Smoking and Breast-feeding ebooksclub.org Tobacco or Health Physiological and Social Damages Caused by Tobacco Smoking Second Edition

Because฀of฀its฀lipophilic฀character,฀nicotine฀passes฀very฀rapidly฀into฀breast฀milk฀where฀it฀ attains฀threefold฀higher฀concentrations฀than฀in฀blood฀ [165,฀166] .฀On฀the฀basis฀of฀the฀volume฀ of฀breast฀milk฀consumed,฀this฀means฀that฀the฀infant฀receives฀6฀µg฀nicotinekg฀body฀weight฀ daily฀ [165] .฀Cotinine฀levels฀are฀an฀indicator฀of฀smoking฀habits฀and฀correlate฀with฀the฀number฀ of฀cigarettes฀smoked฀ [167] .฀The฀infant’s฀urinary฀cotinine฀comes฀from฀the฀cotinine฀in฀the฀ mother’s฀breast฀milk.฀It฀is฀dificult฀to฀assess฀what฀proportion฀derives฀from฀inhalation฀because฀ of฀passive฀exposure฀by฀being฀in฀the฀same฀room฀as฀smokers฀ [168] .฀The฀elimination฀half-life฀ for฀nicotine฀in฀breast฀milk฀is฀somewhat฀higher฀than฀that฀in฀the฀mother’s฀blood฀97฀±฀20฀vs.฀ 81฀±฀9฀min;฀p฀฀0.05,฀whereas฀cotinine฀concentrations฀remain฀fairly฀consistent฀during฀a฀4-h฀ interval฀without฀smoking฀ [166] .฀Newborn฀infants฀breast-fed฀by฀smokers฀and฀unexposed฀to฀pas- sive฀smoking฀show฀low฀plasma฀levels฀of฀nicotine฀0.2–1.6฀ngml฀and฀cotinine฀5–30฀ngml.฀ Newborn฀infants฀breast-fed฀by฀non-smokers฀did฀not฀have฀measurable฀amounts฀of฀the฀two฀ substances฀in฀plasma฀ [169] .฀As฀shown฀by฀the฀data฀presented฀in฀Table฀ 8.7 ,฀breast-feeding฀ mothers฀clearly฀contribute฀to฀raised฀plasma฀nicotine฀levels. Nicotine฀and฀cotinine฀concentrations฀in฀breast฀milk฀increase฀with฀the฀number฀of฀cigarettes฀ smoked฀daily,฀with฀concentrations฀up฀to฀1.6฀ng฀nicotineml฀and฀20฀ng฀cotinineml฀having฀ been฀measured฀ [170] .฀Concentrations฀arising฀as฀a฀result฀of฀passive฀smoking฀are฀markedly฀ lower.฀Nicotine฀and฀cotinine฀levels฀were฀measured฀by฀gas฀chromatography฀in฀34฀human฀milk฀ samples:฀nicotine฀was฀not฀found฀in฀the฀6฀samples฀of฀milk฀from฀non-smokers฀but฀was฀detected฀ in฀the฀28฀samples฀from฀smokers฀average:฀91฀ppb;฀ranging฀from฀20฀to฀512฀ppb฀ [171] .฀The฀ varying฀nicotine฀levels฀did฀not฀cause฀any฀adverse฀effects฀in฀the฀breast-fed฀children฀ [171] .฀ Urinary฀cotinine฀levels฀in฀breast-fed฀infants฀of฀smoking฀mothers฀were฀ten฀times฀higher฀than฀ those฀in฀bottle-fed฀infants฀of฀smoking฀mothers฀ [172] .฀Cotinine฀levels฀were฀also฀increased฀ when฀infants฀of฀non-smoking฀mothers฀lived฀in฀households฀with฀other฀smokers.฀In฀this฀group฀ the฀differences฀compared฀with฀infants฀of฀smoking฀mothers฀were฀very฀minimal฀ [172] ,฀sug- gesting฀that฀passive฀smoking฀must฀be฀recognised฀as฀a฀pivotal฀cause฀of฀the฀accumulation฀of฀ products฀of฀combustion.฀In฀addition,฀Cd 2+ ฀levels฀in฀breast฀milk฀are฀raised฀in฀smokers฀ [27] . Overall,฀breast-feeding฀is฀useful฀because฀the฀risk฀of฀childhood฀wheezing฀is฀reduced,฀even฀ where฀mothers฀smoke฀ [173] .