Tobacco Documents Online

6. Zucker DM. Lakatos E, Webber LS et ai. for. the CATCH Study Group. Statistical design of the Child and Adoles- cent Trial for Cardiovascular Health (CATCH): implications of cluster random- ization. Controlled Clin Trials. 1995:16:96- 118. 7. Luepker RV, Perry CL, McKinlay SM, et al. for the CATCH Collaborative Group. Outcomes of a field trial to improve children's dietary pauems and physical activity. JAMA. 1996:275:768-776. 8. Hayes R, Mosha E Nicoll A. et al. A community trial of the impact of improved sexually transmitted disease treatment on the HIV epidemic in rural Tanzania: 1. Design. AIDS. 1995:9:919-926. 9. Grosskurth H, Mosha E Todd J, et al. Impact of improved treatment of sex- ually transmitted diseases on HIV infection in na-ai Tanzania: randomized controlled trial. Lancet. 1995:346:530-536. 10. Chlebowski RT, Grosvenor M. The scope of nu~tion intervention trials with cancer- related endpoints. Cancer. 1994:74:2734- 2738. [1. Rosso~w JE, Finnegan LP, Harlan WR, Pinn VW, Clifford C, McGowan JA. The evolution of the Women's Health Initiative: perspectives from the NIH. JAm Med Worn Assoc. 1995;50:50-55. 12. Freedman LS, Green SB. Statistical de- signs for investigating several interven- tions in the same study: methods for cancer prevention trials. J Nail Cancer Inst. 1990,82:910-914. 13. Baring JE, Hermekens CH. Cost and efficiency in clinical trials: the U.S. Physi- cians' Health Study. Star Meg 1990;9:29- 33. Editorials, Annotations, Topics 14. Steering Committee of the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing Physicians' Health Study. N Engl J Med. 1989:321:129-135. 15. Hennekens CH, Buring JE. Manson JE, et al. Lack of effect of long-term supplemen- tation with beta carotene on the incidence of raalignant neoplasms and cardiovascular disease. N Engl J MecL 1996;334:1145- !149. 16. Green SB, Byar DE Using observational data from registries to compare treatments: the fallacy of omnimetrics. Star Med. 1984;3:361-370. 17. Peto R. Collins IL Gray R. Large-scale randomized evidence: large, simple trials and overviews of trials. J Clin Epidemiol. 1995;48:23--40. Annotation: Cigarette Smoking, Nutrition, and Birthweight Cigarette smoking during pregnancy is associated with numerous adverse outcomes of pregnancy for both mother and infant. These include increases in preterm delivery (often mediated by an increase in the incidence of placenta previa and abrnptio placentae), perinatal mortality, and, possibly, spontaneous abor- tion.I Postnatal effects on the child include deficits in long-term physical growth, intellectual performance, and be- havioral development, but it is often difficult to determine if these and other deleterious outcomes are related to expo- sure to cigarette smoking in utero or posmatally,m Pregnant smokers deliver infants who, on average, are 200 g lighter than those of nonsmokers. Smoking is also associated with a twofold increase in the risk of low birthweight (<2500 g)) In his extensive review of risk factors for low birthweight, Kramer3 identified maternal smoking as the single largest modifiable risk factor for both intrauterine growth retardation and prematurity in developed countries. It is estimated that maternal smoking is responsible for 20% to 30% of low birthweight among infants and 10% of infant deaths in the United States3 In this issue of the Journal, Heller- stedt and her coworkers4 studied 1343 obese and nonobese pregnant women to assess whether maternal pregravid obesity or weight gain during pregnancy could ametiorate the negative effects of smoking on birthweight. Although obesity or high gestational weight gain did not eliminate the birthweight-lowering effects of smok- ing in this study, there was evidence that cigarette smoking, combined with low maternal weight gain, was associated with the highest risk of low birthweight for the infants of both obese and normal-weight gravidaso These findings are not surprising in view of the biological evidence that maternal smoking appears to cause fetal growth restriction through both nonnutri- tional and nutritional routes. It is unlikely that high maternal prepregnant weight or high gestational weight gain can modify the increased concentrations of carboxyhe- moglobin in both maternal and fetal blood or the relative fetal hypoxia that have been proposed as the major underlying biologi- cal causes of the observed relationship between maternal cigarette smoking and low birthweight.