smoking and drinking behavior before and during pregnancy of

Smoking and Drinking BehaviorBefore and During Pregnancy ofMarried Mothers of Live-BornInfants and Stillborn Infants

KATE PRAGER, ScDHENRY MALIN, MADANIELLE SPIEGLER, MAPEARL VAN NATTA, MAPAUL J. PLACEK, PhD

Dr. Prager is a Demographer, and Dr. Placek is a Statistician,Division of Vital Statistics, National Center for Health Statistics,Public Health Service. Dr. Placek is also director of the 1980National Natality Survey and the 1980 National Fetal MortalitySurvey.

Mr. Malin is Acting Chief and Ms. Spiegler is a Psychologist,Surveillance Branch, Division of Biometry and Epidemiology,National Institute on Alcohol Abuse and Alcoholism, PublicHealth Service. Ms. Van Natta, Senior Research Analyst on thestaff of the NIAAA-funded Alcohol Epidemiologic Data Systembased at CSR, Inc., generated the tabulations for this study.

Tearsheet requests to Paul Placek, PhD, Division of Vital Sta-tistics, National Center for Health Statistics, Rm. 1-44 CenterBldg., 3700 East-West Highway, Hyattsville, Md. 20782.

Synopsis ....................................

Data from the 1980 National Natality Survey (NNS)and the 1980 National Fetal Mortality Survey (NFMS)

are used to describe the drinking and smoking behaviorof married mothers before and during pregnancy ac-cording to maternal race and Hispanic origin, age, andeducation. Typically, smokers were white mothers under25 years ofage with a high school education or less, anddrinkers were white mothers 25 years of age and olderwith more than a high school education.

Wheni pregnancy was confirmed, reductions in smok-ing and drinking occurred. However, mothers of still-born infants were less likely to stop smoking than werethe mothers of live-born infants.

Although the prevalence of drinking was much higherthan was the prevalence of smoking among the mothersincluded in these surveys, the reduction in drinking wasmuch more pronounced than was the reduction in smok-inig. For nearly every sociodemographic subgroup, theprevalenice of smoking was higher and the prevalence ofdrinking was lower among mothers of stillborn infantsthan among mothers of live-born infants. Some of thesedifferences are due to the age-race-health status makeupof the two NNS-NFMS populations sampled, and care-fully controlled multivariate analyses are required tospecify the relationship of maternal smoking and drink-ing to birth outcome. This descriptive analysis is the firststep in that process.

THE SURGEON GENERAL HAS WARNED women aboutthe hazards to the infants of mothers who smoke ciga-rettes or consume alcohol before or during pregnancy(1):

Smoking slows fetal growth, doubles the chance of low birthweight, and increases the risk of stillbirth. Recent studiessuggest that smoking may be a significant contributing factor in20 to 40 percent of low weight infants born in the United Statesand Canada. Studies also indicate that infants of mothers regu-larly consuming large amounts of alcohol may suffer from lowbirth weight, birth defects, and/or mental retardation. Clearly,both previously developed habits need careful attention duringpregnancy.

Excessive alcohol use is also associated with a patternof abnormalities called fetal alcohol syndrome (FAS).The National Institute on Alcohol Abuse and Alcoholismhas reported to Congress (2):

Some clinical studies of alcoholic mothers and some animalstudies give evidence that heavy use of alcohol during preg-

nancy may result in a pattern of various abnormalities in theoffspring. . Current estimates conservatively suggest anincidence on the order of magnitude of I per 2,000 live births.Some evidence suggests that among 100 mothers drinkingmore than 1 ounce of absolute alcohol per day one might findone case of FAS. On this basis, FAS would be the third leadingcause of birth defects associated with mental retardation, ex-ceeded only by Down's syndrome and spina bifida. Of thethree, only FAS is preventable.

Although researchers have reported a decrease indrinking (3) and smoking during pregnancy (4), thestudies have been based on small numbers of women inselected localities. We report on changes in drinking andsmoking behaviors during pregnancy for a national sam-ple of married mothers who delivered either live births orstillbirths in 1980. Late fetal deaths are also called "still-births" and will be referred to as such in this paper.Variations in smoking and drinking are examined beforeand during pregnancy according to maternal race andHispanic origin, age, and education.

March-April 1984, Vol. 99, No. 2 117

Data Source

Data used in this article are based on unweightedrespondent questionnaires from the 1980 NationalNatality Survey and the 1980 National Fetal MortalitySurvey. Details of the national surveys' design and sam-pling techniques are discussed elsewhere in this issue (5).About 6 months after delivery, 7,825 married mothers oflive-born infants and 4,814 married mothers of stillborninfants were mailed a questionnaire to assess social anddemographic characteristics and prenatal behavior, in-cluding smoking and drinking. Nonrespondents to twomailings received telephone interviews using an abbrevi-ated version of the mailed questionnaire. However, thetelephone interview did not include questions on smok-ing and drinking behavior before pregnancy-only after.Therefore, this article is based on the 4,405 marriedmothers of live-born infants and 2,616 married mothersof stillborn infants who responded to the mailed ques-tionnaire. Item nonresponse on returned questionnaireswas uniformly low. For the critical behavioral variablesrelated to smoking and drinking, item nonresponseamong mothers of live-born infants did not exceed 2.0percent and averaged 1.3 percent. Among mothers expe-riencing stillbirths, item nonresponse averaged 1.4 per-cent. In this analysis, values were imputed for those fewitems for which there was no response.

