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Effects of passive smoking (environmental tobacco smoke) on pregnancy outcome at district hospital, Jhansi, Uttar Pradesh.


Background: Adverse effects of exposure to environmental tobacco smoke (ETS) during pregnancy are associated with small-for-gestational age babies, increased perinatal mortality and morbidity, and early preterm delivery.

Objective: (1) To assess prevalence of passive smoking during pregnancy. (2) To assess the effects of exposure to ETS on outcome in pregnancy.

Material and Methods: It is a hospital-based cross-sectional study conducted at a district hospital from June 2014 to November 2014. Three hundred non-smoking women (20-35 years) delivering a singleton live baby were studied. A pre-tested, semi-structured questionnaire was used for data collection. SPSS version 16.0 was used for the analysis of data. Chi-square was used for categorical variable and unpaired student's t-test for continuous variable for comparison.

Results: Among the 300 women studied, 26% (78) were exposed to ETS. Those exposed to ETS, there was a significantly higher incidence of preterm births (32%) and small-for-gestational age babies (27%) compared to the unexposed. The mean birth weight of babies born to exposed mothers was 282 g less compared to those born to non-exposed mothers.

Conclusion: The awareness about the harmful effects of passive smoking is poor. Evaluation of ETS exposure and steps to avoid it during pregnancy should be an important part of antenatal care.

KEY WORDS: Environmental tobacco smoke (ETS), preterm, LBW, SGA, smoking-related knowledge


Exposure from breathing airborne tobacco smoke products is what is commonly called environmental tobacco smoke (ETS). [1] Over the last two decades, there has been increased public health concern regarding the harm caused to non-smokers who are involuntarily exposed to ETS. The term "passive smoking" usually refers to the inhalation of smoke that is either exhaled by a smoker or released as side-stream smoke from a burning cigarette. [2] Another name for passive smoking is "involuntary smoking," or "second-hand smoking" (SHS) because the person who inhales it often has no choice in the matter.[2,3] Side-stream smoke constitutes about 85% of the smoke present in the room and contains many potentially toxic gases in higher concentrations than in the main-stream smoke. [1] The effects of cigarettes on the pregnant woman and developing fetus are numerous with a wide range of squeals that will remain with the fetus for the rest of her life. The literature on the association between ETS and pregnancy outcome has shown that exposure to ETS increases the risk of adverse birth outcomes. [4] The International Consultation on Environmental Tobacco Smoke (ETS) and Child Health concluded that maternal exposure to smoking during pregnancy is a major cause of reduced birth weight, decreased lung function, and sudden infant death syndrome (SIDS).[2,3] There is no safe level of SHS exposure. The World Health Organization has estimated that globally almost half of all children are exposed to ETS. [5] The toxins in SHS (nicotine and carbon monoxide) directly cause harmful effects on the fetus. [7] Exposure during pregnancy is associated with low birth weight (LBW), small-for-gestational age (SGA), perinatal death, and reduced lung function.[2-4] There is strong consistent evidence that exposure to ETS in childhood increases the risk of early respiratory infections, causes chronic respiratory symptoms, and increases exacerbation. The adverse health effects of passive smoking have been studied in developing and underdeveloped countries only occasionally. Most of the studies from India are on the pulmonary effects of passive smoking. [3] In this study, we examined the effects of exposure to ETS on the maternal and fetal outcome in pregnancy. Further knowledge is needed about the type of SHS exposure (at home, work, or outside home/work), the quantity of ETS exposure (average number of exposure hours per week), and the timing of ETS exposure (first, second, and third trimesters).


(1) To assess the prevalence of ETS exposure among pregnant women. (2) To assess the effects of exposure to ETS on outcome in pregnancy. (3) To assess the anthropometric measurements of babies born to ETS-exposed mothers and ETS-unexposed mothers.

Material and Methods

It is a hospital-based cross-sectional study conducted at a district hospital in Jhansi, Uttar Pradesh from June 2014 to November 2014. Three hundred non-smoking women aged between 20 and 35 years delivering a singleton live baby were studied. Younger than 20 and older than 35 years old women were excluded to eliminate age-related complications of pregnancy and still births were also excluded. Inclusion criteria were based on the following conditions: (1) women with singleton pregnancy; (2) term and preterm delivery ([greater than or equal to]37 and <37 gestation week counted from the last menstrual period and/or early ultra-sound scan); (3) women who did not smoke during the index pregnancy; and (4) women both exposed and non-exposed to passive smoking were included. After obtaining the permission of chief superintendent of the district hospital, data were collected from the Medical Birth Registry of hospital, and obstetric and medical details of the mothers were also noted from the hospital records. Women who gave consent for participation were interviewed as soon as possible after birth and before leaving the hospital. Following the delivery, each woman was interviewed according to a pre-tested, semi-structured questionnaire to enquire if they had been exposed to ETS. All neonates in our study were weighed on an electronic scale and other anthropometric measurements (such as length and head circumference) were completed by the interviewers. The outcome variables considered in this analysis were mean birth weight, LBW, preterm delivery, and SGA, and Apgar score at 1 and 5 min was also considered. The outcomes of variables were as follows: LBW (weight < 2500 g at birth), preterm delivery (gestational age < 37 weeks), and SGA (birth weight > two standard deviations below the reference median birth weight for the infant's gestational age).

