Tobacco use and secondhand smoke exposure during pregnancy in low- and middle-income countries: the need for social and cultural research


Michele Bloch, Tobacco Control Research Branch, National Cancer Institute, Executive Plaza North, room 4038, 6130 Executive Boulevard, MSC 7337, Bethesda, MD 20892-7337, E-mail:


Tobacco use is a leading cause of death and of poor pregnancy outcome in many countries. While tobacco use is decreasing in many high-income countries, it is increasing in many low- and middle-income countries (LMICs), where by the year 2030, 80% of deaths caused by tobacco use are expected to occur. In many LMICs, few women smoke tobacco, but strong evidence indicates this is changing; increased tobacco smoking by pregnant women will worsen pregnancy outcomes, especially in resource-poor settings, and threatens to undermine or reverse hard-won gains in maternal and child health. To date, little research has focused on preventing pregnant women's tobacco use and secondhand smoke (SHS) exposure in LMICs. Research on social and cultural influences on pregnant women's tobacco use will greatly facilitate the design and implementation of effective prevention programs and policies, including the adaptation of successful strategies used in high-income countries. This paper describes pregnant women's tobacco use and SHS exposure and the social and cultural influences on pregnant women's tobacco exposure; it also presents a research agenda put forward by an international workgroup convened to make recommendations in this area.


In many high-income countries, cigarette smoking is the leading preventable cause of poor pregnancy outcomes and is also the leading preventable cause of premature death for both men and women (1). Smoking during pregnancy has been causally linked to premature rupture of membranes, placenta previa, placental abruption, preterm delivery, fetal growth restriction and low birth weight, and sudden infant death syndrome (SIDS) (2). Exposure to secondhand smoke (SHS), also known as passive smoking and environmental tobacco smoke, is a cause of lung cancer and heart disease deaths in adults who do not smoke themselves, and a cause of lower respiratory tract illnesses, middle ear disease and SIDS in infants and children (3).

In high-income countries considerable research has focused on preventing and reducing tobacco use by women, including pregnant women. In contrast, in low- and middle-income countries (LMICs) few studies have addressed pregnant women's tobacco use and SHS exposure; however several factors make this research area an urgent priority. First, the prevalence of smoking among women is already high in some LMICs, and appears to be increasing in many others (4). Second, the generally high prevalence of smoking by men in LMICs means that pregnant women and young children are frequently exposed to SHS. Third, girls and young women in LMICs are increasingly the target of tobacco industry marketing campaigns aimed at normalizing tobacco use among women (5, 6). Finally, protective factors which operated in many LMICs, including cultural constraints on women's smoking, are eroding because of globalization, modernization, and improvements in the status of women (7).

This paper describes women's tobacco use during pregnancy and postpartum in high-income countries, the available data on women's tobacco use and SHS exposure in LMICs, and social and cultural factors influencing women's tobacco use and SHS exposure, particularly during pregnancy. We also provide the findings of an international working group convened to review the literature and make recommendations for a research agenda focused on expanding knowledge of social and cultural factors influencing pregnant women's tobacco use and SHS exposure in LMICs.

Women's smoking behaviors during pregnancy and postpartum in high-income countries

In high-income countries, an estimated 6–22% of women smoke cigarettes during pregnancy (Figure 1). These rates vary according to the maturity of tobacco control initiatives, and also according to characteristics of the pregnant woman, including age, marital or relationship status, education, income, race/ethnicity, level of addiction, presence of co-morbid mental health conditions, other substance use, and social network influences (8–11). The increasing concentration of smoking in disadvantaged populations is an important contributor to health disparities in many high-income countries (12, 13).

Figure 1.

Cigarette smoking prevalence: adult women and pregnant women, selected high-income countries. WHO World Regions: Region of the Americas (Americas), Eastern Mediterranean Region (EMRO), European Region (EURO), Western Pacific Region (WPRO). Adult women's cigarette smoking prevalence: Data for Canada from Canadian Tobacco Use Monitoring Survey, 2008. Data for all other countries from WHO Report on the Global Tobacco Epidemic, 2008, the MPOWER Package. Pregnant women's cigarette smoking prevalence: 1, Canadian Tobacco Use Monitoring Survey, 2008; 2, U.S. Pregnancy Risk Assessment Monitoring System, 2009; 3, not available; 4, European Perinatal Health Report, 2008; 5, Tobacco in Australia: Facts and Issues, 3rd Edition, 2008; 6, Preventive Medicine 2007;45:15–20.