Several things are important to note. The proportion ofbirths to unmarried mothers varies widely by race, age,and other variables. For example, in 1980, 89 percent ofall white mothers were married at the time of delivery ascompared with only 45 percent of black mothers (6). Thesmoking and drinking behaviors of unmarried mothersmay differ from those of married mothers. It is alsoimportant to note that the sample data in this article arenot weighted to reflect national estimates, but selectedcomparisons with weighted data did not reveal any se-rious differences.

Mothers were asked which national origin they identi-fied with most. Nearly two-thirds of those who identified

with the Hispanic origin reported their race as white.Approximately one-third reported their race as other thanblack or white, and about 1 percent reported themselvesas black. In this paper, we combined race and Hispanicorigin to create four mutually exclusive race-ethnicitycategories: white non-Hispanic, black non-Hispanic,Hispanic, and other. In the presentation and discussionof the results that follow, it should be emphasized thatwhite refers to white non-Hispanic and that black refersto black non-Hispanic. The residual other category is aheterogeneous group including American Indians, Alas-kan Natives, Asians, and Pacific Islanders. When whiteis contrasted with all other races in the presentation ofdata on age and educational attainment, the all othergroup includes Hispanic, black non-Hispanic, and othernon-Hispanic.

Regarding smoking, mothers were asked, "On theaverage, how many cigarettes did you smoke per daybefore you found out that you were pregnant?" and "Onthe average, how many cigarettes did you smoke per dayafter you found out that you were pregnant?" Womenwho reported smoking one or more cigarettes per daywere defined as smokers.

Regarding drinking, women were asked, "Did youdrink any alcoholic beverages (beer, wine, or liquor)during the 12 months before your 1980 delivery?" and ifyes, "How often did you usually drink alcoholic bev-erages, that is, beer, wine, and/or liquor?" and "On theday or days that you drank, how much did you drink onthe average per day?" Identical questions were asked forthe periods before pregnancy and during pregnancy.Convenient check boxes were provided, with 8 possibleresponses ranging from "every day" to "did not drink atall", and with 12 possible responses ranging from "12or more drinks" to "did not drink at all."

Alcohol consumption, defined as the average dailyconsumption of absolute alcohol expressed in ounces,was calculated as follows from responses to the ques-tions regarding drinking:

alcohol consumption = ounces of absolute alcohol con-sumed per day on the average

= 0.5 x quantity factor x fre-quency factor

The factor of 0.5 ounces per drink is used to translate thequestionnaire response to ounces of alcohol consumed.This 0.5 factor is approximately the ounces of absolutealcohol contained in one beer, one glass of wine, or onemixed drink. The quantity factor is the average numberof drinks per day. The frequency factor translates theanswer to "How often do you drink?" into number ofdrinking occasions. A mother who had one drink threetimes a week or three drinks once a week would have hadthe same average daily consumption of alcohol.

118 Public Halth Reports

Findings-Live Births

Prepregnancy smoking and drinking behav-ior. Figure I shows the distribution of mothers experi-encing live births according to both smoking and drink-ing habits. Before pregnancy, nearly one-third ofmothers smoked and more than one-half drank. Morethan one-third of mothers abstained from both smokingand drinking, and one-fifth both smoked and drank.However, these behaviors varied substantially amongdifferent subgroups of mothers.

Smoking. The prevalence of smoking was highestamong white mothers (table 1). Almost one-third ofthese mothers smoked before pregnancy, compared withabout one-fourth of black mothers. Less than one-quarterof Hispanic mothers and about one-fifth of the mothersof other races smoked.Smoking prevalence decreased with age among white

mothers. Nearly I out of 2 mothers under 20 years of agesmoked, but about I out of 4 mothers age 25 and oldersmoked. Among all other mothers, the same pattern ofdecreased smoking with increased age prevailed.

Mothers under 20 years of age are excluded from theanalysis according to educational attainment becausesome women would not have had a chance to completetheir education. The prevalence of smoking declinedsteadily with increased education among white mothers;60 percent of mothers with less than 12 years of educa-

tion smoked as compared with only 15 percent of thosewith 16 years' education or more. Among the all othergroup of mothers, college graduates were the least likelyto smoke, but no other differences by years of educationwere found.

Drinking. As with smoking, drinking was most com-mon among white mothers. More than 58 percent ofwhite mothers drank, compared with 39 percent of blackmothers and 40 percent of Hispanic mothers.

