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Association between environmental tobacco smoke before and during pregnancy and the risk of adverse birth outcomes: a birth cohort study in Wuhan, China

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Associations between environmental tobacco smoke (ETS) and the risk of adverse birth outcomes may be confounded. We aimed to clarify the associations of ETS before and during pregnancy with the risk of adverse birth outcomes and determine whether the associations were modified by key potential confounders. A total of 7147 non-smoking mothers from the Tongji Maternal and Child Health Cohort (TMCHC) in Wuhan, China, were included in the final analyses. ETS status was self-reported by pregnant women at their first antenatal care visit before 16 gestational weeks. Information on birth outcomes was extracted from delivery records. Poisson regression was used to identify the association between ETS before and during pregnancy and the risk of adverse birth outcomes. Exposures to ETS before and during pregnancy were reported by 645 (9.0%) and 464 (6.5%) mothers, respectively. Compared with no ETS, continued ETS during pregnancy was associated with an increased risk of preterm birth (PTB) (RR: 1.55, 95% CI: 1.07, 2.25) after adjustment for potential confounders. The association remained consistent in medically indicated PTB and late PTB. The risk of PTB associated with continued ETS during pregnancy was significantly increased in mothers more educated (P for interaction < 0.05). However, the increased risk of low birth weight (LBW) or small for gestational age (SGA) births by ETS during pregnancy was not observed. Exposure to ETS during pregnancy was associated with a higher risk of PTB, but not LBW or SGA births in a Chinese birth cohort.

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Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.


  • American College of O, Gynecologists (2013) ACOG committee opinion no. 560: medically indicated late-preterm and early-term deliveries. Obstet Gynecol 121(4):908–910

    Article  Google Scholar 

  • Andrews (2008) Early preterm birth: association between in utero exposure to acute inflammation and severe neurodevelopmental disability at 6 years of age - discussion. Am J Obstet Gynecol 198(4):466.e1-466.e11

  • Ashford KB, Hahn E, Hall L, Rayens MK, Noland M, Ferguson JE (2010) The effects of prenatal secondhand smoke exposure on preterm birth and neonatal outcomes. J Obstet Gynecol Neonatal Nurs 39(5):525–535

    Article  Google Scholar 

  • Baba S, Wikstrom AK, Stephansson O, Cnattingius S (2012) Influence of smoking and snuff cessation on risk of preterm birth. Eur J Epidemiol 27(4):297–304

    Article  Google Scholar 

  • Batech M, Tonstad S, Job JS, Chinnock R, Oshiro B, Allen Merritt T, Page G, Singh PN (2013) Estimating the impact of smoking cessation during pregnancy: the San Bernardino County experience. J Community health 38(5):838–846

    Article  Google Scholar 

  • Battarbee AN, Sinkey RG, Harper LM, Oparil S, Tita ATN (2020) Chronic hypertension in pregnancy. Am J obstet Gynecol 222(6):532–541

    Article  Google Scholar 

  • Bushnik T, Yang S, Kaufman J, Kramer M, Wilkins R (2017) Socioeconomic disparities in small-for-gestational-age birth and preterm birth. Health Rep 28(11):3–10

    Google Scholar 

  • Cantarutti A, Franchi M, Monzio Compagnoni M, Merlino L, Corrao G (2017) Mother’s education and the risk of several neonatal outcomes: an evidence from an Italian population-based study. BMC Pregnancy Childbirth 17(1):221

    Article  Google Scholar 

  • Chiu HT, Isaac Wu HD, Kuo HW (2008) The relationship between self-reported tobacco exposure and cotinines in urine and blood for pregnant women. Sci Total Environ 406(1-2):331–336

    Article  CAS  Google Scholar 

  • Crump C, Sundquist J, Sundquist K (2020) Preterm delivery and long term mortality in women: national cohort and co-sibling study. BMJ 370:m2533

    Article  Google Scholar 

  • Cui H, Gong TT, Liu CX, Wu QJ (2016) Associations between passive maternal smoking during pregnancy and preterm birth: evidence from a meta-analysis of observational studies. PLoS One 11(1):e0147848

    Article  Google Scholar 

  • Dahlin S, Gunnerbeck A, Wikstrom AK, Cnattingius S, Edstedt Bonamy AK (2016) Maternal tobacco use and extremely premature birth - a population-based cohort study. BJOG 123(12):1938–1946