Many high-income countries have developed interventions to reduce smoking during pregnancy. A 2009 Cochrane Collaboration Review found that clinical interventions were effective in helping pregnant women stop smoking (14). In addition, it is estimated that up to 45% of pregnant smokers quit spontaneously, often during the first trimester, in the absence of any formal intervention. However, the rate of postpartum relapse is very high, ranging from 70 to 80% by 12 months, with disadvantaged women the most vulnerable to relapse (15–16). Stotts et al. refer to the phenomena of quitting during pregnancy as ‘temporary abstinence,’ and they have questioned the appropriateness of typical cessation theory and practice for pregnant and postpartum women (17). It has been argued that encouraging pregnant women to quit smoking to improve the health of the developing fetus has sometimes come at the expense of focusing on the woman herself, and the development of women-specific and women-centered approaches to cessation; in turn, this focus has not optimized the long-term goal of cessation to improve women's own health (18).

In an effort to improve cessation rates for women, including pregnant women, research in high-income countries has focused on understanding factors unique to women that contribute to their continuing to smoke. This research has found that women smoke to cope with negative emotions and stress; to mediate issues such as trauma, sexual and physical abuse, domestic violence, and poverty; to develop a modern, sophisticated image; to control their weight; and for other reasons (19, 20). Graham et al. have argued that broadening tobacco control's focus to encompass social and health disadvantages would contribute to preventing and reducing women's tobacco use (21).

While it is important to understand the experience of high-income countries in addressing tobacco use in pregnancy, it is unlikely that these research findings and interventions will be directly transferable to LMICs. Any intervention will require significant adaptation for acceptance and success in country- and culture-specific settings. Pregnant women's tobacco use and SHS exposure patterns are heavily influenced by demographic, social, and cultural factors, which differ greatly between countries and between groups of women within countries. The design and financial resources of health systems, and health care providers' knowledge, training and interest in tobacco control and prevention, will also strongly impact the transferability of the experiences of high-income countries. Additionally, previous models of the uptake of tobacco use may not accurately predict uptake patterns for the 21st century. Girls' and women's tobacco uptake may occur more rapidly because of globalization, urbanization, and dramatic changes in mass media and communication technology (22).

Women's tobacco use and SHS exposure in LMICs

The World Health Organization (WHO) provides age-standardized estimates of the prevalence of adult tobacco smoking in LMICs for each of the six WHO world regions (Table 1). The data indicate that, while prevalence varies widely, smoking by women is lower than among men in all WHO regions (23). However, prevalence estimates are not available for all LMICs, and, as in high-income countries, overall prevalence figures can mask significant differences in use patterns between population groups within a country. Importantly, because tobacco use by women is stigmatized in many countries, prevalence figures represent a conservative estimate of the problem. Finally, very few LMICs have data on tobacco use by pregnant women and no standardized prevalence data are available for non-smoked tobacco products for either sex. The following description of regional tobacco use patterns relies primarily on age-standardized prevalence data from WHO; selected other studies are also included.

Table 1. Adult smoking prevalence in low- and middle-income countries (LMICs) by World Health Organization (WHO) region.
WHO regionaCurrent smoking any tobacco product (%)Primary tobacco products usedLMICsLMICs reporting data
  1. aWHO world regions country lists available at:

  2. bPrevalence of current tobacco smoking, % adults (15 years and older), as of 2005. Includes all countries (low-, middle- and high-income) in the region. WHO World Health Statistics, 2009.

  3. cAge-standardized prevalence, % current smoking of any tobacco product by adults (15 years of older). WHO MPOWER Package, 2008.

