the prevalence of concurrent tobacco and alcohol use among women aged 18–44 years by pregnancy status and indirectly estimated pregnancy-related disuse rates.
Results: The percentage of women who used alcohol and tobacco decreased significantly from 1987 to 1990 among pregnant (5.4% to 3.0%) and nonpregnant women (17.6% to 14.2%), but thereafter did not change significantly. The estimated pregnancy-related disuse rate of tobacco and alcohol increased insignificantly from 70% in 1987 to 82% in 1997. Among women who used both substances, pregnancy-related disuse was slightly greater for alcohol alone (74%) than for tobacco alone (52%). There was not a significant decline in concurrent use of tobacco and alcohol between 1987 and 1997 among women 18–20 years old (pregnant, 4.4% to 3.6%; nonpregnant, 13.5% to 13.7%). That age group also showed a smaller pregnancy-related disuse rate than older women (1997, 74% versus 83%).
Conclusion: The steady trend in concurrent use of tobacco and alcohol by young women emphasizes the need for enhanced efforts to reduce the initiation of tobacco and alcohol use by young people. Women who report abuse of tobacco or alcohol should be evaluated for abuse of both substances, and interventions should address abuse of both substances.
The public health implications of alcohol use or tobacco smoking are compounded for women because of adverse outcomes related to pregnancy and other reproductive health issues and because of the effect that adults’ use of tobacco or alcohol has on their children’s health.1–4 Adverse effects, including infertility, preterm birth, and spontaneous abortions, can be caused by tobacco or alcohol, and they might cause some effects synergistically.1–4 Smoking and alcohol use cluster in similar population subgroups, and the use of one product increases the risk of use of the other.5
In the United States during the 1980s, the prevalence of smoking and alcohol consumption declined.6 However, in the 1990s, the prevalence of smoking increased among adolescents and young adults.7 Among women of childbearing age, the prevalence of smoking decreased from 27% in 1987 to 24% in 1991 and varied little thereafter.8 The prevalence of alcohol consumption in women of childbearing age also decreased from 56% in 1988 to 51% in 1992, then varied little thereafter.9 We assessed national trends in pregnancy-related differences in concurrent use of tobacco and alcohol among women of reproductive age, with an emphasis on pregnant women. We used data from a population-based survey10 from 33 states that represented all of the major United States geographic regions and contained about three fourths of the United States population.11
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Materials and Methods |
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We restricted our analysis to data from 33 states that collected information on smoking and alcohol consumption consistently throughout the study period. In the behavioral risk factor surveillance system,8–10 information on smoking was collected each year, whereas information on alcohol consumption was collected each year from 1987 through 1993 and once every 2 years thereafter. We limited our analysis to women aged 18–44 years. We combined responses to questions on smoking and alcohol consumption to obtain the prevalence of concurrent use. From the total sample we collected percentages of pregnant and nonpregnant women who reported using tobacco and alcohol. We do not have information on each woman’s smoking or alcohol consumption habits before and after she realized she was pregnant, so we indirectly estimated8,9 pregnancy-related disuse rates for concurrent use from the prevalence rate ratio, using the formula: 1 - (% pregnant ÷ % nonpregnant). We converted disuse rates to percentages and assumed that pregnancy-related disuse rates reflected quit rates. For example, if 25% of nonpregnant women and 15% of pregnant women were smokers, the prevalence rate ratio would be 0.6 (ie, 15 ÷ 25 = 0.6), meaning that 60% of women continued to smoke after becoming pregnant or 40% ([1.0-0.6] x 100 = 40%) quit after becoming pregnant.