Although smoking was less prevalent among older andbetter educated mothers, drinking was more prevalentamong this group. Among white mothers, drinking prev-alence increased from 44 percent for mothers with less

Figure 1. Percent distribution of married mothers of live-born infants according to smoking and drinking behaviors beforeand during pregnancy; United States, 1980i-E E _ E v - . se. _ __ __ * R _

l__I111I}illi \ :: .: F 3e:a-_____||-l _l l | | | _ | \.¢£:, . X l l X__ I-l -S_ S iVEIlli_ % jE______ s li

_ 1|1 I_31 __ ______ l | 1__111I ii _lli |__ _ 1111_ l l 111I I | I | | __ | | |

__ |._ . _ _____ | | -__ * |__ | _ _____ 1 , |I __ I | I l li_ | _ | i |I__ I | I l _ | __ _11111__ | l |, __ I | I . =_i _ . , -_, - S . _ _ . .I __ | | | I E | I-

l__ || l _ | __ 111___ | |

SOURCE: National Center for Health Statistics data from the 1980 National Natality Survey.


than 12 years of education to 68 percent for mothers with mothers. The i

16 or more years of education. Among the all other increased age;group, drinking was less prevalent for those 30 years of all other mothage and older but did not vary by education.

Abstention.Smoking and drinking. About 22 percent of white before pregnat

mothers both smoked and drank, compared with about black mothers,13 percent of black mothers and 14 percent of Hispanic half of Hispan

Table 1. Smoking' and drinking2 behavior, before pregnancy, of married mothers ofteristics, United States, 1980

combination of behaviors decreased withand education for both white mothers anders.

Abstention from smoking and drinkingncy was high among Hispanic mothers,, and mothers of other races. About one-lic mothers and black mothers abstained.

live-born infants, according to selected charac-

Percentage of mothers Percentage distributon

Neithersmoked Smoker Smoker Drinker

All All nor but not and but notCharacteristic Number smokers drinkers Total drank drinker drinker smoker

All married mothers.

Race, ethnicityWhite, non-Hispanic ...........Black, non-Hispanic ...........Hispanic .....................Other .......................

AgeAll races:Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

White, non-Hispanic:Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

All other:3Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

Education4All races:

0-1 1 years .................12 years ...................13-15 years ................16 years or more ...........

White, non-Hispanic:0-1 1 years .................12 years ...................13-15 years ................16 years or more ...........

All other: 3


4,405

3,727247253178

3301,3931,608846228

2641,1861,384714179

6620722413249

4321,823936884

2951,615796757

30.9

32.424.723.319.7

47.336.827.323.225.4

49.638.428.225.227.4

37.927.121.912.118.4

49.834.425.014.5

60.036.225.115.1

137 27.7208 21.2140 24.3127 11.0

55.0

58.139.239.933.2

40.353.058.258.653.1

40.554.961.264.158.1

39.442.039.728.834.7

40.754.559.463.9

43.756.563.168.2

34.338.938.638.6

100.0 34.9 10.0 20.8 34.2

100.0100.0100.0100.0

100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

31.749.451.058.4

39.135.133.834.237.3

37.532.831.328.431.8

45.548.349.665.257.1

36.335.133.233.9

27.832.730.530.3

10.2 22.2 36.011.3 13.4 25.99.1 14.2 25.78.2 11.2 21.9

20.611.98.07.29.7

22.012.37.57.4

10.1

15.29.7

10.76.18.2

22.910.47.42.2

28.510.86.41.6

26.724.819.316.015.8

27.726.120.717.817.3

22.717.411.26.1

10.2

26.924.017.612.3

31.525.418.713.5

13.628.138.942.737.3

12.928.840.546.440.8

16.724.628.622.724.5

13.930.541.851.6

12.231.244.454.7

54.7 10.9 16.8 17.554.3 7.7 13.5 25.548.6 12.9 11.4 27.155.9 5.5 5.5 33.1

1 Smokers are those who smoked at least 1 tobacco cigarette per day.2 Drinkers are those who consumed at least 1 drink (0.5 oz of absolute alcohol) once

a month.3 Includes all other races and other ethnic groups not shown separately.4 Includes only mothers who are 20 years of age and older.

120 Public Health Reports

Nearly three-fifths of other mothers abstained, but lessthan one-third of white mothers abstained from smokingand drinking before pregnancy.

Through the 30-34 year age group, abstention in-creased with age for all other mothers and decreased withincreasing age for white mothers, but varied little byeducational attainment for either race group.

Typically, smokers were white mothers under 25years with a high school education or less, and drinkerswere white mothers 25 years and older with more than ahigh school education. Younger white mothers and whitemothers with 12 years of education or less were mostlikely to consume both alcohol and cigarettes. Hispanicmothers, black mothers, and other mothers were morelikely to abstain and less likely to either smoke or drinkthan white mothers.

