Tobacco use and secondhand smoke exposure among pregnant women in low- and middle-income countries: a call to action


Jorge E. Tolosa, Associate Professor of Obstetrics & Gynecology, Oregon Health & Science University, Division of Maternal Fetal Medicine, Coordinator Global Network for Perinatal & Reproductive Health, 3181 SW Sam Jackson Park Rd, L-458, Portland, OR, 97239, USA. E-mail:

Tobacco use and exposure to secondhand smoke (SHS) are widely viewed as serious threats to the health of pregnant women, infants, and children around the world. In many high-income countries, tobacco use has been a leading preventable cause of morbidity and mortality for women and men, and a leading preventable cause of poor pregnancy and infant outcomes, such as low birthweight, preterm delivery, placental abruption, and sudden infant death syndrome (SIDS) for many years (1). In many low- and middle-income countries (LMICs) the prevalence of tobacco use by women, including pregnant women, is low. However, recent surveys suggest that this situation is changing and that women in these countries are a target of the tobacco industry (2, 3). Increased tobacco use and exposure to SHS among pregnant women in LMICs, where poor pregnancy outcomes are already common, threatens to undermine improvements in maternal and child health in these countries. Reducing active smoking among pregnant women and eliminating SHS exposure of pregnant women and infants are directly relevant to Millennium Development Goals 4 (Reduce Child Mortality) and 5 (Improve Maternal Health) (4).

On the 8–10 September 2008, the Global Network for Perinatal and Reproductive Health (GNPRH), together with the US Centers for Disease Control and Prevention (CDC) and the US National Cancer Institute (NCI) convened an expert meeting entitled ‘Tobacco Exposure During Pregnancy in Low- and Middle-Income Countries: Establishing Research Priorities.’ Participants included tobacco control and reproductive health experts from high-, middle-, and low-income countries. Three articles in this issue of Acta Obstetricia et Gynecologica Scandinavica convey the findings from these deliberations; they summarize the available literature and provide recommendations for research on the following three topics:

  • • Social and cultural factors influencing pregnant women's use of tobacco and exposure to SHS.
  • • Interventions to promote tobacco cessation and reduce SHS exposure during pregnancy in high-, low- and middle-income counties.
  • • Description of non-cigarette tobacco use by women and characterization of risks for adverse pregnancy outcomes resulting from such use.

A brief summary of the research recommendations of the conference can be found in Table 1. Additionally, a number of broad conclusions can be drawn from the three articles:

