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Objectives. We examined pregnant women’s use of cigarettes and other tobacco products and the exposure of pregnant women and their young children to secondhand smoke (SHS) in 9 nations in Latin America, Asia, and Africa. Methods. Face-to-face surveys were administered to 7961 pregnant women (more than 700 per site) between October 2004 and September 2005. Results. At all Latin American sites, pregnant women commonly reported that they had ever tried cigarette smoking (range: 78.3% [Uruguay] to 35.0% [Guatemala]). The highest levels of current smoking were found in Uruguay (18.3%), Argentina (10.3%), and Brazil (6.1%). Experimentation with smokeless tobacco occurred in the Democratic Republic of the Congo and India; one third of all respondents in Orissa, India, were current smokeless tobacco users. SHS exposure was common: between 91.6%(Pakistan) and 17.1%(Democratic Republic of the Congo) of pregnant women reported that smoking was permitted in their home. Conclusions. Pregnant women’s tobacco use and SHS exposure are current or emerging problems in several low- and middle-income nations, jeopardizing ongoing efforts to improve maternal and child health.
We conducted a multicenter, cross-sectional survey of a convenience sample of pregnant women in 9 research units of the Global Network. The participating research units worked with pregnant women at study sites in Latin America (Argentina, Brazil, Ecuador, Guatemala, and Uruguay), Africa (Democratic Republic of the Congo [DRC] and Zambia), and Asia (Pakistan and 2 states in India). The number and location of recruitment sites for each research unit are shown in Table 1. Sociodemographic Characteristics of Pregnant Women in 9 Developing Countries: Survey on Tobacco Use, 2004–2005 Note. DRC = Democratic Republic of the Congo; ECLAMC = Estudio Colaborativo Latinoamericano de Malformaciones Congenitas (Latin American Collaborative Study of Congenital Malformations). The questionnaire was designed for face-to-face verbal administration by trained interviewers. Where possible, we used items from preexisting surveys, such as the Global Youth Tobacco Survey,11 the 2000 US National Health Interview Survey,12 and the Smoke-Free Families Screening Form,13 to develop the questionnaire. Survey topics included pregnant women’s use of tobacco products, knowledge of health hazards, perception of the social acceptability of tobacco use by women, and exposure to advertising both for and against tobacco and pregnant women’s and children’s SHS exposure. The research team in each country translated the master English version of the questionnaire into the language or languages most commonly spoken by the intended respondents. A back-translation was compared with the original English version, and discrepancies were returned to the sites for resolution. Each participating site conducted a pretest of the questionnaire with approximately 20 pregnant women drawn from the target population of the main survey. The final version of the questionnaire required an average of 25 minutes to administer across all sites. Interviewers were selected by the site team and included physicians, nurses, medical and nursing students, and other health professionals. Data were collected between October 2004 and September 2005. Response rates were between 97.7% and 100%. All respondents were asked, “Have you ever tried cigarette smoking, even 1 or 2 puffs?” and those responding “yes” were considered to have ever experimented with cigarettes. Those who had ever experimented with cigarettes were asked if they had ever smoked daily and if they had smoked 100 cigarettes or more in their lifetime. Respondents who answered “yes” to either or both questions were considered to have ever been a regular cigarette smoker. Respondents who had ever been a regular cigarette smoker and those who had ever experimented with cigarettes were then asked about their current smoking. Those who acknowledged they were currently smoking were considered current smokers. Similarly, all respondents were asked if they had ever tried “any other forms of tobacco, besides cigarettes?” and those responding “yes” were considered to have ever experimented with any other tobacco product. Respondents who had ever experimented were queried separately about each product for up to 4 other tobacco products; they were asked if they had ever used the product daily and if they had used the product 100 or more times in their lifetime. Respondents who answered “yes” to either or both questions were considered to have ever been a regular user of that product. Respondents who had ever been a regular user and those who had ever experimented were asked about their current use. Those who acknowledged they were currently using the product were considered current users. All respondents were asked, “Is smoking of tobacco products allowed in your home?” All respondents were also asked, “How often are you indoors and around people who are smoking cigarettes or other types of tobacco products?” and “How often are your children, 5 years or younger, indoors and around people who are smoking cigarettes or other types of tobacco products?” Permitted responses to the latter 2 questions were rarely or never, sometimes, frequently, or always. All respondents were asked, “Do you think it is acceptable for women in your community to smoke cigarettes, or not?” and “Do you think it is acceptable for women in your community to use other tobacco products, or not?” Each research site administered the questionnaire to a convenience sample of 700 or more pregnant women (N = 7961) presenting for prenatal care. Participants were identified at prenatal care clinics, hospitals, health centers, and in Orissa, India, community sites accessible to the research team. Eligibility requirements included being aged 18 to 46 years and being beyond the first trimester of pregnancy. Women believed to be mentally or physically incapable of participating in the survey, as judged by the interviewer, were excluded. We obtained written consent from all willing, eligible women, except in Pakistan and Ecuador, where verbal consent was permitted. Respondents did not receive incentives or reimbursement for their participation. Interviews were conducted with the maximum privacy possible in each setting. Standard procedures, established to ensure data quality, included training programs for the interviewers, supervisors, and data-entry staff; a reporting system to monitor data collection and processing activities; and procedures for verifying interviewers’ work. The in-country research team conducted interviewer training, with materials and supervision provided by the data coordinating center, Research Triangle Institute. Trainees completed a certification test to determine whether they were prepared to solicit participation in the study and administer the questionnaire or they needed additional training. For each interviewer, supervisory staff recontacted a 5% to 10% sample of participants to verify that the interview occurred and to confirm key data. A data management system developed for each site included data-entry range and intra- form consistency checks (e.g., skip patterns) to ensure high-quality keying. Staff selected a 10% sample of completed questionnaires for key verification. We reviewed any verification exercise with an error rate of greater than 0.5% to identify the source of error and correct the problem. An Internet-based field-monitoring system tracked progress in each country. Each site set a target sample of 750 completed interviews to estimate parameters of knowledge, attitudes, and behaviors as low as 0.05 with a coefficient of variation of about 15%. Staff entered data into a data management system developed with Microsoft Access 2002 (Microsoft Corp, Redmond, Wash). Data were reviewed for consistency and completeness at the data coordinating center. Questionnaires with incomplete or inconsistent information were returned to the sites for resolution. We used SAS version 9.0 (SAS Institute Inc, Cary, NC) for data analysis. We calculated descriptive statistics (frequencies, percentages, means, and standard deviations) for each site, excluding missing data from the analysis.
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