Change in smoking and drinking behavior duringpregnancy. Mothers were much more likely to stopdrinking than to stop smoking during pregnancy (table2). Of those who had the habit before pregnancy, 30percent stopped drinking and 18 percent stopped smok-ing. Of mothers who both smoked and drank prior topregnancy, 43 percent gave up either cigarettes or alco-hol or both, reducing the prevalence of both habits fromI out of 5 pregnant women to 1 out of 8 (fig. 1). Twentypercent of mothers with either of these habits beforepregnancy became abstinent during pregnancy, increas-ing the prevalence of abstinence from 1 out of 3 to I outof 2 mothers.

Change in smoking. More than 25 percent of theHispanic mothers who smoked stopped smoking duringpregnancy, compared with 18 percent of white mothersand 13 percent of black mothers. No significant dif-ferences by age were found in the proportion whostopped smoking. However, educational attainment wasdirectly related to the tendency to stop smoking. Ofwhite mothers who smoked, 10 percent of mothers withthe least education stopped and 25 percent of motherswith the most education stopped. Thus, the differencebetween the highest and lowest educational groups in theprevalence of smoking became even greater during preg-nancy than it was before pregnancy.

Change in drinking. Nearly 30 percent of white andHispanic mothers and almost 40 percent of black andother mothers who drank stopped drinking during preg-nancy. For mothers under 35 years, the age of the moth-ers who drank was inversely related to the tendency tostop drinking; in short, older mothers were less likely tostop drinking than younger mothers. However, therewere no significant differences by education in the pro-portion who stopped drinking.

Table 2. Change in smoking' and drinking2 behavior, during preg-nancy, of married mothers of live-born infants, according to se-

lected characteristics, United States, 1980

With 1 or both habits (percent) With both habits

and stoppedStopped Stopped Became 1 or both

Characteristic smoking drinking abstinent (percent)

All married mothers 17.6 29.6 19.6 43.1

Race, ethnicityWhite, non-Hispanic ... 17.7 29.2 19.2 43.0Black, non-Hispanic .... 13.1 37.1 26.4 33.3Hispanic .............. 25.4 27.7 20.2 50.0Other3 ................ 8.6 37.3 20.3 50.0

Age4All races:Under 20 years ..... 19.9 39.1 17.4 54.520-24 years ........ 17.4 33.2 19.1 46.525-29 years ....... : 18.0 29.5 21.3 41.230-34 years ........ 18.9 22.4 18.5 33.335 years and older 6.9 28.1 17.5 36.1

White, non-Hispanic:Under 20 years ..... 21.4 41.1 18.2 57.520-24 years ........ 17.1 32.6 18.4 46.125-29 years ........ 17.7 29.8 21.3 41.330-34 years ........ 19.4 21.4 17.8 33.135 years and older 8.2 25.0 15.6 35.5

Education4,5All races:0-11 years ......... 9.8 29.5 9.5 40.512 years ............ 16.9 30.8 19.3 42.013-15 years ........ 21.8 25.2 20.0 40.016 years or more .... 24.2 29.7 25.5 45.9

White, non-Hispanic:0-11 years ......... 10.2 31.0 9.4 40.912 years ............ 15.9 30.2 18.4 41.213-15 years ........ 23.5 24.7 19.9 40.916 years or more .... 24.6 28.7 24.6 40.1


a month.3 Includes all other races and other ethnic groups not shown separately.4 For all other races, number of cases was too small to meet standards for precision

or reliability. Therefore, data for all other races are not shown.5 Includes mothers who are 20 years of age or older.


Change in behavior of mothers who smoked anddrank. Mothers who both smoked and drank before preg-nancy were more likely to give up alcohol than cigarettesduring pregnancy. Of these mothers, 43 percent of whitemothers and 33 percent of black mothers gave up one orboth behaviors during pregnancy, compared with 50percent of Hispanic and other mothers (table 2).

Percent becoming abstinent. Of mothers who eithersmoked or drank or had both habits before pregnancy,about one of every five became abstinent during preg-nancy.

Quantity andfrequency of cigarettes and alcohol con-sumed. Table 3 shows the changes in amount of smoking

Table 3. Smoking and drinking behavior, during pregnancy, of married mothers of live-born infants, according to behavior beforepregnancy, United States, 1980

Before pregnancy During pregnancy (percent)Behavior

Number Percent Total None Level 1 Level 2

Average daily smokingAll behaviors ............ 4,405 100.0 100.0 74.5 12.0 13.5

None' ...................... 3,044 69.1 100.0 99.9 0.1 0.01-10 cigarettes (Level 1) ..... 412 9.4 100.0 31.3 65.8 2.911 cigarettes or more (Level 2)

.......................... . ..949 21.5 100.0 11.8 26.8 61.4

Average weekly drinkingAll behaviors ............ 4,405 100.0 100.0 60.9 35.9 3.2

None2 ...................... 1,981 45.0 100.0 99.1 0.8 0.1Less than 3 drinks (Level

1 )3 ...................... 1,741 39.5 100.0 34.5 64.6 0.93 drinks or more

(Level 2)4 ................ . 683 15.5 100.0 17.4 64.6 18.0

1 Did not smoke even 1 cigarette a day.2 Consumed less than 1 drink (0.5 oz of absolute alcohol) less than once a month.

3 Consumed 0.01-0.19 oz of absolute alcohol each day on the average.4 Consumed 0.19 oz or more of absolute alcohol each day on the average.