฀It฀is฀still฀better฀–฀but฀far฀from฀ideal฀–฀to฀smoke฀and฀breastfeed฀ than฀to฀smoke฀and฀not฀breastfeed฀ [174,฀175] ,฀although฀it฀is฀known฀that฀smokers฀breastfeed฀for฀ a฀clearly฀shorter฀period฀than฀non-smokers฀ [176] ,฀owing฀possibly฀to฀a฀reduction฀in฀prolactin฀ levels฀ [177] .฀Initial฀investigations฀also฀suggest฀that฀breast-feeding฀for฀5–6฀months฀beneits฀the฀ child’s฀cognitive฀development฀to฀a฀greater฀extent฀than฀breast-feeding฀for฀3฀months฀ [178] . Infant฀exposure฀pattern Nicotinecreatinine฀ratio฀ ng฀nicotinemg฀creatinine Cotininecreatinine฀ratio฀ ng฀cotininemg฀creatinine Newborn฀infants฀breast-fed฀฀ by฀smoking฀mothers฀and฀ unexposed฀to฀passive฀smoking 14฀5.0–110.0 110฀10–550 Non-breast-fed฀infants฀exposed฀ only฀to฀passive฀smoking 35฀4.7–218.0 327฀117–780 Infants฀exposed฀to฀passive฀smoking฀ and฀to฀smoke฀via฀breast฀milk 12฀3.0–42.0 550฀225–870 Table 8.7 ฀฀฀Urinary฀excretion฀of฀nicotine฀and฀cotinine฀in฀breast-fed฀infants฀ [169] Median฀nicotinecreatinine฀and฀cotininecreatinine฀ratios฀and฀ranges

8.8 Medical Care Costs Attributable to Smoking During Pregnancy

In฀recent฀years,฀several฀calculations฀have฀been฀made฀in฀an฀attempt฀to฀estimate฀the฀inancial฀ burden฀on฀the฀health฀insurance฀schemes,฀and฀hence฀on฀society,฀arising฀from฀smoking฀dur- ing฀pregnancy฀ [179–182] .฀In฀1993,฀in฀the฀USA฀medical฀care฀expenditures฀attributable฀to฀ smoking฀were฀estimated฀to฀be฀US50฀billion฀ [179] .฀The฀pregnant฀smoker฀runs฀consider- able฀risks฀for฀herself,฀her฀pregnancy฀and฀her฀child,฀and฀this฀behaviour฀by฀pregnant฀women฀ places฀a฀major฀economic฀burden฀on฀society,฀estimated฀at฀US135–167฀million฀in฀the฀USA฀ in฀1993฀ [183] ฀although฀others฀have฀suggested฀a฀igure฀as฀high฀as฀US1.4฀billion฀ [184] .฀ Some฀studies฀have฀exclusively฀considered฀costs฀as฀they฀relate฀to฀the฀newborn฀child฀or฀ infant฀ [185] .฀One฀recent฀study฀of฀birth฀and฀irst-year฀costs฀for฀mothers฀and฀infants฀demon- strated฀incremental฀costs฀of฀US23,697฀for฀placental฀abruption฀and฀US21,944฀for฀respira- tory฀distress฀syndrome฀ [186] .฀In฀contrast,฀costs฀have฀been฀reported฀as฀US914฀for฀LBW฀ and฀US428฀for฀lower฀respiratory฀tract฀infection.฀The฀sum฀of฀the฀additional฀costs฀attribut- able฀to฀maternal฀smoking฀during฀pregnancy฀for฀all฀conditions฀yielded฀a฀total฀ranging฀from฀ US1,142–1,358฀per฀smoking฀pregnant฀woman฀ [186] .฀Similar฀results฀have฀been฀reported฀ in฀a฀German฀study฀from฀1999฀in฀770,744฀live฀births฀and฀with฀a฀20.3฀smoking฀prevalence฀ among฀pregnant฀women:฀from฀this฀population฀of฀pregnant฀women,฀preterm฀deliveries฀in฀a฀ hospital฀setting฀incurred฀additional฀expenditure฀of฀36฀million฀ [187] . In฀view฀of฀these฀facts฀it฀is฀an฀urgent฀priority฀that฀effective฀programmes฀be฀initiated฀ among฀women฀to฀encourage฀smoking฀cessation฀at฀the฀very฀start฀of฀pregnancy.