  4. Note: EMRO, Eastern Mediterranean region; SEARO, Southeast Asian region; WPRO, Western Pacific region.

Africa2.90.313.518.17.638.6Cigarettes, smokeless tobacco4528
EMRO4.30.39.832.525.862.7Cigarettes, waterpipe169
SEARO4.52.626.439.830.265.9Cigarettes, bidis, diverse smokeless products119


Overall, the African region has the world's lowest reported per capita cigarette consumption. In many African countries women's cigarette smoking prevalence is well < 10%. In some countries women are also known to use smokeless tobacco products (24). Tobacco smoking by African men is the lowest of any world region (18.1%), suggesting that fewer pregnant women will be exposed to SHS in this region than in others. The major factor deterring tobacco use is thought to be low consumer purchasing power, while the major barrier to tobacco control is the widely held perception of the importance of tobacco to the economy of some countries in the region (25).

Eastern Mediterranean

Tobacco use in this region includes both cigarettes and waterpipe (also known as shisha, narghile and hookah), a traditional form of tobacco use. Most LMICs in the region have very low smoking prevalence among women (<5%), but much higher levels among men (>25%). However, WHO reports slightly higher women's smoking prevalence in Jordan (9.8%), Lebanon (7.0%) and Pakistan (6.6%). Additionally, studies suggest that smoking prevalence during pregnancy may reach 21% in Lebanon and 19% in Jordan (26). Several recent studies suggest that waterpipe use is increasing in the region and may be becoming a ‘behavioral norm’ for women, who believe that it is a safe alternative to cigarettes and more socially acceptable because it is ‘traditional,’ social, and attractive (27).

European region

The LMICs in the European region primarily consist of the formerly communist nations of Eastern and Southern Europe where tobacco use has long been a leading contributor to morbidity and mortality for women and men (28). Women's smoking prevalence exceeds 25% in many LMICs in this region, including Serbia (42.3%), Bulgaria (27.8%), Poland (27.2%) and the Russian Federation (26.5%). Rates of male tobacco use in many LMICs in the region exceed 40%, and several exceed 50%, including the Russian Federation (70.1%), Ukraine (63.8%), and Georgia (57.1%). The end of communist rule and the transition to a market economy was accompanied by massive changes in the region's cigarette industry, as many national monopolies were privatized and transnational tobacco companies entered formerly closed markets (29). These market changes have been associated with increased smoking prevalence among both men and women. Notably, the evidence strongly links increased smoking among women to the presence of active transnational tobacco companies (30, 31).

Latin America

Tobacco is native to the Americas, and has long played a role in the cultural and spiritual life of the region's indigenous peoples, chiefly as a feature of shamanistic practices (32). Today, cigarettes are the primary tobacco product used in the region. Women's smoking prevalence varies widely, but is especially high (>25%) in the Southern Cone countries of Argentina (25.4%), Uruguay (28.0%), and Chile (33.6%), as well as in Cuba (28.3%), Venezuela (27.0%) and Bolivia (29.2%). In Brazil, the world's second largest producer of tobacco leaf, lifetime use of tobacco by adolescent girls and boys is very similar (16.2 vs. 15.2%) (33). A recent study provides comparable, though not nationally representative data on smoking during pregnancy for five Latin American countries; the prevalence of smoking during pregnancy was 18% in Uruguay, 10% in Argentina, 6% in Brazil, and <1% in Ecuador and Guatemala (34). A study among low-income pregnant women in Santiago, Chile, showed that 28% of smokers continued smoking during pregnancy, and 60% of non-smoking pregnant women reported exposure to SHS in their home (35).

Western Pacific region

This region includes China, the world's most populous nation and the world's largest producer and consumer of cigarettes. Very few Chinese women smoke tobacco products (4%), highlighting the opportunity to prevent an epidemic of smoking-caused disease among this group of women. In contrast, Chinese men have among the highest smoking prevalence in the world (60%), making the potential for pregnant women's SHS exposure very high (36). Though many LMICs in the region have smoking patterns similar to China, three have a much higher prevalence of women's smoking: Nauru (52%), Cook Islands (20%), and Samoa (23%).