    Article  CAS  Google Scholar 

  • Hilden K, Magnuson A, Hanson U, Simmons D, Fadl H (2020) Trends in pregnancy outcomes for women with gestational diabetes mellitus in Sweden 1998-2012: a nationwide cohort study. Diabet Med 37(12):2050–2057

    Article  CAS  Google Scholar 

  • Hoyt AT, Canfield MA, Romitti PA, Botto LD, Anderka MT, Krikov SV, Feldkamp ML (2018) Does maternal exposure to secondhand tobacco smoke during pregnancy increase the risk for preterm or small-for-gestational age birth? Matern Child Health 22(10):1418–1429

    Article  Google Scholar 

  • Ion R, Bernal AL (2015) Smoking and preterm birth. Reprod Sci 22(8):918–926

    Article  CAS  Google Scholar 

  • Ion RC, Wills AK, Bernal AL (2015) Environmental tobacco smoke exposure in pregnancy is associated with earlier delivery and reduced birth weight. Reprod Sci 22(12):1603–1611

    Article  CAS  Google Scholar 

  • Jaakkola JJ, Jaakkola N, Zahlsen K (2001) Fetal growth and length of gestation in relation to prenatal exposure to environmental tobacco smoke assessed by hair nicotine concentration. Environ Health Perspect 109(6):557–561

    Article  CAS  Google Scholar 

  • Jaddoe VW, Troe EJ, Hofman A, Mackenbach JP, Moll HA, Steegers EA, Witteman JC (2008) Active and passive maternal smoking during pregnancy and the risks of low birthweight and preterm birth: the Generation R Study. Paediatr Perinatal Epidemiol 22(2):162–171

    Article  Google Scholar 

  • Katz J, Lee AC, Kozuki N, Lawn JE, Cousens S, Blencowe H, Ezzati M, Bhutta ZA, Marchant T, Willey BA, Adair L, Barros F, Baqui AH, Christian P, Fawzi W, Gonzalez R, Humphrey J, Huybregts L, Kolsteren P, Mongkolchati A, Mullany LC, Ndyomugyenyi R, Nien JK, Osrin D, Roberfroid D, Sania A, Schmiegelow C, Silveira MF, Tielsch J, Vaidya A, Velaphi SC, Victora CG, Watson-Jones D, Black RE, CHERG Small-for-Gestational-Age-Preterm Birth Working Group (2013) Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis. Lancet 382(9890):417–425

    Article  Google Scholar 

  • Ko TJ, Tsai LY, Chu LC, Yeh SJ, Leung C, Chen CY, Chou HC, Tsao PN, Chen PC, Hsieh WS (2014) Parental smoking during pregnancy and its association with low birth weight, small for gestational age, and preterm birth offspring: a birth cohort study. Pediatr Neonatol 55(1):20–27

    Article  Google Scholar 

  • Kobayashi S, Sata F, Hanaoka T, Braimoh TS, Ito K, Tamura N, Araki A, Itoh S, Miyashita C, Kishi R (2019) Association between maternal passive smoking and increased risk of delivering small-for-gestational-age infants at full-term using plasma cotinine levels from The Hokkaido Study: a prospective birth cohort. BMJ Open 9(2):e023200

    Article  Google Scholar 

  • Lee NL, Samet JM, Yang G, Zhou M, Yang J, Correa A, Lees PS (2012) Prenatal secondhand smoke exposure and infant birth weight in China. Int J Environ Res Public Health 9(10):3398–3420

    Article  Google Scholar 

  • Leng J, Wang P, Shao P, Zhang C, Li W, Li N, Wang L, Nan H, Yu Z, Hu G, Chan JC, Yang X (2017) Passive smoking increased risk of gestational diabetes mellitus independently and synergistically with prepregnancy obesity in Tianjin, China. Diabetes Metab Res Rev 33(3)

  • Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, Lawn JE, Cousens S, Mathers C, Black RE (2016) Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet 388(10063):3027–3035

    Article  Google Scholar 

  • Luo YJ, Wen XZ, Ding P, He YH, Xie CB, Liu T, Lin JM, Yuan SX, Guo XL, Jia DQ, Chen LH, Huang BZ, Chen WQ (2012) Interaction between maternal passive smoking during pregnancy and CYP1A1 and GSTs polymorphisms on spontaneous preterm delivery. PLoS one 7(11):e49155

