© Borgis - New Medicine 2/2012, s. 45-51
*Andrea Fogarasi-Grenczer1, Ildikó Rákóczi2, Péter Balázs3, Kristie L. Foley4
Socioeconomic factors and health risks among smoking women prior to pregnancy in Hungary
1Semmelweis University, Faculty of Health Sciences, Institute of Health Promotion and Clinical Methodology, Department of Family Care and Methodology, Hungary
Head of Institute: Gyula Domján, MD, PhD
2University of Debrecen, Health Care Faculty, Institute of Health Sciences, Department of Family Care Methodology and Public Health, Hungary
Head of Department: Zsigmond Kósa, MD, PhD
3Semmelweis University, Faculty of General Medicine, Institute of Public Health, Hungary
Head of Institute: Anna Tompa, MD, PhD
4Medical Humanities Program, Davidson College, North Carolina, USA
Director: Lance K. Stell, PhD
Summary
Aim. To assess the social and economic factors that influence tobacco smoking prior to pregnancy.
Material and methods. This research was conducted among mothers who gave birth to babies in the two least developed counties in Hungary (Borsod-Abaúj-Zemplén and Szabolcs-Szatmár-Bereg) in 2009. Data were obtained from medical records of obstetrical wards and structured interviews conducted by local maternity and child service. There were 7,877 women with complete data on smoking habits among 9,040 women in the study. This represents 9.4% of total live births in Hungary and 71.1% of all live births in the two counties.
Results. The overall prevalence of smoking prior to pregnancy was 46.0%. Smoking women were typically less than 18 years old, underweight, with the lowest levels of education, those living in non-contractual cohabitation, and those with unhealthy dietary habits (p<0.001), further living in deep poverty (p < 0.05).
Conclusions. While planning preventive actions to reduce female tobacco use in gestational age, the socioeconomic situation must be considered.
Introduction
While male tobacco smoking has levelled off in most of the developed countries, the frequency of smoking among women is on the rise. The European average is near 34%. Hungary is comparable to Greece, Portugal, Bosnia, Spain, and the United Kingdom. Only in Austria and Serbia is the frequency of smoking among women higher than in Hungary (1). Young girls start smoking very early and are often addicted smokers by the time they reach young adulthood. The prevalence of tobacco smoking among women aged 18-44 is 30.8% in Hungary (2). The level of education and the mother’s active employment influence smoking cessation (3). Tobacco use and exposure to secondhand smoking is extremely dangerous for the mother and the foetus. Smoking contributes to premature birth (< 37 weeks gestation), low birth weight (< 2500 grams) (4). In 2009 Hungary’s preterm births (PTB) and low birth weight (LBW) frequency (8.7% and 8.4%) was well-above the average of the European Union (EU), which was 6% (4, 5). In addition, 85% of the morbidity among newborn babies is due to PTB and/or LBW. The frequency of developmental disorders, stillbirth and other infant conditions (6), and the incidence of SIDS are growing (7).
In our study we aimed to identify socioeconomic factors that predicted smoking prior to pregnancy among mothers who gave birth to babies in the two least developed counties in Hungary (Borsod-Abaúj-Zemplén = BAZ, and Szabolcs-Szatmár-Bereg = Szabolcs) in 2009.
Material and methods
Our research was approved by the Ethical Committee of Semmelweis University. In the two countries mentioned above, mothers who gave birth to live babies between January 1, 2009 and December 31, 2009 were invited to participate in our research. The final sample was 9,040 mothers, which represents 71.1% of all mothers (N = 12,732) of live birth cases in these two counties. It means 9.4% of all live births (96,442) in Hungary during 2009. Mothers were informed about the aims of the research and the method we applied, and they provided formal consent to participate.
Data were obtained from medical records of obstetrical wards and through in-person interviews administered by the local maternity and child service.
Demographic, Social and Economic status: we measured the mothers’ age groups (years < 18, 18-34, 35-40, 41+), ethnicity (self-admitted as Roma or non-Roma), body mass index (BMI = kg/m2) converted to a categorical variable (underweight = <18.49, normal weight = 18.5-24.9, overweight = 25-29.9, obese = 30 or greater), level of education (less than 8 grades of primary school, completed 8 grades, secondary education, college and/or university), employment status (employed, unemployed, varia as students, disabled, on social benefit), marital status (married, non-contractual cohabitation, separated or divorced, single or widowed), number of children converted also to 3 categories (1-2, 3-6, 7-13), and dwelling circumstances (full, partial amenities and without basic amenities [running water, indoor plumbing, and heat]). Level of income/capita was determined by comparing the self-reported family income with data of the Central Statistical Office (CSO). Thus, the upper limit of deep poverty is reached if there are two children and two employed adults in the family and the income per capita is less than half of the average income per capita of the relevant year (8, 9). Poverty means 50-80%, at poverty level 80-120%, sufficient 120-170% and wealthy above 170% of this level.