Southeast Asian region

With few exceptions, countries in this region have very low levels of women's smoking (<10%), but much higher rates of smoking by men (>30%). In India, state-level estimates of women's smoking range from 0.3 to 22% and chewing tobacco use from 0.2 to 60.7%, with wide variations observed by region, level of education, and social class (37, 38). Pregnant women in India are thought to use tobacco products at rates similar to those of their age-matched, non-pregnant counterparts (39). Nepal is the only country in the region in which men's and women's cigarette smoking rates are similar (29.3 vs. 26.2%). In Indonesia, smoking prevalence is estimated at 4.5% for women and 65.9% for men; a recent study found that more than 65% of women with children under 5 years of age reported that family members were exposed to SHS most of the time in their household (40). In recent years, the tobacco industry has targeted Indonesian women through advertisements and through the development of women's cigarette brands (41).

The Global Youth Tobacco Survey (GYTS)

provides comparable data on tobacco use, both cigarettes and other tobacco products, for girls and boys aged 13–15, for all WHO regions. GYTS data (1999–2005) found the difference in cigarette smoking between boys and girls is smaller than the difference between men and women, suggesting that as girls age, they will smoke more like their male counterparts than in the past. The GYTS also finds that, except in the Americas and the European region, boys' and girls' use of non-cigarette tobacco products is as high or higher than their use of cigarettes, highlighting the importance of monitoring and addressing the use of all types of tobacco products (42).

Social and cultural factors influencing pregnant women's tobacco use and exposure to SHS

Many social and cultural factors are already known to influence pregnant women's tobacco use and SHS exposure. Understanding these and other factors will be critical in the design and implementation of culturally appropriate tobacco prevention and control programs specifically for women in LMICs.

Tobacco use during pregnancy

Several studies indicate that some women, including some pregnant women, perceive a benefit to using tobacco products. In India, for example, many women who chew tobacco consider it to aid in performing manual labor, suppressing hunger, reducing toothache, relieving morning sickness and controlling labor pains (43). A study of pastoralist women in Northern Kenya found that women (including pregnant women) chew tobacco regularly, believing that it calms the stomach and relieves hunger; chewing tobacco is given to children beginning at age three for similar reasons (Ivy Pike, personal communication, October 15, 2009). Studies from India and other regions, have found that some pregnant women limit their food intake and adopt other strategies to help ensure a small baby and thus an easier delivery (44). The extent to which tobacco, often considered to be an appetite suppressant, is used in this way during pregnancy is not known. Pregnant women's lack of knowledge and misconceptions about physiology also play a role in continued tobacco use. For example, a study from Lebanon reports that it is common for poorly educated women to believe that the fetus is ‘in a bag,’ and therefore protected from harm (45). Globally, many studies show that women, particularly low-income women, use cigarettes to cope with stress (46, 47). During pregnancy, women report concern that quitting will increase stress for the fetus and for themselves. In Lebanon, many pregnant women who continue to smoke believe that the withdrawal symptoms and the psychological distress of quitting smoking are more harmful to the fetus than their continued smoking continued smoking (45).

Tobacco use postpartum

In countries where women's tobacco use is common, a range of factors may trigger relapse among women who had quit tobacco use during pregnancy, including physiological changes, resumption of pre-pregnancy social patterns, and lack of understanding of the importance of continued non-smoking after delivery. The attitudes and behaviors of partners and friends may also contribute. Those who refrained from smoking around the woman during her pregnancy may no longer do so after delivery; some may even offer the woman cigarettes. Studies from high-income countries find that some women resume smoking postpartum to help them lose weight or to manage stress (48, 49). Postpartum tobacco use may also negatively impact breastfeeding patterns. Studies from high-income countries find that mothers who smoke produce less breast milk and tend to breastfeed for shorter periods of time, compared with non-smoking mothers (50). Currently, it is not known whether postpartum tobacco use affects the initiation or duration of breastfeeding among women in LMICs, or if there are indigenous beliefs about the effects of tobacco use on the quantity and quality of breast milk.