We also determined the percentage of concurrent users of tobacco and alcohol among women who were smokers or alcohol users. The current dietary recommendation for alcohol in the United States for women is to not exceed one drink per day,12 so we also assessed the percentage of women who smoked and had more than one drink per day (at least eight drinks a week), and the percentage of women who were smokers and binge drinkers (at least five drinks on one occasion). Respondents aged 18–20 years were combined in one category to assess young adults’ use of tobacco and alcohol.13 We weighted the state-specific data to reflect the overall population distribution of the 33 states. Using direct standardization, we adjusted the overall prevalence rates of concurrent use of tobacco and alcohol to the age distribution of pregnant women in the 1987 sample. Standard errors and 95% confidence intervals (CIs) were estimated using the software for survey data analysis (SUDAAN; Research Triangle Institute, Research Triangle Park, NC). We created least-squares linear regression models (using the inverse of the variance estimates for weights) to determine statistical significance of the linear trends in prevalence rates. We created logistic regression models for interaction between calendar year and pregnancy status to determine statistical significance of the variation over time in pregnancy-related disuse rates. P < .05 was considered statistically significant. Most outcome measures showed a linear relationship with calendar year or no significant secular variation, so the results of the stratified analyses were reported only for the beginning and ending years.
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Results |
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Among pregnant and nonpregnant women who reported any alcohol use, 20% also smoked. Among women who reported smoking, 25% of pregnant and 56% of nonpregnant women also drank alcohol. The percentage of women who were concurrent users of tobacco and alcohol decreased significantly among pregnant women from 1987 through 1990 (5.4% to 3.0%) and among nonpregnant women from 1987 through 1991 (17.6% to 14.2%, P < .05), but did not vary significantly thereafter. From 1987 through 1997 there was no statistically significant decrease in the percentage of women who were smokers and binge drinkers (pregnant, 1.6% to 1.0%; nonpregnant, 5.6% to 5.4%). Over the entire study period, 0.3% of pregnant women and 2.4% of the nonpregnant women reported smoking and consuming more than one alcoholic beverage a day (an average of eight drinks or more per week).
From 1987 through 1997, pregnancy-related disuse rates increased slightly (P > .05) among women who reported concurrent use of tobacco and alcohol (70% [95% CI 59%, 78%] to 82% [95% CI 72%, 93%]) and among women who reported smoking and binge drinking (71% [95% CI 40%, 87%] to 82% [95% CI 62%, 100%]). Among women who smoked and drank more than one alcoholic beverage per day, in all years combined, the pregnancy-related disuse rate was 86% (95% CI 72%, 98%). For women who used both tobacco and alcohol, in all years combined, the pregnancy-related disuse rate was greater for alcohol alone (74%, 95% CI 60%, 89%) than for smoking (52%, 95% CI 42%, 64%).
Young pregnant women (aged 18–20 years) had nearly the same prevalence of concurrent use of tobacco and alcohol as all pregnant women throughout the study period (Figure 1
). The annual variation in the prevalence of concurrent use of both substances among young pregnant and nonpregnant women was not statistically significant (Figure 1, Table 1). There was a sharp decrease in the prevalence of concurrent use among older pregnant women, so by 1997 pregnant women aged 18–20 years had a significantly higher prevalence rate than older women (Table 1). Young women also had smaller pregnancy-related disuse rates than older women (Table 1).
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). White women had the largest, and a statistically significant, increase in pregnancy-related disuse rates between 1987 (59%) and 1997 (78%) (Table 1). Among pregnant and nonpregnant women, the prevalence of the concurrent use of tobacco and alcohol was inversely related to education level and was substantially higher among unmarried women compared with married women (Table 1). Among nonpregnant women, those who were nonwhite or unemployed had a higher prevalence of concurrent use of tobacco and alcohol than their counterparts. |
Discussion |
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In this survey, the bias in the reporting of tobacco and alcohol use when asked in relation to pregnancy might be low because the question on pregnancy was asked independently, after questions on smoking and alcohol were asked. By excluding persons without telephones, persons under 18 years old, and those who do not live in private residences, these data might underestimate or overestimate the actual prevalence of smoking and alcohol consumption. Pregnancy-related quitting of concurrent use was higher than reported for tobacco or alcohol alone (50% and 70%, respectively in 1995).8,9 Unmarried women who had the highest prevalence of concurrent use were also among those reported to be at increased risk of tobacco use and alcohol use in other studies.8,9 Despite considerable national efforts to restrict alcohol and tobacco use by young people and by pregnant women, our data indicate that young pregnant women have equal access to those substances, as do older women. The high prevalence of concurrent use among young women who are pregnant might indicate comorbidity, including risky sexual behavior and equally high rates of use among their male peer groups.14
Given that more than half of women do not recognize they are pregnant until after the fourth week of gestation,15 the potential to unknowingly expose a fetus to alcohol or tobacco is high. However, the notion of reducing tobacco and alcohol use before conception15 is simplistic. Addictions to nicotine and alcohol are progressive and chronic. Routine methods to detect alcohol or tobacco abuse might not be sufficient to identify those who abuse alcohol or tobacco. In the United Kingdom, about 16% of a survey’s respondents reported that they did not admit to their doctors that they smoked.16 Given that, on average, women of childbearing age have about 6.4 visits to physicians each year,17 it is feasible to engage them in alcohol and tobacco interventions. Counseling on avoidance of tobacco and alcohol misuse should be integral in care for women of childbearing age, particularly for those who do not use effective contraception. Chronic users of alcohol and tobacco should be advised about opportunities for pregnancy postponement until abstinence is achieved.