~ However, the results of numerous studies suggest that smoking and maternal weight gain during preg- nancy are independent, additive predic- tors of birthweight and that women who smoke are more likely to experience a low gestational weight gain) In addition, smoking appears to decrease the availabil- ity of dietary energy, increase the require- ment for iron, and reduce the availability of such nutrients as vitamin Btz, amino acids, vitamin C, folate, and zincJ Unfor- tunately, although pregnant smokers may have higher nutritional needs than non- smokers, cigarette smoking is associated with the consumption of less healthy diets by both pregnant6-s and nonpregnant women) Thus, the combination of ciga- rette smoking and poor dietary intake may expose the fetuses of smokers to two insults, each of which is associated with poor intrauterine growth. Despite these widely known facts, 25% to 30% of American women still smoke during pregnancy)° In a national sample, 27% of these women quit sponta- neously during the early part of preg- nancy,t| About a third of those who quit on their own early in pregnancy start smoking again later in gestation,t2 This means that they are likely to be smoking again during the third trimester of preg- nancy, the time when smoking has the greatest deleterious effect on fetal weight gain.13 Unfortunately, many women report not receiving advice about smoking from their prenatal care providers. Only 71% of White and 64% of Black women in a nationally representative sample reported receiving advice about smoking during prenatal care.l'* Even with the best results from smoking-cessation programs (a 50% increase in quitting rote over control subjects, 1.4% to 17.2% of whom will quit with usual prenatal carel°) that are offered to the three-fourths of pregnant smokers who don't quit on their own, the vast majority of women who smoked at conception continue to smoke throughout pregnancyJ° What kind of nutritional advice should health care providers offer preg- nant women who smoke or who have quit since conception and are at high risk of relapse? It does not appear that encourag- ing smokers to gain more weight than nonsmokers with a similar body mass index will eliminate the negative effects of smoking on birthweight or other out- comes of pregnancy. However, because Editor's Note. See related article by Hellerstedt et al. (p 591) in this issue. o o April 1997. Vol. 87, No. 4 American Journal of Public Health 543

Edi~riads, A~notations, Topics pregnant women who smoke cigarettes are at increased risk of both having a poor dietary intake and low weight gain during gestation, and because pregnant women who quit smoking are at increased risk of excessive weight gain during gestation,15 individualized nutritional counseling is recommendedtS,16 in addition to smoking- cessation efforts. Every pregnant woman deserves access to information, counseling, and appropriate interventions that support the healthiest possible outcomes for her and her developing fetus. Research is needed to improve the efficacy of smoking- cessation interventions for pregnant women, which are already known to be cost effective.17 Research is also needed to identify effective interventions to improve maternal dietary intake and ensure ad- equate weight gain during pregnancy, especially for cigarette smokers. Further- more, we need to find affordable and efficient ways to integrate these activities into all health care settings, including public clinics, private practice, and man- aged care. [] l(~thleen M. Rasmussen Division of Nutrition Sciences Cornell University Barbara Adams School of Public Health University of California Berkeley References I. Institute of Medicine. Subcommittees on Nutritional Status and Weight Gain during Pregnancy and Dietary Intake and Nutrient Supplements during Pregnancy, Food and Nutrition Board. Nutrition during Preg- nancy: Weight Gain; Nutrient Supple- ments. Washington, DC: National Acad- emy Press; 1990. 2. Dol~n-Mullen R Ram/fez G, Gruff/Y. A recta-analysis of randomized U'ials of prenatal smoking cessation interventions. Am J Obstet GynecoL 1994;171:1328- 1334. 3. Kramer MS. Intrauterine growth and gesta- tional duration determinants. Pediatrics. 1987;80:502-51 I. 4. Hellerstedt WL, I-times JH, Story M, Alton IlL Edwards LE. The effects of cigarette smoking and gestational weight change on birth outcomes in obese and normal-weight women.Am J Public Health. 1997;87:591- 596. 