Estimation of sample size

The sample size was calculated using the formula:

n = 4pq/[L.sup.2]

Where Considering 95% confidence interval and taking passive smoking prevalence (p) of 24% and "L", absolute error in the estimate of p as 10%. The sample size was estimated to be 292, but for the convenience of the statistical analysis the sample size was rounded off to 300.

Statistical analysis

Data were entered into a Microsoft Excel spreadsheet and then transferred to Statistical Package for Social Sciences (SPSS[R]) (trial version 16.0) for the analysis of data in this study. Chi-square was used for categorical variable and unpaired student t-test for continuous variable for comparison, and p-value < 0.05 was considered statistically significant. All women were free to participate and they were assured of confidentiality of their personal information.


Table 1 shows the socio-demographic characteristics of the study participants. Fifty percent of the women aged between (26-30 years). Almost 50% of the participants were illiterate. As per occupation, most of the study participants were housewife. More than 90% of the women belonged to middle (38%) and lower (54%) socio-economic class. Almost 26% of the women had the history of smoking exposure in family or outside.

Figure 1 shows the sources of exposure of ETS. Out of 300 women, 78 were exposed to ETS, in which 40 women were exposed from both husband and others (outside, work, relatives), 28 were exposed exclusively from husband only.

Figure 2 shows the hour of exposure of ETS through different sources (home, work, outside) in all three trimesters. Maximum exposure was seen in the first trimester compared to the second and third trimesters. The number of hours was almost same in all trimesters when home was the source of ETS. In the third trimester, the number of hours of exposure from work and outside was low compared to the first and second trimesters, which indicates that during the third trimester there is restriction of movements and limitations of pregnant women.

Table 2 shows that while majority of variables have not shown significant association between pregnancy outcome and ETS exposed or non-exposed, but there is more prevalence of preterm birth, SGA, LBW, and Apgar score at 5th minute in the ETS-exposed group compared to the non-exposed, and it was statistically significant.

Table 3 shows that the mean birth weight of newborn in the exposed group is 282 g less than that of the non-exposed group, and it was statistically significant. There is no significant difference seen between the exposed and the non-exposed groups for birth length, head circumference, and chest circumference.


In this study, it was found that exposure to ETS in pregnant women was significantly associated with a higher risk of SGA birth and LBW. Several epidemiological studies have shown similar effects. A meta-analysis of studies conducted before mid-1995 reported an overall relative risk (RR) of 1.2 (95% CI, 1.1 to 1.3) for LBW at term or SGA among the infants born to mothers exposed to ETS during pregnancy. [6] A recent small, case-control study found an association of IUGR with detectable nicotine level in mothers' hair samples. [7] In this study, self-reported exposure is also taken into account for quantifying the exposure. The validity of self-reported exposure to ETS has been tested in a large multi-country, multi-centered collaborative trial. [8] The study demonstrated that non-smoking women could provide appropriate estimates of their exposure, which correlated well with their biochemically measured exposure levels. A recently published study has stated that self-reporting could be underestimating the low levels of exposure.[9] The mean birth weight of babies born to mothers exposed to ETS, in this study, was lower than that of babies born to unexposed mothers, Similarly, the birth weights have been found to be lower in studies that have compared self-reported ETS exposure from all sources (home and work). [9] Another study shows that exposure to SHS among non-smoking pregnant women can also cause a decrease in birth weight.[10-12] Our findings on the association between ETS exposure and preterm births are more in accord with findings of the studies.[11-13] Few other studies give almost the same result.[14,15] There are limited data available from India. In a study from Vellore, India, it was shown that "passive smoking was associated with a decrease in birth weight of 63 g (95% CI 12-114 g) even after adjusting for other variables known to affect birth weight". [14] In a study from Mumbai, shown the levels of nicotine and minor tobacco alkaloids in the main-stream and sidestream smoke. [15] A study demonstrated that ETS exposure for at least 2 h per day resulted in a mean birth weight reduction of 85 g and a twofold increased risk of LBW among the infants of non-smokers. [14] A study carried out among pregnant women in north western India has shown that most women believed that smoking was harmful to the developing fetus and did not take any preventive steps to avoid exposure to environmental tobacco. [4] In a study reported from Australia, it was shown that men, whose partners were pregnant, were largely unaware that their own smoking could pose a specific risk to the fetus and were reluctant to quit smoking. [16] Studies have also shown that women exposed to ETS were slightly more likely to deliver an SGA infant or to experience preterm delivery.[2,4,10] There are certain limitations of this study. First, deliveries in the district hospital do not represent the whole population. Second, exposure to ETS was based on women's self-report that is likely to be imprecise and subject to recall bias. Third, we did not assess the long-term outcome on growth and neurodevelopment of the babies. Last, we have not included active smoking in our study, though its effect is disastrous on pregnancy outcome.