Figure 2. Percent distribution of married mothers of stillborn infants according to smoking and drinking behaviors beforeand during pregnancy: United States, 1980

SOURCE: National Center for Health Statistics data from the 1980 National Fetal Mortality Survey.


and drinking after pregnancy was confirmed according tosmoking and drinking levels before pregnancy. Of the 31percent of mothers who smoked before pregnancy, mostsmoked more than 10 cigarettes per day. Of thesesmokers, about 12 percent stopped smoking during preg-nancy, and an additional 27 percent reduced their con-sumption. In addition, one-third of those who smokedfewer than 10 cigarettes per day stopped smoking duringpregnancy. The prevalence of mothers who smokedmore than 10 cigarettes per day during pregnancydropped from 22 percent before pregnancy to about 14percent during pregnancy, and the prevalence of non-smokers increased from 69 percent to 75 percent.

Fifty-five percent of mothers drank before pregnancy,but only 16 percent had three drinks or more per week.About 17 percent of these level 2 drinkers stopped theirdrinking during pregnancy, and another 65 percent re-duced their consumption. In addition, one-third of level1 drinkers stopped drinking altogether during pregnancy.The prevalence of women drinking three or more drinksper week dropped during pregnancy to only 3 percent,while the prevalence of nondrinkers increased from 45percent to 61 percent.

Findings-Stillbirths

Prepregnancy smoking and drinking among mothersof stillborn infants. As can be seen in figure 2, thedistribution of prepregnancy smoking and drinking be-haviors of mothers who experienced stillbirths is quitesimilar to that of mothers of live-born infants. (It shouldbe stressed that while these live birth-stillbirth data arepresented in a parallel fashion, they are intended to beonly descriptive in nature. This analysis is not designedto study the relationship of smoking and drinking to birthoutcome because such an analysis would have to controlcarefully for race, age, socioeconomic status, and mater-nal health factors.)As with mothers of live-born infants, about one-third

of the mothers experiencing stillbirths smoked (34 per-cent) and about half of them drank (49 percent); one-fifthengaged in both behaviors before pregnancy (21 per-cent). Comparisons between mothers of live-born andstillborn infants revealed only small differences. Beforepregnancy, more mothers of stillborn infants abstainedfrom both smoking and drinking (38 percent) than didmothers of live-born infants (35 percent). Also, fewermothers of stillborn infants drank (49 percent) than didmothers of live-born infants (55 percent). However,mothers experiencing stillbirths more often smoked (34percent) than did mothers of live-born infants (31 per-cent).

Smoking. As with mothers of live-born infants, smok-ing was more common among white mothers (35 per-

cent) than among black (30 percent), Hispanic (27 per-cent), or other mothers (20 percent), as table 4 indicates.The largest proportion of smokers was in the under 20years age group; smoking prevalence declined throughages 25-29 years, but it was higher for mothers 35 yearsand older. This pattern held for white and all othermothers.The prevalence of smoking declined steadily with in-

creasing education among white mothers; among whiteand all other mothers, college graduates were the leastlikely to smoke. The most striking and consistent behav-ioral difference between mothers experiencing stillbirthsand the live-birth group is that, for nearly every sub-group, prevalence of smoking was generally higheramong the stillbirth group than the live-birth group.Otherwise, the differences between the two groups ofmothers were fairly small. There were some exceptions,however. For example, among all other mothers 35 yearsand older, 33 percent of mothers of stillbirths smokedcompared to only 18 percent of mothers of live-borninfants. Among all other mothers who were high schoolgraduates, 31 percent of mothers experiencing stillbirthssmoked compared with only 21 percent of mothers expe-riencing live births.

Drinking. Drinking was most prevalent among whitemothers. More than half of the white mothers (52 per-cent) drank before pregnancy, compared with 34 percentof black mothers, 35 percent of Hispanic mothers, and27 percent of other mothers. Among whites, drinkingwas most prevalent among the 25-29 year old group (57percent) while, among all others, drinking did not varyby age. The prevalence of drinking increased with yearsof education (in contrast to smoking, which decreasedwith more years of education).

Smoking and drinking. About 22 percent of whitemothers both smoked and drank, compared with 19 per-cent of black mothers, 16 percent of Hispanic mothers,and 11 percent of all other mothers. The prevalence ofthis combination was highest among teenage mothersand decreased with age. Mothers who were college-educated were least likely to combine smoking anddrinking. The total proportion of mothers who bothsmoked and drank was the same for mothers experienc-ing stillbirths as for mothers of live-born infants (21percent).

