EVALUATING THE ASSOCIATION BETWEEN MATERNAL SMOKING THREE MONTHS BEFORE PREGNANCY AND INFANT ADMISSION INTO A NEONATAL INTENSIVE CARE UNIT AMONG AMERICAN INDIAN AND ALASKAN NATIVES IN 8 STATES Open Access

Abstract

Purpose: Maternal smoking is one of the preventable risk factors for adverse infant outcomes. The aim of this study was to assess the association between maternal smoking three months before pregnancy and infant Neonatal Intensive Care Unit (NICU) admission among American Indian and Alaskan Native women in AK, MN, NE, NNM, OK, OR, UT and WA. It was hypothesized that infants born to women who smoked three months before pregnancy would more likely be admitted into the NICU.

Methods. PRAMS surveillance data from 2004 through 2011 from the PRAMS from Phases 5 and 6 were obtained from the CDC. Of the 95,428 mothers, analyses were conducted on 12,448 American Indian/Alaskan native mothers who had singleton births born in a hospital setting with no births defects. To assess the association between maternal smoking three months before pregnancy and infant NICU admission, odds ratios were calculated using multiple logistic regression controlling for covariates.

Results: There was no association for pre-pregnancy smoking and infant's NICU admission. Even when the association of heavy maternal smoking pre-pregnancy and infant NICU admission was assessed, no statistically significant association was revealed, (OR: 1.39, 95% CI: 0.67, 2.86). Only SGA was statistically associated with infant NICU admission, with SGA infants having a 2.02 higher odds of admission into the NICU compared to those who were not SGA (95% CI: 1.38, 2.96).

Conclusion: Although AI/AN women have the highest smoking prevalence compared with other racial/ethnic groups, pre-pregnancy smoking among this cohort of AI/AN pregnant women did not predict infant admission into a NICU. To end tobacco usage among AI/AN, tribes need to address prevention and treatment programs. For example, cessation programs need to be fully funded, the price of tobacco products should be increased, more smoke-free policies should be adopted, a reduction in tobacco advertising and promotion must occur, and more anti-tobacco media campaigns need to be promoted. Primary care and obstetric clinicians need to be trained to advise patients to quit smoking, and more counseling and cessation referral services must be established.

Table of Contents

TABLE OF CONTENTS

TABLE OF CONTENTS. 7

CHAPTER I: Background/Literature Review.. 11

Historical Overview of American Indians and Alaskan Natives. 11

Overview of present day American Indians and Alaskan Natives. 12

Summary of American Indian Tribes and Alaskan Natives in the 8 states (Alaska, Minnesota, Nebraska, New Mexico, Oklahoma, Oregon, Utah and Washington). 12

State of American Indian and Alaskan Native Health. 14

Tobacco a Sacred Commodity. 15

Cigarette Smoking. 16

Tobacco Industry in AI/AN communities. 17

Maternal Smoking Pre-Pregnancy. 18

Adverse Infant Outcomes of Cigarette Smoking. 20

Maternal Smoking and Fetal Exposure to Lead. 21

Maternal Smoking, Low-Birth Weight and Preterm Birth. 21

Maternal Smoking and Birth Defects. 22

Maternal Smoking and NICU Admission. 21 Maternal Smoking and Social Economic Status. 24

Smoking and the Affordable Care Act (ACA). 24

Objective. 24

CHAPTER II: MANUSCRIPT. 25

INTRODUCTION.. 25

METHODS. 26

Specific Aim.. 26

Hypothesis. 26

Study Design. 27

Measures. 27

Analyses. 31

RESULTS. 33

Sample Characteristics. 33

Descriptive Statistics. 33

Bivariate Logistic Regression. 33

Logistic Regression Analysis. 35

Analysis in the Appendix. 38

DISCUSSION.. 39

Limitations. 40

CHAPTER III: PUBLIC HEALTH IMPLICATIONS AND FUTURE DIRECTION.. 41

REFERENCES. 43

FIGURES. 51

FIGURE 1. Study Sample. 51

FIGURE 2. Causal DAG (Directed Acyclic Graph). 52

FIGURE 3. SGA percentile guidelines (83). 53

FIGURE 4. Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965-2011 (38). 54

TABLES. 52

Table 1. Distribution of Pre-Pregnancy Smoking (Exposure) and NICU Admission (Outcome) Pooled across Covariates for AI/AN women, PRAMS 2004-2011. 55

Table 2. The Unadjusted Association between Infant Admission into the NICU and Pre-pregnancy Smoking Pooled Across 8 States - PRAMS 2004-2011. 55

Table 2a. The Unadjusted Association between Infant Admission into the NICU and Maternal and Infant Characteristics Pooled Across 8 States - PRAMS 2004-2011. 56

Table 2b. The Unadjusted Association between AI/AN Women Who Smoked Three Months Before Pregnancy and Maternal and Infant Characteristics Pooled Across 8 States - PRAMS 2004 - 2011. 57

Table 3a. The Number of Cigarettes Smoked Three Months before Pregnancy Among AI/AN Women Across 8 States, PRAMS 2004 - 2011. 58

Table 3b: Association between Infant Admission into the NICU and Number of Cigarettes Smoked per Day Among AI/AN Women Across 8 States, PRAMS 2004 - 2011. 58

Table 3c. The Unadjusted Association between Infant Admission into the NICU and Pre-pregnancy Smoking Pooled Across 8 States - PRAMS 2004-2011. 58

Table 4a. INTIAL LOGISTIC REGRESSION MODEL : Adjusted Odd Ratios for Maternal Characteristics and the Risk of Infant NICU Admission for AI/AN Singleton Live Births , PRAMS 2004-2011*. 59

Table 4b. FINAL LOGISTIC REGRESION MODEL: Adjusted Odd Ratios for Maternal Characteristics and the Risk of Infant NICU Admission in a Cohort of AI/AN Singleton Live Births, PRAMS 2004-2011*. 60

Table 5a. CRUDE AND INITIAL LOGISTIC MODEL: Association between Number of Cigarettes Smoked per day and Infant NICU Admission. 61

Table 5b. FINAL LOGISTIC MODEL: Association between the number of cigarettes smoked per day and Infant NICU admission*. 62

APPENDIX. 63

Table 6a. Summary Statistics of AI/AN Women Who Smoked Three Months before Pregnancy Across 8 States PRAMS 2004 - 2011 (n =4,971). 63

Table 6b. Summary Characteristics of AI/AN Women Whose Infant Was Admitted into the NICU Across 8 States, PRAMS 2004-2011 (n=1,558). 64

SAS CODE TO CALCULATE FEDERAL POVERTY LEVEL. 65

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Keyword	Maternal Smoking American Indian NICU Alaskan Native Maternal Health Pre-Pregnancy
Committee Chair / Thesis Advisor	Hogue, Carol J, Emory University
Committee Members	Raskind-Hood, Cheryl, Emory University
Partnering Agencies	CDC

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