Current public health interventions in the United States might have reached their peak in reducing tobacco and alcohol abuse among pregnant women, as was reported for antismoking campaigns in other industrialized countries.16 Developing nations whose smoking and alcohol rates among women are still at low levels have the opportunity to learn from these findings about the difficulties associated with reducing tobacco and alcohol use among established users. The long-term objective of decreasing the burden of pregnancies exposed to tobacco and alcohol can be achieved only by preventing initiation of smoking and alcohol use by young people.
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Footnotes |
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Received February 9, 2000. Received in revised form June 19, 2000. Accepted July 7, 2000.
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References |
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2. Kuzma JW, Kissinger DG. Patterns of alcohol and cigarette use in pregnancy. Neurobehav Toxicol Teratol 1981;3:211–21.[Medline]
3. Jensen TK, Hjollund NH, Henriksen TB, Scheike T, Kodstad H, Giwercman A, et al. Does moderate alcohol consumption affect infertility? Follow up study among couples planning first pregnancy. BMJ 1998;317:505–10.
4. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996;97:560–8.
5. Breslau N, Peterson E, Schultz L, Andreski P, Chilcoat H. Are smokers with alcohol disorders less likely to quit? Am J Public Health 1996;86:985–90.
6. Preliminary tables, 1995. In: National household survey on drug abuse. Rockville, Maryland: Office of Applied Studies, Substance Abuse and Mental Health Services Association, 1996.
7. Centers for Disease Control and Prevention. Tobacco use among high school students-United States, 1997. MMWR 1998;47:229–33.[Medline]
8. Ebrahim SH, Floyd RL, Merrit RK 2nd, Decoufle P, Holtzmman D. Trends in pregnancy-related smoking rates in the United States during 1987–1996. JAMA 2000;283:361–6.
9. Ebrahim SH, Diekman ST, Decoufle P, Tully M, Floyd RL. Pregnancy-related alcohol use among women in the United States, 1988–95. Prenat Neonat Med 1999;4:39–46.
10. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981–1987. Public Health Rep 1988;103:336–75.
11. Statistical abstract of the United States: 1994. Washington, DC: Bureau of the Census, 1994.
12. United States Department of Agriculture and the United States Department of Health and Human Services. Nutrition and your health: Dietary guidelines for Americans. 4th ed. Washington, DC: United States Government Printing Office, 1995.
13. Toomy TL, Rosenfeld C, Wagenaor AC. The minimum legal drinking age: History, effectiveness, and ongoing debate. Alcohol Health Res World 1996;20:213–8.
14. Wechsler H, Davenport A, Dowdall A, Dowdall G, Moeykevis B, Cartillo S. Health and behavioral consequences of binge drinking in college: A national survey of students at 140 campuses. JAMA 1994;272:1672–7.[Abstract]
15. Floyd RL, Decoufle P, Hungerfold DW. Alcohol use prior to pregnancy recognition. Am J Prev Med 1999;17:101–7.[Medline]
16. World Health Organization. Antismoking campaigns fail in industrialized countries. Bull World Health Organ 1999;77:449.
17. Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. National Center for Health Statistics. Vital Health Stat 1995;10:113.
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