Social norms restraining women's tobacco use

In many LMICs, the stigma traditionally associated with female tobacco use has been a key factor restraining tobacco use by women and girls. In these countries, smoking has been considered a culturally inappropriate behavior for women, with women who smoke viewed as morally flawed, unfeminine, rebellious, ‘loose,’ and/or sexually promiscuous; tobacco smoking is seen to damage a woman's reputation and impair her prospects for a good marriage (51, 52). Social norms proscribing tobacco use by women are often a reflection of societies in which men hold greater social power, and can exert broad control over women's behavior. Social disapproval of women's smoking has been linked to more general restrictions on women's behavior, particularly restrictions on women's sexual behavior, and may be considered ‘part and parcel of structures that relegate women to subservient positions within the family and wider community’ (53, 54). Social disapproval may also reflect religious traditions, and/or antipathy towards ‘Western’ customs, which may be viewed as threatening to traditional social values. Additionally, women's lower income and limited ability to control household spending may affect women's tobacco use (55). A key challenge will be to constrain the growth in women's tobacco use in LMICs, as modernization and emancipation erode traditional constraints on women's behavior, including women's smoking behavior, and to put in place tobacco control efforts that ensure ongoing improvements in the status of women (56).

Tobacco industry efforts to promote smoking among women

In many high-income countries during the 20th century, the tobacco industry capitalized on women's changing roles to influence social norms to favor tobacco use for women (57). With overall tobacco use by men and women now declining in most high-income countries, the tobacco industry has increasingly targeted women and girls in LMICs. Tobacco advertisements, promotion and sponsorship associate women's smoking with images of independence, sophistication, sex appeal, slimness, and Western culture (19, 58). As in high-income countries, ‘feminized’ cigarettes, long, extra slim, light, or ‘low-tar’ brands, have been created specifically for the female market in countries such as India, Indonesia and China, where women's smoking prevalence is very low (59–61). In some Asian countries, the tobacco industry has employed young women to distribute free samples of cigarettes and promotional items on streets, at concerts, and in shopping malls (62). Importantly, there is evidence that tobacco marketing is having an impact on women's tobacco use, especially among urban, educated, ‘westernized’ women, who often serve as role models and trend setters for other women. For example, in India, Indonesia, the Philippines and Thailand, countries with low overall female smoking prevalence, observational data suggest that it is becoming more common for highly educated women who work in non-governmental organizations to smoke as a sign of ‘emancipation’ from traditional barriers (Nichter M, personal communication, October 22, 2009). A cross-sectional study of Chinese migrant women found higher rates of ever smoking among restaurant workers and commercial sex workers than other women; education was a protective factor, while exposure to female-branded cigarettes was a risk factor for ever smoking (63).

The role of entertainment media

The impact of portraying tobacco use in movies and other entertainment media, including images of tobacco product brand names and logos, has been studied in several high-income countries. This work demonstrates that portrayals of tobacco use in movies and other entertainment media are very common, and that images of cigarette smoking in films can influence adolescent and adult viewers' beliefs about social norms for smoking, the function and consequences of smoking, and their personal intention to smoke (64). A study conducted among Mexican adolescents found that exposure to smoking in movies was associated with susceptibility to smoking, favorable attitudes toward smoking, and perceived peer prevalence of smoking (65). Reference to smoking in films was commonly reported as a reason for smoking among college students in India (66). In Brazil, glamorous and sophisticated images of female smokers in the media were found to be important contributing factors to smoking initiation among girls (67).

Exposure to SHS

In LMICs where few women smoke themselves, smoking by men can pose a serious health threat to women, infants, and children. In many LMICs, SHS exposure adds to existing exposures from indoor air pollution from burning of solid fuels and/or heavy levels of outdoor air pollution (68, 69). A study that measured household air nicotine concentrations in 31 LMICs found that women and children living with smokers were commonly exposed to SHS in their homes (70). A study conducted in nine LMICs found high reported levels of SHS exposure of pregnant women and their young children in several countries; exposure was highest in Pakistan, where nearly half of all women reported they and their young children were frequently or always exposed to SHS indoors (34). A recent survey in India and Indonesia indicated that despite frequent exposure to SHS by multiple family members, over 80% of women reported their household had no rules about smoking, and over 75% of women reported they felt powerless to influence smoking in the home by their husband and other men (40). Empowering women to limit their exposure to SHS in the home poses a special challenge, because it directly addresses couple and family dynamics, and gender inequality in the private sphere (71, 72).