Abstention. Abstention from smoking and drinkingbefore pregnancy was much lower for white mothers (34percent) than for black (55 percent), Hispanic (54 per-cent), or other (65 percent) mothers. Abstention wasmore prevalent among older white mothers, but variedlittle by education. For most subgroups, abstention rates


before pregnancy were higher among mothers who expe-rienced fetal deaths than among those who bore liveinfants. This apparent anomaly from what might other-wise be expected reinforces our earlier caution againstdrawing inferences about birth outcome from these de-scriptive data.

Changes in smoking and drinking behavior duringpregnancy. Mothers of stillborn infants were more

likely to stop drinking (33 percent) than to stop smoking(16 percent) during pregnancy (table 5). The reduction indrinking was slightly greater for mothers of stillborninfants than for mothers of live-born infants (33 percentcompared with 30 percent), but the reduction in smokingwas slightly smaller (16 percent compared with 18 per-cent). Forty-four percent of the mothers experiencingstillbirths who both smoked and drank gave up eithercigarettes or alcohol or both, compared with 43 percent

Table 4. Smoking' and drinking2 behavior, before pregnancy, of married mothers of stillborn infants, according to selected charac-teristics, United States, 1980

Percent of mothers Percent distribution

Neithersmoked Smoker Smoker Drinker

All All nor but not and but notCharacteristic Number smokers drinkers Total drank drinker drinker smoker

All married mothers .....

Race, ethnicityWhite, non-Hispanic ...........Black, non-Hispanic ...........Hispanic .....................Other3 .......................

2,616

2,15424713679

33.9

35.230.027.220.3

48.9

52.334.035.326.6

100.0 37.9 13.2 20.6 28.3

100.0100.0100.0100.0

34.0 13.7 21.5 30.854.7 11.3 18.6 15.453.7 11.0 16.2 19.164.6 8.9 11.4 15.2

AgeAll races:Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

White, non-Hispanic:Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

All other:3Under 20 years .............20-24 years ................25-29 years ................30-34 years ................35 years and older ..........

Education4All races:


White, non-Hispanic:0-1 1 years .................12 years ...................13-15 years ................16 years or more ...........

All other:30-1 1 years .................12 years ...................13-15 years ................16 years or more ...........

211792866520227

176675713427163

55.539.327.327.734.4

58.540.327.930.035.0

35 40.0117 33.3153 24.293 17.264 32.8

3491,102460494

236948374420

45.836.125.918.6

54.236.925.719.5

113 28.3154 31.286 26.774 13.5

45.047.352.449.443.2

47.749.656.753.246.6

31.434.232.732.334.4

30.946.855.961.3

36.048.660.264.5

20.435.737.243.2

100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0

100.0100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

100.0100.0100.0100.0

30.836.938.739.241.9

27.334.134.634.436.8

48.653.057.561.354.7

24.215.88.9

11.415.0

25.016.38.7

12.416.6

20.012.89.86.5

10.9

31.323.518.416.419.4

33.524.019.217.618.4

20.020.514.410.821.9

13.723.934.133.123.8

14.225.637.535.628.2

11.413.718.321.512.5

42.1 26.9 18.9 12.038.9 14.3 21.9 25.038.3 5.9 20.0 35.935.2 3.4 15.2 46.2

30.9 33.1 21.2 14.836.5 14.9 22.1 26.635.3 4.6 21.1 39.031.7 3.8 15.7 48.8

65.5 14.2 14.2 6.253.9 10.4 20.8 14.951.2 11.6 15.1 22.155.4 1.4 12.2 31.1

I Smokers are those who smoked at least 1 tobacco cigarette per day.2 Drinkers are those who consumed at least 1 drink (0.5 oz of absolute alcohol once

a month.

3 Includes all other races and other ethnic groups not shown separately.4 Includes only mothers who are 20 years of age and older.


of the mothers of live-born infants; the same proportionof mothers in both groups became totally abstinent (20percent).

Changes in smoking. The proportion of Hispanicmothers who stopped smoking (46 percent) was morethan three times that of white (14 percent) or black (15percent) mothers of stillborn infants. Also, mothers 35years and older were less likely to give up smoking thanmothers under 35. Finally, better educated mothers weremore likely to stop. smoking than less educated mothers.