The prevalence of exposure of pregnant women to ETS in our study is high at 26% and it is associated with reduced birth weight, and SGA babies. Evaluation of ETS exposure and steps to avoid it during pregnancy should be an important part of antenatal care. Programs to raise awareness and motivate behavioral change among pregnant women and their partners are needed to reduce the harmful effects of prenatal and postnatal exposure to tobacco smoke. ETS awareness and control strategies for the home, in addition to smoking cessation strategies, should be incorporated into tobacco education programs in schools. Smokers could be reminded that, as they do not expose their co-workers among the general public in many places to smoke, they should extend the same protection to their children and partners.


On the basis of findings of the study, the following issues should be considered:

* Public health implication-behavioral change communication is required toward smoking in public places.

* Smoking cessation programs for husband and also for public.

* Surveillance of passive smoking on target groups (young married women, less educated women, unmarried, women of rural areas and low socio-economic backgrounds)

* Regular antenatal checkups and child health clinic is a must.


The authors express heartfelt gratitude to all the study participants of this research who shared their valuable experiences and spent their precious time.


[1.] US Department of Health and Human Services. The Health Consequences of Involuntary Smoking. DHHS (PHS) 87-8398. Washington, DC: USGPO, 1984.

[2.] Deshmukh JS, Motghare DD, Zodpey SP, Wadhva SK. Low birth weight and associated maternal factors in an urban area. Indian Pediatr 1998; 35: 33-6.

[3.] Gupta D, Aggarwal AN, Jindal SK. Pulmonary effects of passive smoking: the Indian experience. Tob Induc Dis 2002; 1: 127-34.

[4.] Goel P, Radotra A, Singh I, Aggarwal A, Dua D. Effects of passive smoking on outcome in pregnancy. J Postgrad Med 2004; 50: 12-16.

[5.] World Health Organization. Environmental Tobacco Smoke Seriously Endangers Children's Health. Available at: (last accessed on February 28, 2005).

[6.] Windham GC, Eaton A, Hopkins B. Evidence for an association between environmental tobacco smoke exposure and birth-weight: a meta-analysis and new data. Paediatr Perinat Epidemiol 1999; 13(1): 35-57.

[7.] Nafstad P, Fugelseth D, Qvigstad E, Zahlsen K, Magnus P, Lindemann R. Nicotine concentration in the hair of nonsmoking mothers and size of offspring. Am J Public Health 1998; 88: 120-4.

[8.] Riboli E, Preston-Martin S, Saracci R, Haley NJ, Trichopoulos D, Becher H, et al. Exposure of nonsmoking women to environmental tobacco smoke: a 10-country collaborative study. Cancer Causes Control 1990; 1: 243-52.

[9.] DeLorenze GN, Kharrazi M, Kaufman FL, Eskenazi B, Bernert JT. Exposure to environmental tobacco smoke in pregnant women: the association between self-report and serum cotinine. Environ Res 2002; 90: 21-32.

[10.] Hruba, D, Kachlik, P. Influence of maternal active and passive smoking during pregnancy on birth weight in newborns. Cent. Eur. J. Public Health 2000; 8: 249-52.

[11.] Rubin DH, Krasilnikoff PA, Leventhal JM, Weile B, Berget A. Effect of passive smoking on birth-weight. Lancet 1986; 2(8504): 415-7.

[12.] Lazzaroni F, Bonassi S, Manruello E, Morcaldi L, Repetto E, Ruocco A, et al. Effects of passive smoking during pregnancy on selected perinatal parameters. Int J Epidemiol 1990; 19: 960-6.

[13.] Chen Y, Pederson LL, Lefcoe NM. Passive smoking and low birth weight. Lancet 1989; 2(8653): 54-5.

[14.] Mathai M, Vijayasri R, Babu S, Jeyaseelan L. Passive maternal smoking and birthweight in a south Indian population. Br J ObstetGynaecol. 1992; 99(4): 342-3.