Health Behaviours: dietary habits related to fresh fruits, vegetables, dairy and meat products in 4 categories of consumption were measured (at least once a day, every other day, once or twice a week, less than once a week). Coffee and alcohol (wine and beer) consumption were measured in 3 categories (coffee: at least every other day, 1-2 times a week and seldom or never, alcohol: at least once a week, less than per week, and never).
Descriptive statistics (means, standard deviations, ranges and frequencies) were used to describe the sample. Bivariate associations were calculated on all variables and their relationship to smoking status using the Pearson’s Chi-square test. Logistic regression analyses were computed to assess the relationship of socioeconomic and health behavior status to smoking prior to pregnancy. Results are reported in odds ratios (ORs) and 95% confidence interval (CI). All data were analysed using SSPS (19.0) statistical program.
Results
The prevalence of tobacco smoking among 7,877 women was 42.0% before pregnancy. Table 1 shows demographic, socioeconomic and life style characteristics of this sample.
Table 1. Smoking habits prior pregnancy related to demographic, socioeconomic and lifestyle characteristics of smoking (n=3421) and non-smoking (n=4456) mothers (N=7877) with live born babies in 2 north-eastern counties in Hungary in 2009.
| Variables | Overall (N) | Smokers (n) | non-Smokers (n) | p-value |
| Ethnicity (n,%) | 6932 | 2993 | 3939 | <0.001 |
| Roma | 2150 | 1235 (41.3) | 915 (23.2) | |
| non-Roma | 4782 | 1758 (58.7) | 3024 (76.8) | |
| Age in years | 7833 | 3402 | 4431 | <0.001* |
| x, (sd) min-max | 27.7 (6.0)
| 26.8 (6.1)
| 28.4 (5.9)
14-46 | |
| Age categories (n,%) | | | | <0.001 |
| <18 | 286 | 133 (3.9) | 153 (3.5) | |
| 18-34 | 6446 | 2846 (83.7) | 3600 (81.2) | |
| 35-40 | 987 | 371 (10.9) | 616 (13.9) | |
| 41+ | 114 | 52 (1.5) | 62 (1.4) | |
| BMI (kg/m2) | 7485 | 3230 | 4255 | N.A. |
mean (sd)
min-max | 22.87 (4.75)
12.89-50.78 | 22.34 (4.69)
13.06-50.78 | 23.28 (4.73)
12.89-47.83 | |
| BMI categories (n,%) | | | | <0.001 |
| Underweight | 1103 | 617 (19.1) | 486 (11.4) | |
| Normal | 4482 | 1904 (58.9) | 2578 (60.6) | |
| Overweight | 1226 | 463 (14.3) | 763 (17.9) | |
| Obesity | 674 | 246 (7.6) | 428 (10.1) | |
| Education (n,%) | 7846 | 3494 | 4815 | <0.001 |
| <8 grades | 750 | 478 (14.0) | 272 (6.1) | |
| Completed 8 grades** | 2286 | 1285 (37.7) | 1001 (22.6) | |
| Secondary | 3429 | 1403 (41.1) | 2026 (45.7) | |
| University/college | 1381 | 244 (7.2) | 1137 (25.6) | |
| Employment (n,%) | 7838 | 3490 | 4432 | <0.001 |
| Employed | 3196 | 1033 (30.3) | 2163 (48.8) | |
| Unemployed | 1899 | 1044 (30.7) | 855 (19.3) | |
| Varia*** | 2743 | 1329 (39.0) | 1414 (31.9) | |
| Marital Status (n, %) | 7849 | 3407 | 4442 | <0.001 |
| Married | 4078 | 1301 (38.2) | 2777 (62.5) | |
| Non-contractual cohabitation | 3371 | 1866 (54.8) | 1505 (33.9) | |
| Separated/divorced | 118 | 68 (2.0) | 50 (1.1) | |
| Single/Widowed | 282 | 172 (5.0) | 110 (2.5) | |
| N. of children | 7877 | 3421 | 4456 | <0.001* |
| x, (sd) min-max | 2.3 (1.5)
1-13 | 2.5 (1.7)
1-13 | 2.1 (1.3)
1-13 | |
| N. of children (n,%) | | | | |
| 1-2 | 5435 | 2144 (62.7) | 3291 (73.9) | <0.001 |
| 3-6 | 2260 | 1160 (33.9) | 1100 (24.7) | |
| 7-13 | 182 | 117 (3.4) | 65 (1.5) | |
| Income/capita (n,%) | 7563 | 3325 | 4238 | <0.001 |
| Deep poverty | 3576 | 2025 (60.9) | 1551 (36.6) | |