Changes in drinking. As with mothers of live-borninfants, white mothers, older mothers, and more edu-cated mothers were less likely to stop drinking duringpregnancy.-

Table 5. Change in smoking' and drinking2 behavior, during preg-nancy, of married mothers of stillborn infants, according to se-

lected characteristics, United States, 1980

With 1 or both habits (percent) With both habitsand stopped

Stopped Stopped Became 1 or bothCharacteristic smoking drinking abstinent (percent)

All married mothers .... 15.5 33.2 20.1 43.5

Race, ethnicityWhite, non-Hispanic ... 13.8 31.9 19.2 41.3Black, non-Hispanic .... 14.9 44.0 21.4 52.2Hispanic .............. 45.9 45.8 39.7 63.6Other 3 ............... 25.0 33.3 17.9 66.7

Age4All races:Under 20 years ..... 12.0 44.2 16.4 48.520-24 years ........ 14.5 39.2 20.8 47.325-29 years ........ 20.3 31.5 22.8 44.030-34 years ........ 16.0 27.2 19.3 37.635 years and older 9.0 23.5 12.9 29.5

White, non-Hispanic:Under 20 years ..... 9.7 45.2 14.8 49.220-24 years ........ 12.1 38.5 20.0 45.125-29 years ........ 19.6 28.5 21.0 40.930-34 years ........ 14.1 26.0 18.2 34.735 years and older 8.8 23.7 15.5 23.3

Education4,5All races:

0-11 years ......... 10.0 36.1 13.4 42.412 years ............ 15.3 36.6 20.5 46.513-15 years ........ 20.2 30.0 22.9 39.116 years or more .... 23.9 25.7 22.8 36.0

White, non-Hispanic:0-11 years ......... 8.6 37.6 12.9 44.012 years ............ 13.4 35.4 19.8 43.513-15 years ........ 19.8 28.0 22.3 35.416 years or more .... 22.0 23.2 20.9 31.8


a month.3 Includes all other races and other ethnic groups not shown separately.4 For all other races, number of cases was too small to meet standards for precision

or reliability. Therefore, data for all other races are not shown.5 Includes only mothers who are 20 years of age and older.

Changes in behavior of mothers who smoked anddrank. Of the mothers of stillborn infants who bothsmoked and drank before pregnancy, 41 percent of whitemothers, 52 percent of black mothers, 64 percent ofHispanic mothers, and 67 percent of other mothers gaveup one or both behaviors during pregnancy.

Percent becoming abstinent. As occurred among themothers of live-born infants, one out of five motherswho smoked or drank or engaged in both behaviorsbefore pregnancy became abstinent during pregnancy.However, two out of five Hispanic mothers becameabstinent.

Quantity andfrequency of cigarettes and alcohol con-sumed. The change in the amount of drinking and smok-ing after pregnancy for mothers of stillborn infants wassimilar to the change observed for mothers of live-borninfants (table 6). Before pregnancy, 24 percent of moth-ers of stillborn infants smoked more than 10 cigarettesper day. About 9 percent of these mothers stopped smok-ing during pregnancy, and 29 percent reduced their con-sumption. Of women who smoked 1 to 10 cigarettes perday before pregnancy, 30 percent stopped smoking dur-ing pregnancy. Overall, the prevalence of nonsmokersincreased from 66 percent before pregnancy to 71 per-cent during pregnancy.

Before pregnancy, 15 percent of the mothers drankthree drinks or more per week. About two-thirds (66percent) of these reduced their consumption, and 18percent stopped drinking entirely. Only 3 percent ofmothers of stillborn infants had three or more drinks perweek during pregnancy. The prevalence of nondrinkersincreased from 51 percent before pregnancy to 67 per-cent during pregnancy.

Discussion

This report has shown major differences in smokingand drinking by maternal race, ethnicity, age, and educa-tion for mothers experiencing stillbirths and live births.However, certain limitations of the data should be noted.First, these differences are based on married mothersonly. Since the proportions of births to unmarried moth-ers vary substantially by these same variables, the dif-ferences in smoking and drinking should not be gener-alized to all mothers. Second, the response rate to twomailings of the questionnaire was only 56 percent (moth-ers interviewed by telephone were excluded from thisanalysis). If nonresponding mothers are more likely to besmokers or drinkers, the estimates we present will below. Finally, mothers may have underreported their be-havior because of guilt feelings aroused by media cam-paigns to persuade them to reduce smoking and drinking


during pregnancy. If so, these estimates of smoking anddrinking could be considered minimum estimates.

Despite these limitations, however, the, results ob-tained for married mothers' smoking and drinking be-haviors before pregnancy resemble those of the generalpopulation of women in the reproductive years (7-10).Smokers, regardless of birth outcome, are typicallywhite, under 25 years of age, and have a high schooleducation or less. Drinkers are typically white and havemore than a high school education. The age profile ofdrinkers among mothers of live-born infants is 25 yearsand older; white mothers of stillborn infants who drinkare more often in the 25-29 year age group, but drinkingdoes not vary by age among other mothers who experi-ence stillbirths. The mothers most likely to consumeboth alcohol and cigarettes are white and younger. Themothers most likely to abstain are Hispanic, black, andof other races.