Table 1. Tobacco exposure during pregnancy in low- and middle-income countries: expert meeting research priorities.
Social and cultural factors influencing pregnant women's use of tobacco and exposure to SHSConduct quantitative and qualitative studies at the level of the individual woman or girl, the household and community, and the health care setting. Conduct studies to determine: At the individual level: Women's knowledge of health hazards of tobacco use, including use during pregnancy and postpartum; perceived ‘benefits’ of tobacco use; perceived social acceptability of tobacco use for women and girls; perceived ability to ask family members not to smoke in the home; awareness and perceptions of cigarette brands and tobacco marketing strategies targeting women; perceived social support for quitting At the household/community level: Pregnant women's exposure to SHS in homes/workplaces; local understanding and concerns about tobacco use and SHS; best mechanisms to raise awareness of harms of tobacco use and SHS exposure; industry targeted marketing strategies in place in individual communities; community implementation of evidence-based tobacco control strategies At the health care setting level: Prevalence of tobacco use among health care providers; providers' knowledge of health risks of tobacco and SHS exposure, including pregnancy-specific health risks; training and perceived ability to deliver cessation interventions; prohibitions on tobacco use in healthcare settings; barriers to providers' assessing and assisting pregnant women to quit tobacco use
Interventions to promote tobacco cessation and reduce SHS exposure during pregnancy in high-, low-, and middle-income countiesEvaluate the impact of tobacco control policy efforts to reduce tobacco use and SHS exposure among pregnant and reproductive age women in LMICs. Develop and evaluate culturally adapted interventions that involve brief health care provider advice to quit tobacco use and reduce SHS exposure by pregnant smokers; evaluate whether psycho-social support, pharmacotherapy, incentives, and addressing other harmful health behaviors can provide additional benefits; develop interventions for delivery by non-traditional health care providers Evaluate the impact of concurrent implementation of population-level and clinical interventions for cessation among pregnant and reproductive age women Determine the safety and efficacy of pharmacotherapies in LMICs where these are routinely used by non-pregnant women
Description of non-cigarette tobacco use by women and characterization of adverse pregnancy outcomes resulting from such useModify existing surveillance systems, or develop new systems, to monitor trends in the use of non-cigarette tobacco products in women of reproductive age Investigate potential associations between the use of non-cigarette tobacco products and adverse reproductive health outcomes, especially preterm delivery, hypertensive disorders of pregnancy, early pregnancy loss, stillbirth and placental abruption Develop surveillance systems to monitor tobacco industry efforts to promote non-cigarette tobacco product use among women Establish a repository or network of repositories for biological specimens and tobacco products samples, and develop standardized materials and protocols for specimen collection, handling, storage and sharing Develop a list of laboratories able to analyze biological and tobacco product samples, as well as standardized control materials and an inter-laboratory validation program Conduct studies to improve our understanding of social and cultural factors influencing women's use of non-cigarette tobacco products Develop and test cessation interventions for non-cigarette tobacco product users
  • • In many LMICs, tobacco use has long been considered a culturally inappropriate behavior for women and girls, and the stigma associated with tobacco use has inhibited tobacco use initiation among women and girls. However, globalization, modernization and efforts to improve the status of women are eroding traditional cultural constraints on women's behavior, including women's tobacco use behaviors. With regard to women in LMICs, there are the dual challenges of maintaining and even reducing the generally low prevalence of cigarette smoking in women, while also reducing the high prevalence of their exposure to SHS, reflective of the high rates of smoking among men in many countries.
  • • As tobacco use by men and women in high-income countries continues to decrease, the multi-national companies and many national tobacco industries have targeted women and girls in LMICs as an untapped and potentially vast market. Western style tobacco marketing frequently associates women's cigarette smoking with independence, sophistication, sex appeal, slimness, and fashion. Additionally, exposures to images of tobacco use in movies and other entertainment media are likely to contribute to a view of cigarette smoking as ‘normal’ in LMICs. Absent effective interventions, increased cigarette smoking may follow further globalization, expansion of free trade through the World Trade Organization and cultural changes that affect the status of women in LMICs.
  • • In high-income countries, a range of clinical and population level interventions have been shown to decrease maternal tobacco use. However, these interventions may require significant adaptation in order to achieve acceptance and success in LMICs. To date, little research has been carried out on the prevention and treatment of tobacco use among pregnant women in LMICs.
  • • Many LMICs, and some high-income countries, lack accurate data, especially population-based data, on pregnant women's tobacco use (both cigarette and non-cigarette products) and on their SHS exposure. In addition, because of the stigma associated with tobacco use by women in many countries, current survey results may underestimate true exposure prevalence. Thus, the data reported in the three papers may offer an incomplete picture of the problem of tobacco use during pregnancy.
  • • While the adverse reproductive health effects of cigarette smoking have been well documented, there is little information on the reproductive health effects of non-cigarette tobacco products, including smokeless tobacco products, cigars and pipes and waterpipes. These products are widely used by women, including pregnant women, in many parts of the world. Assessing the health effects of these products in LMICs is complicated by the diversity of products, variability in patterns of use globally, and by difficulties inherent in studying adverse pregnancy outcomes.

Today, a key driver of tobacco control efforts at the global level is the WHO Framework Convention on Tobacco Control (FCTC) (5). The FCTC, the first treaty ever negotiated under WHO leadership, was developed in response to the globalization of the tobacco epidemic and the need for control strategies that were also operative at the global level; as of September, 2009, 167 countries were parties to the treaty. The evidence-based interventions required by the FCTC will be very useful to help prevent and control tobacco use and SHS exposure among girls and women of reproductive age. However, the FCTC alone should not be relied upon to prevent the anticipated rise in women's tobacco use. Specific, focused attention on surveillance, research and interventions to prevent tobacco use initiation by girls and young women in LMICs is also needed.

In an effort to build on the FCTC process, the WHO published its first ‘Report on the Global Tobacco Epidemic,’ in 2008. This report puts forward the ‘MPOWER’ framework for tobacco control, which calls for monitoring of the tobacco epidemic; offering assistance to quit; protecting non-smokers from exposure to SHS; warning smokers of the health effects of smoking; enforcing advertising bans; and raising taxes on tobacco products (3). Although MPOWER calls for protection (P) of non-smokers from exposure to SHS, and the FCTC targets exposure to SHS in its Article 8, WHO policy recommendations give little direction on limiting exposure in the home, the principal place where most women and children are exposed to SHS (6, 7). Experience in high-income countries shows that households are now choosing to ‘be smokefree’ or to limit smoking to specific rooms or areas of the home (6). Unfortunately, such policies are infrequent in LMICs and strategies are needed to promote them (7).