[15.] Pakhale SS, Maru GB. Distribution of major and minor alkaloids in tobacco, mainstream and sidestream smoke of popular Indian smoking products. Food Chem Toxicol 1998; 36: 1131-8.

[16.] Wakefield, M, Reid, Y, Roberts, L, Mullins, R, Gillies, P. Smoking and smoking cessation among men whose partners are pregnant: a qualitative study. Soc Sci Med 1998; 47: 657-64.

How to cite this article: Gupta S, Malhotra AK, Verma SK, Deka M, Yadav R, Singh S. Effects of passive smoking (environmental tobacco smoke) on pregnancy outcome at district hospital, Jhansi, Uttar Pradesh. Int J Med Sci Public Health 2015; 4: 1090-1094

Source of Support: Nil, Conflict of Interest: None declared.

Department of Community Medicine, Maharani Laxmi Bai Medical College, Jhansi, Uttar Pradesh, India.

Correspondence to: Shubhanshu Gupta, E-mail:

Received February 28, 2015. Accepted March 3, 2015


DOI: 10.5455/ijmsph.2015.28022015229

Table 1: Distribution of the study sample according to
socio-demographic data (n = 300)

Characteristics                               Frequency      %

Age (years)
  20-25                                        67           22.4
  26-30                                       148           49.4
  31-35                                        85           28.3
  Hindu                                       123           41
  Muslim                                      143           47.7
  Others                                       34           11.3
  Illiterate                                  149           49.6
  Primary and middle education                111           37
  Secondary and high education                 40           13.4
  Housewife                                   227           75.6
  Employed                                     73           24.4
Monthly income (per capita)
  <3000                                       138           46
  >3000-10000                                 140           46.6
  >10000                                       22            7.4
  Upper and upper middle                       25            8.3
  Middle                                      115           38.4
  Lower                                       160           53.3
Family type
  Nuclear                                      50           16.6
  Joint                                       250           83.4
  Rural                                       138           46
  Peri-urban                                   59           19.6
  Urban                                       103           34.4
History of passive smoking in family/outside
  Yes                                          78           26
  No                                          222           74

Husband only          17
Husband and others    29
Others only            6

Figure 1: Distribution of sources of passive smoking among the study
respondents (n = 78) (a).
(a) Out of 300 respondents, 78 exposed to ETS, while 222 were

Note: Table made from pie chart.

         1st trimester    2nd trimester    3rd trimester

Home         13.09            13.2              13.1
Work          5.75             4.8               2.75
Outside       4.8              4.86              2.5

Figure 2: Mean ETS exposure in hours/week from home, work, and
outside in the first, second, and third trimesters.

Note: Table made from bar graph.

Table 2: Association of ETS exposed and non-exposed with effects
on pregnancy outcome, prenatal problems (n = 300)

Items                         ETS
                       Exposed    Non-exposed  [chi square]  p-value
                        (n = 78)   (n = 222)

Preterm birth             25         41          6.206       0.01 (*)
Full-term birth           53        181
Fetal distress
No                        60        180          0.624       0.429
Yes                       18         42
Spontaneous               53        170          2.252       0.133
Induced                   25         52
NVD                       63        182          0.057       0.811
6Csarean section          15         40
No                        57        190          6.209       0.01 (*)
Yes                       21         32
No                        71        207          0.418       0.51
Yes                        7         15
Congenital mal
No                        70        211          2.735       0.098
Yes                        8         11
LBW (<2500gms)
No                        55        187          6.96        0.008 (*)
Yes                       23         35
Apgar score (1st min)
<7                         6          8          2.16        0.14
7+                        72        214
Apgar score (5th min)
<7                        12         14          6.01        0.01 (*)
7+                        66        208

(*) p-value < 0.05 is considered statistically significant.

Table 3: Comparison of anthropometric measurements of babies born to
ETS-exposed and ETS non-exposed women

Items                                   ETS
                       Exposed                  Non-exposed
                       (n = 78) (a)             (n = 222) (a)

Birth weight          2407 [+ or -] 0.46      2689 [+ or -] 3.22
Birth length         49.62 [+ or -] 3.05     49.87 [+ or -] 2.42
Head circumference   34.05 [+ or -] 1.44     34.14 [+ or -] 1.72
Chest circumference  32.05 [+ or -] 1.32     32.16 [+ or -] 2.32


Birth weight              0.0001 (*)
Birth length              0.549
Head circumference        0.735
Chest circumference       0.692

(a) Mean [+ or -] SD (standard deviation).
(*) p-value < 0.05 is considered statistically significant.
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Title Annotation:Research Article
Author:Gupta, Shubhanshu; Malhotra, Anil Kumar; Verma, Santosh Kumar; Deka, Mrigen; Yadav, Rashmi; Singh, S
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Date:Aug 1, 2015
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