8.9 Concluding Remarks

• ฀ Current฀knowledge฀indicates฀that฀cigarette฀smoking฀during฀pregnancy฀and฀the฀breast- feeding฀period฀has฀considerable฀harmful฀effects฀on฀foetal฀health฀and฀on฀the฀infant’s฀ initial฀growth฀phase. • ฀ Smoking฀mothers฀run฀a฀major฀risk฀for฀their฀child,฀not฀only฀in฀terms฀of฀higher฀rates฀of฀abor- tion,฀premature฀placental฀abruption฀and฀LBW,฀but฀also฀of฀malformations฀cleft฀lippalate,฀ limb฀defects฀etc.,฀while฀differing฀views฀persist฀concerning฀the฀risk฀of฀Down฀syndrome. • ฀ These฀harmful฀effects฀are฀evidently฀caused฀by฀hypoxic฀reactions฀during฀smoking,฀with฀ subsequent฀increased฀levels฀of฀carboxyhaemoglobin,฀as฀has฀also฀been฀observed฀in฀cases฀ of฀CO฀poisoning฀which฀have฀resulted฀in฀the฀birth฀of฀malformed฀infants.฀To฀this฀must฀be฀ added฀the฀now฀proven฀placenta-toxic฀properties฀of฀cadmium,฀a฀substance฀which฀preg- nant฀women฀absorb฀in฀increased฀amounts฀during฀smoking. • ฀ During฀the฀irst฀months฀of฀life,฀large฀numbers฀of฀infants฀die฀from฀SIDS,฀a฀condition฀that฀ is฀also฀triggered฀by฀maternal฀and฀passive฀smoking,฀as฀shown฀by฀the฀detected฀presence฀ of฀cotinine฀in฀victims’฀urine฀and฀hair. • ฀ No฀uniied฀view฀currently฀exists฀concerning฀the฀involvement฀of฀nicotine฀in฀these฀harmful฀ effects,฀particularly฀since฀only฀animal฀experiments฀have฀been฀conducted฀in฀this฀area,฀and฀ it฀is฀questionable฀whether฀the฀indings฀obtained฀can฀be฀transposed฀to฀human฀pregnancy.฀On฀ the฀basis฀of฀at฀least฀the฀experimental฀animal฀studies฀to฀date,฀no฀malformations฀have฀come฀ to฀light.฀The฀regulation฀of฀dopaminergic฀receptors฀is฀altered,฀and฀while฀it฀has฀been฀postu- lated฀that฀cardiopulmonary฀regulation฀is฀disturbed,฀this฀has฀by฀no฀means฀been฀proved. • ฀ Overall,฀almost฀all฀complications฀in฀the฀unborn฀child฀occurring฀during฀pregnancy฀can฀ be฀attributed฀to฀the฀combustion฀products฀of฀tobacco,฀including฀the฀formation฀of฀CO.฀ This฀body฀of฀evidence฀might฀also฀justify฀reconsideration฀of฀the฀use฀of฀smoking฀cessa- tion฀therapy฀with฀nicotine฀products฀in฀pregnant฀women. • ฀ Alongside฀the฀harmful฀effects฀to฀the฀child,฀the฀additional฀economic฀burden฀imposed฀on฀ the฀state฀and฀society฀should฀be฀suficient฀reason฀for฀implementing฀effective฀smoking฀ cessation฀programmes. References ฀ 1.฀Anonym฀ 1994฀ Dokumentation฀ über฀ Mutterschaftsvorsorge฀ und฀ Entbindungen,฀ Tabelle฀ 3.฀ Kassenärztliche฀Bundesvereinigung,฀Köln ฀ 2.