Tobacco exposure in pregnancy should be viewed in the context of the larger global challenges to women's health. In a recently released report, ‘Woman and Health, Today's Evidence, Tomorrow's Agenda,’ the WHO notes that: ‘A health transition is sweeping around the world, leading to a shift in the patterns of death and disease – away from infectious diseases and maternal conditions to non-communicable and chronic diseases. However, the transition is happening at different rates in different parts of the world. In many settings, women are confronted by a dual burden of traditional health threats related to infectious diseases and maternal conditions alongside emerging challenges associated with non-communicable diseases’ (8). This ‘double burden’ of disease, in which tobacco exposure plays a significant role, threatens impoverished women, their families, their communities, and the under-resourced health systems in many LMICs.

A consistent theme in each of the three papers resulting from the 2008 expert meeting is the need for more and better data, and the need for more investment in research targeting women in LMICs. Similarly, the new WHO report also calls attention to the paucity of reliable data, noting ‘this report is also a call for better data, for more research, for more systematic monitoring of the health of the female half of the world, and for addressing the barriers that girls and women face in protecting their health and in accessing health care and information’. Surveillance and specific research addressing pregnant women and tobacco exposure are critical for monitoring the extent of the problem, adapting and evaluating effective programmatic and policy interventions, and informing decision makers in the public and private sectors, at the global, regional, country, and local level, how to allocate scarce financial and human resources.

The Global Tobacco Surveillance System (GTSS) is one strategy to obtain better data on girls' and women's tobacco use. The GTSS aims to enhance countries' capacity to monitor tobacco use, guide national tobacco prevention and control programs, and facilitate comparison of tobacco-related data at the national, regional, and global levels; it is also a source of information for monitoring and evaluating the impact of the WHO FCTC and MPOWER strategies. The GTSS includes school-based surveys of youth, school professionals, and students in health professional schools and household-based surveys of adults. The GTSS recently marked its 10th anniversary; however, less than half of countries (48%) have minimum tobacco data for youth and adults (9). To facilitate standardized data collection, CDC, WHO, and their international partners are currently developing core questions for use in existing population-based surveys, entitled ‘Core Tobacco Questions for Surveys: Subset of the Global Adult Tobacco Survey.’ Countries with high or increasing rates of tobacco use among women and girls should consider adding questions on tobacco and pregnancy to their population-based surveys to obtain reliable data for programmatic and policy efforts.

In LMICs, women receive care from diverse health care providers, including physicians, nurses, midwives, traditional birth attendants and others. Obstetrician-gynecologists and others who provide care to pregnant and reproductive age women have a critical role to play in reducing SHS exposures and in preventing and reducing tobacco use by women and girls. The prevalence of tobacco use among these providers is often unacceptably high, and this remains an important barrier to these health professionals intervening effectively with patients and their families and with communities. In addition, many health care providers lack understanding of the health effects of tobacco use, including the reproductive health effects, and most lack training in how to help pregnant women quit tobacco use or to protect themselves and their children from SHS exposure. Strategies are urgently needed to enhance awareness and further engage obstetricians-gynecologists, as well as other health care providers, in practice and research to understand and address women's tobacco use and SHS exposure. Additionally, tobacco control professionals and activists need to join with maternal and child health practitioners and programs to reduce women's tobacco use and SHS exposure; too often, clinical and public health personnel are isolated from one another, and do not collaborate sufficiently to achieve shared goals.

Approximately 85% of the world's 3.3 billion females live in LMICs, where statistics on maternal and infant health morbidity and mortality are for the most part quite poor. The health of these women is important in its own right, but is also important to the health and future of their children, families, and communities. The historical advances in maternal and child health attributed to prenatal care, attended births, and immunization programs will be adversely affected if the preventable problem of tobacco use among reproductive-aged women is not confronted. The FCTC alone is not sufficient, and clinicians, maternal, and child health program planners, and policy makers need to focus specifically on this issue as it threatens the health of too many women. The research agenda put forth by the expert group in three articles in this dedicated issue of the journal (Nichter M, et al.; England L, et al.; Oncken C, et al.) is a call to action for funding support, scientific inquiry, and evidence-based interventions to reduce tobacco use and SHS exposure among pregnant women.


Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The findings and conclusions are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Cancer Institute. Dr. Bloch provided depositions on behalf of the U.S. government in the U.S. Department of Justice lawsuit, U.S.A. v. Phillip Morris U.S.A., Inc. et al., as part of her official duties. Dr. Samet was previously a member of the Pfizer Global Tobacco Advisory Board.