Knowledge of health hazards of tobacco and SHS exposure

WHO has noted that ‘few tobacco users understand the full extent of their health risk’ (23). It is likely that knowledge of the risks of tobacco use and SHS exposure is especially lacking among poorly educated and illiterate pregnant women. The available studies support these broad generalizations. A study from the Dominican Republic found that men and women generally viewed smoking as harmful, but perceived health risks were vague and the benefits of quitting were rarely mentioned (73). Similarly, research conducted in China, India and Indonesia has shown that while people commonly associated smoking with lung cancer, most did not associate smoking with coronary heart disease, peripheral vascular disease, stroke, or tuberculosis (43, 74). A study conducted in Zambia and the Democratic Republic of the Congo showed that few pregnant women were able to name diseases or health conditions linked to women's smoking, smoking during pregnancy, or SHS exposure (75). Erroneous information about tobacco use is also believed to be widespread. For example, around the world many people mistakenly believe that it is safe to smoke only a few cigarettes a day (<10), or to smoke expensive brands of cigarettes (76). Tobacco industry efforts are sometimes a contributing factor; advertisements for ‘light’ or ‘low-tar’ cigarettes typically imply that they are less harmful than other cigarettes, despite the scientific consensus to the contrary (77). In 2006, a U.S. federal district court judge found that U.S. cigarette manufacturers had denied and distorted the link between smoking and disease, the health hazards of SHS, the addictive nature of cigarette smoking, falsely marketed and promoted low-tar cigarettes as less harmful than others and intentionally marketed to young people, despite claims to the contrary (78).

The culture of health care

Approximately half the world's pregnant women (48%) have adequate access to antenatal care (at least four visits), whether provided by physicians, nurses, midwives, or traditional birth attendants (79). The tobacco use knowledge, attitudes and behaviors of these providers can have a powerful influence on pregnant women. Health professionals who use tobacco are poor role models for the lay public and are less likely to advise their patients to quit. A recent review found that physician smoking has steadily declined in many high-income countries (although prevalence rates >25% were documented in several high-income countries including Italy, Japan, and France), but that many LMICs have high physician smoking rates (80). A survey of Jordanian obstetrician–gynecologists found that 41.6% of male physicians and 21.9% of female physicians smoked tobacco (81). Overall, 54.3% of those surveyed reported they provide cessation counseling to their patients, although physicians who smoked were far less likely to do so than their never smoking counterparts (25.5 vs. 75.3%); of those who asked about tobacco use, 68.8% recommended that their patients reduce their smoking, while only 31.2% advised women to set a quit date. Similar findings have been found among physicians in primary health care centers in Indonesia who report low levels of advising men to quit if their wife is pregnant (male physicians 37%; female physicians 51%); however, exit interviews found that only 3% of patients remember receiving this message from their physician (82). The Global Health Professions Student Survey was recently conducted among third-year students attending dental, medical, nursing, and pharmacy schools in 80 sites in 31 countries, primarily LMICs; in all four disciplines, more than 20% of students were current cigarette smokers in over half the sites, and at most sites, fewer than 40% of students reported having received training on smoking cessation counseling (83). A recent meta-analysis concluded that health provider advice delivered in routine care settings had a greater impact on smoking cessation than all other major tobacco control strategies (84). However, in LMICs, the training of obstetrician–gynecologists in the reproductive health effects of tobacco use and smoking cessation counseling is inadequate or non-existent.

Tobacco growing communities

Tobacco is grown in more than 120 countries. Tobacco agricultural workers, often women and children, may suffer from green tobacco sickness, caused by dermal absorption of nicotine from contact with wet tobacco leaves, and exposure to large quantities of pesticides (85). A study from Vietnam found tobacco cultivation was associated with a range of health problems, with women more commonly affected than men (86). Research is needed to understand the role of women in tobacco farming in LMICs, including the health effects for pregnant women of participating in tobacco agriculture.