| Poverty | 2177 | 817 (24.6) | 1360 (32.1) | |
| At poverty level | 1126 | 298 (9.0) | 828 (19.5) | |
| Sufficient/Wealthy | 684 | 185 (5.6) | 499 (11.8) | |
| Housing conditions (n,%) | 7386 | 3212 | 4147 | <0.001 |
| Full amenities | 4390 | 1540 (47.9) | 2850 (68.3) | |
| Partial amenities | 1379 | 689 (21.5) | 690 (16.5) | |
| Without amenities | 1617 | 983 (30.6) | 634 (15.2) | |
| Dietary habits | | | | |
| Fresh fruits (n,%) | 7812 | 3397 | 4415 | <0.001 |
| At least once a day | 5420 | 2100 (61.8) | 3320 (75.2) | |
| Every other day | 812 | 386 (11.4) | 426 (9.6) | |
| Once or twice a week | 1044 | 570 (16.8) | 474 (10.7) | |
| Less than once a week | 536 | 341 (10.0) | 195 (4.4) | |
| Vegetables (n,%) | 7807 | 3391 | 4416 | <0.001 |
| At least once a day | 4696 | 1788 (52.7) | 2908 (65.9) | |
| Every other day | 1176 | 510 (15.0) | 666 (15.1) | |
| Once or twice a week | 1296 | 701 (20.7) | 595 (13.5) | |
| Less than once a week | 639 | 392 (11.6) | 247 (5.6) | |
| Dairy products (n,%) | 7809 | 3446 | 4414 | <0.001 |
| At least once a day | 5522 | 2211 (65.1) | 3311 (75.0) | |
| Every other day | 924 | 421 (12.4) | 503 (11.4) | |
| Once or twice a week | 797 | 430 (12.7) | 367 (8.3) | |
| < once a week | 566 | 333 (9.8) | 233 (5.3) | |
| Meat products (n,%) | 7776 | 3374 | 4402 | <0.001 |
| At least once a day | 4914 | 2035 (60.3) | 2879 (65.4) | |
| Every other day | 1500 | 656 (19.4) | 844 (19.2) | |
| Once or twice a week | 1034 | 505 (15.0) | 529 (12.0) | |
| Less than once a week | 328 | 178 (5.3) | 150 (3.4) | |
| Coffee (n,%) | 7715 | 3362 | 4353 | <0.001 |
| At least once a day | 3708 | 2235 (66.5) | 1473 (33.8) | |
| Every other day | 124 | 65 (1.9) | 59 (1.4) | |
| 1-2 times a week | 148 | 48 (1.4) | 100 (2.3) | |
| Seldom/never | 3735 | 1014 (30.2) | 2721 (62.5) | |
| Alcohol (wine/beer) (n,%) | 7606 | 3362 | 4616 | <0.001 |
| At least once a week | 40 | 40 (1.2) | 18 (0.4) | |
| Less than a week | 556 | 328 (9.9) | 228 (5.3) | |
| Never | 6992 | 2945 (88.9) | 4047 (94.3) | |
* t-probe, all other p-values were processed by the Pearson’s chi-square test
** Primary school
*** Disabled, student, etc.
Smoking women were younger (average age 26.8 years, range 14-46) 57.4% of Roma women were smoking compared to 36.8% of the non-Roma. The proportion of smokers was more than two times greater among those who did not complete 8 grades of primary school. Married women are less likely to smoke than non-married women (38.2% and 54.8% respectively). Deep poverty is more prevalent among smokers (60.9%) than non-smokers (36.3%). Housing conditions without amenities doubles the proportion of those who smoke (30.6% versus 15.2%). 10% of smoking women consume fresh fruits less than once a week compared to 4.4% among non-smoking women. Drinking coffee at least once a day was nearly two times more frequent among smoking women (66.5% v. 33.8%).
In a multivariable logistic regression model (tab. 2), factor significantly associated as protective against smoking was the age more than 18 years. Smokers were underweight versus overweight and obesity, women with less than 8 grades of primary school were more likely to smoke than those with university or college graduation. Non-contractual cohabitation versus being married facilitated smoking like living in deep poverty versus at poverty level. Women with daily consumption of caffeine were the most likely to smoke prior to pregnancy.