5. Longo LD. The biological effects ofcafoon monoxide on the pregnant woman, fetus and newborn infant. Am J Obstet GynecoL 1977;129:69-103. 6. Trygg IL Lund-Larscn K, Sandstad B, Hoffman JI-l, Jacobsen G, Bakketeig IS. Do pregnant smokers eat differently from pregnant non-smokers? Paediatr Perinat Epidemiol. 1995;9:307-318. 7. Haste FM, Brooke 03, Anderson HR, Bland JM. The effect of nutritional intake on outcome of pregnancy in smokers and non-smokers. Br J Nutr 1991;65:347-354. 8. Haste FM, Brooke OG, Anderson HR, ct al. Nutrient intakes during pregnancy: observations on the influence of smoking and social class. Am J Clin Nutr. 1990;51: 29-36. 9. McPhillips JB, Eaton CB, Gans KM, et ai. Dietary differences in smokers and non- smokers from two southeastern New En- gland communities. J Am "Diet Assoc. 1995;84:287-292. I 0. Floyd RL, Rimer BK, Giovino GA, Mullen PD, Sullivan SE. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annu Rev Public Health. 1993;14:379-411. 11. Fingethut LA, Kleinman JC, Kendrick JS. Smoking before, during, and after preg- nancy. Am J Public Health. 1990;18:541- 544. 12. Quinn VP, Mullen PD, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery. Addict Behav. 1991:16:29-- 40. 13. Lieberman E, Gremy I, Lang JM, Cohen AP. Low birthweight at term and the timing of fetal exposure to maternal smoking. Am J Public Health. 1994;84:1127-1131. 14. Kogan MD, Kotelchuck M, Alexander Johnson WE. Racial disparities in reported prenatal care advice from health care [axaviders.AmJ Public Health. 1995;84:82- 88. 15. Institute of Medicine. Committee on Nutri- tional Status during Pregnancy and Lacta- tion. Nutrition Services in Perinatal Care. Washington, DC: National Academy Press, 1992. 16. Mongoven M, Dolan-Mullen P, Gruff JY, Nicol L, Buran K. Weight gain associated with prenatal smoking cessation in white, non-Hispanic women. Am J Obstet Gyne- col. 1996;174:72-77. 17. W~mdsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: its behavioral impact and cost benefit. Am J Public Health. 1993;83:201-206. Annotation: HIV Prevention Challenges--Realistic Strategies and Early Detection Programs European public health officials have succeeded in protecting their young people from human immunodeficiency virus (HIV) in ways that American policymak- ers have not. The most significant and dramatic increases occurred in Switzer- land over 7 years in condom use, fear of contracting HIV, and knowledge of HIV prevention strategies. These positive changes concurred with the implementa- tion of a coherent and comprehensive national policy of stopping AIDSJ The changes, greatest among youths aged 17 to 25 years, were larger than changes simultaneously observed among youths in the United States, France, Germany, Scotland. and Sweden. These data demon- strate the potential efficacy of consistent application over time of intensive national intervention programs. However, the data also highlight the need for additional HIV pre~,ention strate- gies. Those who want children, for example, must abandon condom use for HIV protection. The prevention strategies in the Swiss agenda do not provide adequate protection from HIV when pregnancy is desired. We must identify strategies that both protect from H/V and allow pregnancy. A combination strategy of HIV testing and monogamy offers one approach. HIV testing allows early detec- tion of infection and has two benefits: the infected can take precautions to limit further transmission and can implement prophylactic treatments such as protease irthibitors2 or azidothymidine during preg- nancy) While HIV testing increased from 3% to 4% (a statistically significant in- crease), the vast majority of the Swiss population is not tested for HIV. In countries with higher seroprevalence rates, the impact of increased condom use will be far less than the potential response to routine HIV testing for early detection of infection.4 While the Swiss data demon- strate the positive behavioral impact of national policies, the data also signal that a new era in prevention must unfold. Policymakers must recognize that early detection of infection is a cornerstone of any national prevention agenda. National challenges exist to adapt realistic goals regarding adolescent sexu- ality, to implement effective HIV preven- tion programs for youth, and to implement early detection programs for HIV. The United States has not increased consistent Editor's Note. See related article by Dubois- Arber et al. (p 558) in this issue. 0 O~ O~ 0 544 American Journal of Public Health April 1997. Vol. 87. No. 4