Research priorities in LMICs

An international working group was convened in September 2008 to review and discuss social and cultural research priorities needed to inform interventions focused on preventing pregnant women's tobacco use and SHS exposure in LMICs. The working group emphasized the need for both quantitative and qualitative research, and the importance of focusing on the level of the individual woman or girl, the household and community, and the health care setting (Table 2). Qualitative research methods, which include participant observation, focus groups, and in-depth interviews, allow for an understanding of the depth, richness, and complexity of social, psychological, and cultural life (87). These methods are especially useful to study social and cultural influences, including the impact of tobacco industry marketing efforts targeted to women. Additionally, a promising approach in low-resource settings is community-based participatory research in which individuals in a particular country and/or community work side-by-side with researchers to develop theory-based, culturally relevant tobacco control strategies. This approach fosters research and capacity building, and has the potential to promote ownership and sustainability, by mobilizing these societies as political and social actors in the tobacco control movement.

Table 2. Recommendations for social and cultural research among women/girls, household/communities and health care settings in low- and middle-income countries.
Individual level/women, girlsHousehold level/community level/women, girlsHealth care setting level level/women, girls
Quantitative data needsQuantitative data needsQuantitative data needs
Prevalence of tobacco use (cigarettes and other tobacco products) Changes in levels of use Changes in age of initiation Knowledge of health risks of tobacco use and secondhand smoke (SHS) exposure Perceived ability to ask family members (men and women) not to smoke in the home Cessation efforts, including during pregnancy and postpartum Harm reduction practices (i.e. smoking reduction) Popular tobacco products for women, girlsExposure to SHS in the home, workplace Rules/policies about smoking in home and workplace Knowledge of and attitudes towards SHS exposure Interest in developing community smoke-free household campaigns Tobacco industry targeted marketing strategies (advertising, promotion, and sponsorship) to women, girls Implementation of evidence-based tobacco control strategies (e.g. tobacco taxes, advertising bans, strong health warning labels)Prevalence of tobacco use (cigarettes and other tobacco products) among health care providers Health care providers' knowledge of health risks of tobacco and SHS exposure, including pregnancy-specific risks Cessation training and perceived ability to deliver cessation interventions Current practices regarding asking, assessing and advising tobacco users to quit Prohibitions on tobacco use in health care settings and other activities to promote non-smoking norms
Qualitative data needsQualitative data needsQualitative data needs
Perceived social acceptability of tobacco use for women, girls Women's perceptions of benefits and risks of tobacco use Perceptions about cigarette brands and tobacco marketing strategies targeting women Tobacco use as a coping strategy for stress, disadvantage Efforts to reduce or quit tobacco Perceived social support for quitting During pregnancy and postpartum: Perceived benefits of smoking during pregnancy, postpartum Efforts to reduce or quit tobacco Specific concerns about quitting during pregnancy Social support for quitting Reasons for relapse to tobacco use postpartum Indigenous ideas about tobacco and breastfeedingLocal understanding and concerns about tobacco use and SHS Perceived environmental risks for women and children Best mechanisms to raise awareness of harms of tobacco use, SHS exposure Women's perceived ability to ask family members (men and women) not to smoke in the home Development of steps to create a community smoke-free household campaignStructure of health care system, including which providers deliver prenatal care Existing barriers to providers' assessing and assisting pregnant women to quit tobacco use Social and cultural factors needing to be addressed in advising women and men to quit Development of culturally appropriate training and materials for different types of health care providers

The working group also noted that it may be possible to expedite data collection by including new questions on existing national surveys of pregnant and reproductive age women, and that in some countries it may be possible to link birth outcome data with maternal tobacco use status. The latter information will be particularly useful for determining how to allocate scarce financial resources. The working group recommended that information gained from research be expeditiously translated into culturally appropriate policies, interventions, and educational efforts for pregnant and reproductive age women. Efforts should also target men and boys, to improve their health and that of their families. In tobacco growing LMICs, research is needed to better understand the social, economic, and health consequences of women's participation in tobacco production, and the impact of tobacco control measures on women and their families. Finally, the working group noted the critical importance of reaching health care providers, especially those who provide care to pregnant and postpartum women, to lower their tobacco use rates, to improve their knowledge of skills in cessation, and to engage them in tobacco control and prevention more generally. Simply ensuring smoke-free environments in health care settings serving pregnant women and children would reduce SHS exposure, support cessation by health care providers and model a non-smoking norm (88).