Although the before-pregnancy profile of smokers anddrinkers among mothers of live-born and stillborn infantsis similar, the most striking and consistent difference isthat for nearly every subgroup, the prevalence of smokingis higher and the prevalence of drinking is lower amongmothers experiencing stillbirths than among mothers oflive-born infants. Abstention rates are also generallyhigher among mothers experiencing stillbirths thanamong mothers of live-born infants. The prevalence ofthe combination of smoking and drinking is the same forboth categories of mothers. However, additional analysesare needed to assess the extent of association betweensmoking or drinking, or both, and birth outcome.When pregnancy is confirmed, reductions in smoking

and drinking occur. However, mothers of stillborn in-fants are less likely to stop smoking than are mothers of

live-born infants. Regardless of birth outcome, the ten-dency to stop smoking is directly related to educationalattainment, and the tendency to stop drinking is inverselyrelated to age for women under 35 years. Overall, theprevalence of drinking is much higher than the preva-lence of smoking, and the reduction in drinking is muchmore pronounced than the reduction in smoking. Thischange is opposite to what might have been expected.Media messages have documented the deleterious effectsof maternal smoking for two decades, while messagesconcerning the hazards of drinking during pregnancyhave been more recent.and more modest. However, it islikely that giving up nicotine is more difficult than givingup light or moderate alcohol consumption. (11).

Since smoking is usually a daily habit, a strong psy-chological and physiological dependency can be created.Most of the mothers in this survey who smoked did sodaily, but most of the mothers who drank did so lessfrequently. In fact, most drinking mothers consumed theequivalent of only one or two drinks weekly. Drinkingthree or more alcoholic beverages per week was rela-tively rare among the women in these surveys. There-fore, alcohol addiction probably was not a factor for themajority of drinking mothers and may have accounted inpart for the larger reduction in drinking than smoking.Furthermore, one study suggested that moderate toheavy drinkers may decrease their drinking during preg-nancy because alcohol becomes distasteful or causesadverse physiological effects (3).A recent review of studies varying in design, popula-

tion base, and analytic procedures shows consistent rela-tionships between maternal smoking during pregnancyand reduction in birth weight of the offspring, and be-tween maternal smoking and increased risk of pregnancy

Table 6. Smoking and drinking behavior, during pregnancy, of married mothers of stillborn infants, according to behavior beforepregnancy, United States, 1980

Before pregnancy During pregnancy (percent)Behavior

Number Percent Total None Level 1 Level 2

Average daily smokingAll behaviors ............ 2,616 100.0 100.0 71.4 13.9 14.7

None' ...................... 1,730 66.1 100.0 100.0 0.0 0.01-10 cigarettes (level 1) ...... 270 10.3 100.0 30.0 68.1 1.911 cigarettes or more (level 2) 616 23.5 100.0 9.1 29.2 61.7

Average weekly drinkingAll behaviors ............ 2,616 100.0 100.0 67.0 30.0 3.0

None2 ...................... 1,337 51.1 100.0 99.3 0.4 0.3Less than 3 drinks (level

1 )3 ...... ................ 897 34.3 100.0 39.6 59.1 1.33 drinks or more (level 2)4

.......................... . ..382 14.6 100.0 18.3 66.0 15.7

1 Did not smoke even 1 cigarette a day.2 Consumed less than 1 drink (0.5 oz of absolute alcohol) less than once a month.

3 Consumed 0.01-0.19 oz of absolute alcohol each day on the average.4 Consumed 0.19 oz or more of absolute alcohol each day on the average.


loss (12). However, the findings on alcohol consumptionduring pregnancy are much less consistent. Typically,study design and measurement problems are confound-ing factors in drinking studies. Also, inconsistent find-ings have been attributed to inattention to the timing offetal exposure to maternal drinking in relation to thephase of pregnancy.

This report and an earlier study (13) of the smokingand drinking behavior of mothers of live-bom infants arebut the first steps to researching the effects of maternalbehavior on fetal growth, development, and survival.The next step, already underway, is to explore the effectsof smoking and drinking on pregnancy outcome, that is,on birth weight and survival. Our preliminary regressionanalysis showed that smoking, and to a lesser extentdrinking, are independently and additively associatedwith low birth weight, after controlling for a largenumber of demographic, maternal, and infant charac-teristics (14). These data are now being re-analyzed tospecify better the effects. Our analyses are constrainedby the limited range of drinking levels observed in thesedata (a preponderance of light to moderate over heavydrinking). Furthermore, these data do not allow us tomeasure effects in relation to drinking before conceptionand drinking in early or late pregnancy. We are, how-ever, looking at differential outcome effects from con-suming different types of beverages: beer, wine, andliquor. These analyses will include appropriate controlsfor sociodemographic, maternal health, and infant healthcharacteristics to allow us to specify precisely the effectof maternal smoking and drinking on birth weight orsurvival.

References ..................................

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2. Malin, H. J.. and Munch, N. E.: Implicated alcohol anddisease entities, alcohol as a risk factor in the nation'shealth. Report of the Alcohol Epidemiologic Data System.Contract No. ADM 281-79-0012, National Institute onAlcohol Abuse and Alcoholism; Alcohol, Drug Abuse, andMental Health Administration. Rockville, Md., Mar. 28,1980.

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smoking and drinking behavior before and during pregnancy of

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