    Article  CAS  Google Scholar 

  • McCowan LM, Dekker GA, Chan E, Stewart A, Chappell LC, Hunter M, Moss-Morris R, North RA (2009) Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. BMJ 338:b1081

    Article  Google Scholar 

  • Moore E, Blatt K, Chen A, Van Hook J, DeFranco EA (2016) Relationship of trimester-specific smoking patterns and risk of preterm birth. Am J Obstet Gynecol 215(1):109. e1-6

  • Niu Z, Xie C, Wen X, Tian F, Ding P, He Y, Lin J, Yuan S, Guo X, Jia D, Chen WQ (2015) Placenta mediates the association between maternal second-hand smoke exposure during pregnancy and small for gestational age. Placenta 36(8):876–880

    Article  CAS  Google Scholar 

  • Qiu J, He X, Cui H, Zhang C, Zhang H, Dang Y, Han X, Chen Y, Tang Z, Zhang H, Bai H, Xu R, Zhu D, Lin X, Lv L, Xu X, Lin R, Yao T, Su J, Liu X, Wang W, Wang Y, Ma B, Liu S, Huang H, Lerro C, Zhao N, Liang J, Ma S, Ehrenkranz RA, Liu Q, Zhang Y (2014) Passive smoking and preterm birth in urban China. Am J Epidemiol 180(1):94–102

    Article  Google Scholar 

  • Salmasi G, Grady R, Jones J, McDonald SD, Knowledge Synthesis G (2010) Environmental tobacco smoke exposure and perinatal outcomes: a systematic review and meta-analyses. Acta Obstet Gynecol Scand 89(4):423–441

    Article  Google Scholar 

  • Satcher D (2000) Reducing tobacco use: a report of the Surgeon General - 2000. Oncology 14(12):1671,1675,1764-5

  • Stillerman KP, Mattison DR, Giudice LC, Woodruff TJ (2008) Environmental exposures and adverse pregnancy outcomes: a review of the science. Reprod Sci 15(7):631–650

    Article  Google Scholar 

  • Swamy GK, Ostbye T, Skjaerven R (2008) Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth. JAMA 299(12):1429–1436

    Article  CAS  Google Scholar 

  • Windham GC, Hopkins B, Fenster L, Swan SH (2000) Prenatal active or passive tobacco smoke exposure and the risk of preterm delivery or low birth weight. Epidemiology 11(4):427–433

    Article  CAS  Google Scholar 

  • Wu T, Hu Y, Chen C, Yang F, Li Z, Fang Z, Wang L, Chen D (2007) Passive smoking, metabolic gene polymorphisms, and infant birth weight in a prospective cohort study of Chinese women. Am J Epidemiology 166(3):313–322

    Article  Google Scholar 

  • Zhou B (2002) Predictive values of body mass index and waist circumference to risk factors of related diseases in Chinese adult population [in Chinese]. Zhonghua Liu Xing Bing Xue Za Zhi 23(1):5–10

    Google Scholar 

  • Zhu L, Zhang R, Lian S, Shi W, Wei W, Wang X, Lv Q, Liu L (2015) Chinese neonatal birthweight curve for different gestational age [in Chinese]. Zhonghua Er Ke Za Zhi 53(2):97–103

    Google Scholar 

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The authors thank all the participants and staff in the TMCHC for their valuable contributions.


This work was supported by the National Program on Basic Research Project of China (No. 2013FY114200) and the Fundamental Research Funds for the Central Universities (HUST2019kfyXMPY008)

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Authors and Affiliations



NY conceived the idea for TMCHC and managed the project. XC, LH, CZ, QL, RC, GS, ZJ, XY, LH, HY, and NY conducted the survey and collected data in Wuhan, China. XC contributed to statistical analysis and wrote the manuscript. NY participated in the discussions concerning the design, interpretation of results, and revision of the paper. All authors contributed to the final approval of the manuscript.

Corresponding author

Correspondence to Nianhong Yang.

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Ethics approval

The study was approved by the Ethics Review Committee of Tongji Medical College, Huazhong University of Science and Technology (No. 201302).

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Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare no competing interests.

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Responsible Editor: Lotfi Aleya

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Chen, X., Huang, L., Zhong, C. et al. Association between environmental tobacco smoke before and during pregnancy and the risk of adverse birth outcomes: a birth cohort study in Wuhan, China. Environ Sci Pollut Res 28, 27230–27237 (2021).

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