Pregnant women's tobacco use and exposure to secondhand smoke are current or emerging problems in developing countries, according to findings from a multinational (but nonrepresentative) survey.1 In six of the nine countries included in the study, most pregnant women surveyed said they had never tried cigarettes. However, three-fourths of those in Argentina and Uruguay had smoked at least once in their lifetime, and 10–18% said they were current smokers. Exposure to secondhand smoke was also common, particularly in Pakistan, where half of pregnant women said they were frequently or always exposed to tobacco smoke indoors.

Developing countries account for nearly 70% of tobacco use worldwide. Although half of men in these countries smoke, only one in 10 women do. However, evidence suggests that tobacco use among women in developing nations is rising. Moreover, even low levels of tobacco use among reproductive-age women raise concerns for public health, not only because of the potential effects of tobacco on women themselves, but also because smoking during pregnancy has been linked to preterm delivery, low birth weight and other fetal problems. These complications pose a particular threat in developing countries, where adequate medical care before, during and after delivery is often lacking.

To examine pregnant women's use of and exposure to tobacco in developing countries, researchers surveyed convenience samples of pregnant women in Argentina, Uruguay, Ecuador, Brazil, Guatemala, Democratic Republic of the Congo, Zambia, India (two states) and Pakistan in 2004–2005. In Brazil and Pakistan, the survey was conducted at a single site; in Argentina, Ecuador and Zambia, participants were recruited from at least seven sites. Data from the Indian states (Orissa and Karnataka) were treated as two distinct samples.

Women were eligible for the study if they were aged 18–46 and in the second or third trimester of pregnancy. At least 700 women were surveyed in each country or state through face-to-face interviews conducted by physicians, nurses and other health professionals; response rates were 98% or better. Key measures included whether the respondent had ever tried a cigarette (even one puff), had ever been a regular smoker or was a current smoker; whether she had ever tried or regularly used, or was a current user of, tobacco products other than cigarettes; whether smoking of tobacco products was allowed in the house and whether the respondent and her young children were exposed to secondhand smoke; and whether she felt it was acceptable for women in her community to smoke cigarettes or use other tobacco products.

Respondents' social and demographic characteristics varied widely, reflecting the diversity of the nine countries. Most women lived in urban areas, except in India and Pakistan, where more than 80% lived in rural communities. In most countries, the mean age was 24–27; more than 90% of respondents were literate, except in Zambia (75%), the two Indian states (60–71%) and Pakistan (24%). Only a quarter (23–27%) of African respondents lived with a tobacco user, but the proportions were higher in Latin America (30–60%) and Asia (56–90%).

Women in Latin America had the highest levels of tobacco use. In each of the five Latin American countries, at least a third of women had ever tried a cigarette; three-quarters of women in Argentina and Uruguay, and three-fifths of those in Ecuador, had done so. In contrast, no more than one in seven women in African or Asian countries had ever tried one. Although levels of regular use were generally much lower, 53% of respondents in Uruguay and 44% of those in Argentina said they had ever been a regular smoker; those two countries also had the highest proportion of respondents who admitted to smoking during their current pregnancy (18% and 10%, respectively). Brazil (6%) and Pakistan (3%) were the only other countries in which more than 1% of respondents reported being current smokers. About a third of women in Argentina (35%) and Uruguay (33%) said that cigarette smoking is acceptable for women, but the proportions were lower elsewhere in Latin America (5–19%) and negligible in Africa and Asia (0–4%).

In most countries, fewer than 5% of respondents had ever tried a tobacco product other than cigarettes. The exceptions were the Democratic Republic of the Congo (42%) and the two Indian states (9–34%). Current use of these products was high in Orissa (34%), where nearly every woman who had ever tried them was still using them, but levels of current use were much lower in the Congo (6%) and Karnataka (5%).

Women who did not use tobacco themselves were nonetheless often exposed to secondhand smoke. In Pakistan, 92% of women said that smoking was allowed in their home, and 50% said they and their young children were frequently or always exposed to tobacco smoke indoors. Slightly more than half (54– 55%) of respondents in Argentina, Uruguay and Orissa reported that smoking was allowed in their home, and at least a fifth of women in Argentina (31%), Brazil (30%), Uruguay (27%) and Karnataka (20%) said that they were frequently or always exposed to smoke indoors.

The study's limitations include the use of convenience samples, rather than nationally representative cohorts, and the possibility that some respondents did not acknowledge their tobacco use. Nonetheless, the investigators conclude that cigarette smoking by pregnant women "is a current or emerging problem in the five Latin American nations surveyed," and that use of smokeless tobacco products is a concern in India, particularly Orissa. In contrast, evidence suggests that Africa remains "in the early stages of the tobacco epidemic." The researchers note that "averting an increase in the prevalence of smoking among women in developing nations is widely recognized as a significant public health opportunity." Because women have low social status in many developing countries, it may not be possible for them to ban tobacco from their homes. The most effective way to reduce tobacco use during pregnancy, according to the researchers, is not to focus on pregnant women themselves, but rather to discourage girls and young women from smoking long before they become pregnant.

—P. Doskoch


Bloch M et al., Tobacco use and secondhand smoke exposure during pregnancy: an investigative survey of women in 9 developing nations, American Journal of Public Health, 2008, 98(10):1833–1840.