Table 2. Multivariable logistic regression model of women’s smoking prior pregnancy versus non-smoking (N=5845) by demographic, social, and lifestyle characteristics in 2 Eastern Hungarian countries.
| Variables | OR | 95% CI | <p-value |
| Roma v. non-Roma | 0.96 | 0.80-1.14 | N.A. |
| Age vs. <18 years | | | |
| 18-34 | 0.38 | 0.25-0.58 | 0.001 |
| 35-40 | 0.25 | 0.18-0.36 | 0.001 |
| 41+ | 0.32 | 0.21-0.46 | 0.001 |
| BMI underweight vs. | | | |
| normal weight | 1.09 | 0.93-1.28 | N.A. |
| overweight | 1.42 | 1.16-1.75 | 0.001 |
| obese | 1.30 | 1.02-1.65 | 0.05 |
| Education <8 grades vs. | | | |
| 8 grades (primary school) | 1.05 | 0.85-1.30 | N.A. |
| secondary | 1.26 | 0.97-1.64 | N.A. |
| university/college | 2.81 | 2.03-3.88 | 0.001 |
| Employed before birth vs. | | | |
| unemployed | 0.87 | 0.74-1.04 | N.A. |
| varia (disabled, student, etc.) | 1.07 | 0.90-1.26 | N.A. |
| Family status vs. married | | | |
| non-contractual cohabitation | 1.76 | 1.33-2.35 | 0.001 |
| separated or divorced | 0.98 | 0.74-1.30 | N.A. |
| single or widowed vs. | 0.88 | 0.52-1.48 | N.A. |
| 1-2 children vs. | | | |
| 3-6 | 0.98 | 0.85-1.13 | N.A. |
| 7 or more | 0.70 | 0.47-1.02 | N.A. |
| Deep poverty of the family vs. | | | |
| poverty | 1.17 | 1.00-1.38 | N.A. |
| at poverty level | 1.42 | 1.14-1.77 | 0.05 |
| sufficient/ wealthy | 1.12 | 0.86-1.46 | N.A. |
| Housing without amenities vs. | | | |
| full amenities | 1.08 | 0.89-1.29 | N.A. |
| partial amenities | 1.00 | 0.82-1.22 | N.A. |
| Consumption <daily vs. daily of... | | | |
| fruit | 1.05 | 0.90-1.22 | N.A. |
| vegetable | 1.16 | 1.01-1.34 | 0.05 |
| dairy | 1.10 | 0.96-1.26 | N.A. |
| meat | 1.04 | 0.92-1.18 | N.A. |
| Caffeine daily vs. <daily | 3.50 | 3.11-3.93 | 0.001 |
Conclusions
According to the WHO report and population-based studies conducted in Hungary, the average frequency of smoking among adult Hungarian women is between 30.8% and 33.9% (1, 2). In our sample 46% of women (between the ages of 14 and 46) who delivered live babies in 2009 were smokers at the time they learned they were pregnant, which demonstrates considerable regional differences within this country. Roma are also disproportionately represented in these communities. Self-identified Roma occurred more frequently (41.3%) among smokers than non-smokers (23.2%). Nevertheless, we found no association with smoking versus non-smoking status prior to pregnancy and the Roma ethnicity in the relevant multivariable logistic regression model, which suggests that Roma ethnicity is a proxy for the underlying social and economic conditions that they experience and not a risk factor for smoking during pregnancy in and of itself. Unfortunately, smoking is strongly related to the Roma identity from childhood, but they are not aware of the facts that many health conditions and symptoms experienced by them and their children are correlated with smoking. In Roma communities, smoking may be one way to cope with the permanent stress load of income insecurity and social isolation (10-12).
We demonstrated that low socioeconomic status increases tobacco use rates more than 1 1/2 times the average population in Hungary. A major initiative to improve health status must emphasize employment opportunities and the level of education in these impoverished communities. Higher level of education determines job opportunities, expertise, and one’s working positions, housing circumstances and level of income, further factors of lifestyle (e.g. such as eating habits). The cooperation of health care, education, civil and governmental organizations is necessary, because these are the most important indispensable devices for the realization of preventive actions against smoking and the improvement in overall well-being (13). Concerning inequalities in accessing health care, setting up available health services at primary and secondary level in rural and underdeveloped regions would also be necessary for expectant mothers.
Acknowledgements
Our study was supported by National Institutes of Health (NIH), National Cancer Institute, National Institutes on Drug Abuse, and Fogarty International Center (Grant Number 1 R01 TW007927-01). Our scientific work was helped by Ágnes Huszár who is a student at Semmelweis University Faculty of Health Sciences, Institute of Health Promotion and Clinical Methodology. We are grateful for the work of district health visitors.
Piśmiennictwo
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