In most high-income countries, smoking during pregnancy has been a significant contributor to poor pregnancy outcomes for many years. While the prevalence of women's tobacco use is currently low in many LMICs, evidence strongly suggests that it will rise in coming decades, and can be expected to worsen the already poor pregnancy outcomes commonly seen in these settings. In many LMICs, existing cultural restrictions on women's tobacco use are part of a larger social structure that relegates women to an inferior social, legal, and political status. As efforts are made to improve the status of women and break down barriers to women's full participation in society, traditional constraints on women's tobacco use will also erode. Already, it is clear that the transnational tobacco companies seek to leverage these developments to promote tobacco use to women in LMICs, replicating the strategies that were used so effectively in high-income countries during the 20th century. These strategies threaten to undermine or reverse hard won gains in maternal and child health in LMICs and must not be allowed to succeed.

The WHO's Framework Convention on Tobacco Control (FCTC), the world's first international public health treaty, is today a leading force for tobacco control and prevention around the world; the treaty specifically suggests that countries ‘address gender-specific risks when developing tobacco control strategies’ (89). Most LMICs have signed the FCTC, and will be required to put in place evidence-based tobacco control policy measures. However, implementation of the FCTC alone should not be relied upon to prevent the anticipated growth in women's and girls' tobacco use in LMICs. There is an urgent need to better understand the social and cultural influences on pregnant and postpartum women's tobacco use to ensure that effective policies and programs are put in place, targeted to this vulnerable group.


We thank the members of the expert working group who contributed to the discussion of the science and the development of research priorities on this topic: Dilyara Barzani, Ministry of Health, Kurdistan Regional Government, Iraq; Michael S. Kramer, McGill University Faculty of Medicine, Montreal, Canada; Ann M. Malarcher, Centers for Disease Control and Prevention, Atlanta, Georgia, U.S.A.; Suneeta Mittal, All India Institute of Medical Sciences, New Delhi, India; and Sheela Shenoy Trivikram, Cosmopolitan Hospitals, Trivandrum, India.

Participants in the expert meeting entitled ‘Tobacco exposure during pregnancy in low- and middle-income countries: Establishing research priorities’ held September 8–10, 2008 were: Bernardo Agudelo-Jaramillo, Erik Augustson, Cathy Backinger, Dilyara Barzani, José Belizán, Vincenzo Berghella, John Bernert, Michele Bloch, Neal Brandes, F. Carol Bruce, Tsungai Chipato, Sven Cnattingius, Patricia Dietz, Mirjana Djordjevic, Thomas Eissenberg, Lucinda England, Ellen Feighery, Mario Festin, Christine Galavotti, Lorrie Gavin, Robert Goldenberg, Lorraine Greaves, Prakash Gupta, Paul Holmes, Carys Horgan, Yvonne Hunt, Ami Hurd, Ann Jensby, Annette Kaufman, Shin Kim, Priyadarshini Koduri, Michael Kramer, Mats Lambe, Harry Lando, Xingzhu Liu, Ann Malarcher, Elizabeth McClure, Mario Merialdi, Suneeta Mittal, Patricia Dolan Mullen, Katherine Murphy, Mimi Nichter, Thomas Novotny, Cheryl Oncken, Michael Paglia, Karen Parker, Alexandra Parks, Zhaoxia Ren, Jonathan Samet, Susan Sanders, Isabel Scarinci, David Stamilio, Mary Ellen Stanton, Alan Tita, Jorge Tolosa, Scott Tomar, Van Tong, Sheela Shenoy Trivikram, Deborah Winn, and Linda Wright.

Disclosure of interests: Bloch provided depositions on behalf of the U.S. government in the U.S. Department of Justice lawsuit, U.S.A. v. Philip Morris USA, Inc. et al., as part of her official duties. All other authors report no competing interests.