฀Voigt฀M,฀Hesse฀V,฀Wermke฀K,฀Friese฀K฀2001฀Rauchen฀in฀der฀Schwangerschaft.฀Risiko฀für฀das฀ Wachstum฀des฀Feten.฀Kinderärztl฀Praxis฀72:26–29 ฀ 3.฀Andres฀RL,฀Day฀MC฀2000฀Perinatal฀complications฀associated฀with฀maternal฀tobacco฀use.฀ Semin฀Neonatol฀53:231–241 ฀ 4.฀Salihu฀HM,฀Aliyu฀MH,฀Pierre-Louis฀BJ,฀Alexander฀GR฀2003฀Levels฀of฀excess฀infant฀deaths฀ attributable฀to฀maternal฀smoking฀during฀pregnancy฀in฀the฀United฀States.฀Matern฀Child฀Health฀J฀ 74:219–227 ฀ 5.฀Ockene฀J,฀Ma฀Y,฀Zapka฀J,฀Pbert฀L,฀Valentine฀GK,฀Stoddard฀A฀2002฀Spontaneous฀cessation฀of฀ smoking฀and฀alcohol฀use฀among฀low-income฀pregnant฀women.฀Am฀J฀Prev฀Med฀233:150–159 ฀ 6.฀Wasserman฀GA,฀Liu฀X,฀Pine฀DS,฀Graziano฀JH฀2001฀Contribution฀of฀maternal฀smoking฀during฀ pregnancy฀and฀lead฀exposure฀to฀early฀child฀behavior฀problems.฀Neurotoxicol฀Teratol฀231:13–21 ฀ 7.฀Lackmann฀GM,฀Angerer฀J,฀Tollner฀U฀2000฀Parental฀smoking฀and฀neonatal฀serum฀levels฀of- polychlorinated฀biphenyls฀and฀hexachlorobenzene.฀Pediatr฀Res฀475:598–601 ฀ 8.฀Ahluwalia฀IB,฀Grummer-Strawn฀L,฀Scanlon฀KS฀1997฀Exposure฀to฀environmental฀tobacco฀ smoke฀and฀birth฀outcome:฀increased฀effects฀on฀pregnant฀women฀aged฀30฀years฀or฀older.฀Am฀ J฀Epidemiol฀1461:42–47 ฀ 9.฀Ananth฀CV,฀Savitz฀DA,฀Luther฀ER฀1996฀Maternal฀cigarette฀smoking฀as฀a฀risk฀factor฀for฀placental฀ abruption,฀placenta฀previa,฀and฀uterine฀bleeding฀in฀pregnancy.฀Am฀J฀Epidemiol฀1449:881–889 10.฀Cnattingius฀S,฀Axelsson฀O,฀Eklund฀G,฀Lindmark฀G฀1985฀Smoking,฀maternal฀age,฀and฀fetal฀ growth.฀Obstet฀Gynecol฀664:449–452 11.฀Wang฀X,฀Tager฀IB,฀Van฀Vunakis฀H,฀Speizer฀FE,฀Hanrahan฀JP฀1997฀Maternal฀smoking฀during฀ pregnancy,฀urine฀cotinine฀concentrations,฀and฀birth฀outcomes.฀A฀prospective฀cohort฀study.฀Int฀ J฀Epidemiol฀265:978–988 12.฀Poppe฀WA,฀Drijkoningen฀M,฀Ide฀PS,฀Lauweryns฀JM,฀Van฀Assche฀FA฀1996฀Langerhans’฀cells฀ and฀L1฀antigen฀expression฀in฀normal฀and฀abnormal฀squamous฀epithelium฀of฀the฀cervical฀trans- formation฀zone.฀Gynecol฀Obstet฀Invest฀413:207–213 13.฀Bernstein฀L,฀Pike฀MC,฀Lobo฀RA,฀Depue฀RH,฀Ross฀RK,฀Henderson฀BE฀1989฀Cigarette฀smok- ing฀in฀pregnancy฀results฀in฀marked฀decrease฀in฀maternal฀hCG฀and฀oestradiol฀levels.฀Br฀J฀Obstet฀ Gynaecol฀961:92–96 14.฀Boyce฀A,฀Schwartz฀D,฀Hubert฀C,฀Cedard฀L,฀Dreyfus฀J฀1975฀Smoking,฀human฀placental฀lac- togen฀and฀birth฀weight.฀Br฀J฀Obstet฀Gynaecol฀8212:964–967