TABLE A31.--Summary of methods use,d in retrospective studies of tobacco use and cancer of the esophagus (cont.)

Author,
Year.
country.
reference

sex

Schwartz et al..
1961,
France (249)

M.

C*SeS                              Controls

Number

362

Method of selection        Number         Method of selection           Collection of data

Admissions to hospitals in Paris and a
few large provincial cities since 1964.

362

Healthy individuals admitted to same hos-   Interviewed by team of
pita1 because of work or traffic acci-    specially trained inter-

Wynder and
Br0ss.
1961,
U.S.A. (SZO)

M.






F.

160






37

Wynder nnd
Brass,
1961.
India (810).

Takano et al.,
1968,
Japan (272)

dents-matched by 5 war age group
and time of admission.

Cancer patients seen in Memorial Hospi-   150   Patients seen in same hospitals during
tal, New York City, and Kingsbridge        same time period with other tumors.
and Brooklyn VA Hospitals during        64%malignant tumor: 3@;&benign con-
1950-59 (86% white).                 ditions. Matched by sge with cancer
                                  patients.
Same hospitals and ssme time period BS    37   Same ss with regard to male controls.
male patients (86% white).             43% had malignant and 57~)$ benign
                                  tumors.

viewers who interviewed
the largest proportion
possible of all cancer
patients. Cases and
matched controls inter-
viewed by ssme person

Data collected by trained
interviewers.

M.
F.

67   Admitted to Tata Memorial Hospital Bom-   134   Patients with other forms of cancer ex-  Interviewed by one per-
27    bay.                          cept for oral cavity and lungs: &s well    son.
                                   as various benign diseases.         10% of male and 4% of
                                                               female cancer eases
                                                       histologically confirmed.

M.
F.

167
33

Patients with esophageal cancer.

lfi?
33

Patients with cancerous and non-can-   Interviews at various
cerous diseases of non-digestive organs.    hospitals. Cases and
                          controls age-matched.


   ~~ _..__~~               ~____~~                         ~~__---~
Bradshaw and     ,M    9x   Patients with esophagrnl cancer.         34,   I'atirnts with non-malitmant disease.     Hospital interviews by

Schonland,
1969,
South Africa
(41).

trained African social
workers.

MCilTi"CZ,
19F9.
Puerto Rico
(133)

                                                     -~ ~__.__~. -
M.    120   Patients with confirmed epidermoid eso-   :x0   120 mnlr. S!l female patients in same hos-   interviews by trained
E`.     5 9     phageal canrer diagnosed in 1966.       177     pital with non-cancerous diagnoses.     Personnel.
                                        240 mnl~, 11X female members from SSIE
                                           rommurrity.                      _____-


ki           TABLE A3la.-Summrg of results of retrospective studies of tobacco use and cancer of the esophagus

      Author.
       Yl?:,r,
      rountw.
     reference

Sadowsky et al.. 1953.
U.S.A. (231).

Percent nonsmokers
Cases     Controls


3.x       13.2

Percent heavy smokers

Cases   Controls
       
         -

Percent inhalers
among smokers

Caxa   Controls

-     -.

Relative risk ratio.
All smokers to
  nonsmokers
All    Heavy
smokers smokers

4.0     -

Sangvhi et al.
1955.
India (1041).

Wynder et al.,
1957,
Sweden (322).

M --
F

     6.5       17.3




    13.0       24.0
(about)RS.O (about)92.0

Awmzgc ~tumbcr of                       3.6     -
hidia smnlicd
15.3     14.1



                                 2.1     -
                                 2.0     -

Staszewki.
i960
Poland (260).

18.0         95.x    59.0        x7.5    80.0         -     -

Schwartz et al..

3.0       11.0      Total amount smoked      39.0    38.0        6.6

1961.                                               daily (cigarettes)
France C-`/9).                                               16.X     16.0

Wyndrr and Brass.
1961. U.S.A. and
India (SIO).



Takanu et al..
ISCH,
Japan (271).

American males           5.0       15.0         48.0    33.0                        3.4     4.4
America" females          41.0       78.0         27.0     16.0                        6.1     3.2
India" males             13.0       28.0                                         2.6
Indian females           18.0       94.0                                         4.5

                   17.0       23.0                                         1.3

Bradshaw and Schonland,                       16.3       31.7         31.6     5.9         -     -        2.6    11.1

1969,
South Africa (41).

Martinez. 1969.                             14.0       23.5         11.9     8.6                        1.8     3.5
Puerto Rico (183).


TABLE A32.-Atypical nuclei in basal cells of epithelium of esophagus of males, by smoking habits and age

Atnical nuclei

Never smoked          current
tWUbHlY          Cigarettes

Ex-cigarettes         Pipe, cigar          Other

NW&    Pet-       NWE-    Per-       NUlTl-    PW-      NU?iT.    PCS--      NUT%   Pe+-
her     cent        ber     cent        ber     rent       bcr     cent       ber    cent

A. Allmen:
  Number men  . . . _.   91
  Total sections'  .  737
  No atypical nuclei  _. .  733
  Some but <60 percent atypical  f....   62
  60 percent or more atypical . .   2

B. Men under age 50:
  Number men   26
  Total sections  . .  223
  No atypical nuclei  . _.  190
  Some but <60 percent atypical     33
  60 percent or more atypical _. _.   -

C. Men aged 50 -69:
  Number men  .   44
  Total sections  . _. _.  379
  No atypicnl nuclei  .  373
  Some but <60 percent atypical .   4
  60 percent or more atypical  .   2

D. Men aged 70 or older:
  Number men . . . . ~. .   21
  Total sections  . . . . . . . . . . . . . . .._..._  186
  No atypical nuclei  _.  170
  Some, but <60 percent atypical     15
  60 percent or more atypical .   -
                        -____

1 Sections with some epithelium present.
Source: Auerbach, 0. et al. (15).

3

-        779      -        131      -        89      -        62      -
100.0       6.762     100.0       1.586     luo.o       766     100.0       622     100.0
93.1        167      2.5        770     48.5        53      6.9       195     37.4
6.6      6.389     793        765     48.3       68R     X9.8       317     60.7
0.3       1,196     17.7         51      3.2        25      3.3        10      1.9

-        236
100.0       2,069     100.0
85.2        71      3.4
14.8      1,853     90.0
-        136      6.6

-        445               109
100.0      3,853     100.0        963
98.4        83      2.2        461
1.1       2,915     75.6        452
0.5        856     22.2         40

-        98               44
100.0        840     100.0        375
91.9        13      1.5        253
8.1        621     74.0        11R
-        206     24.5         4

2x
25R
56
195

luu.o
21.7
75.6
2.7

100.0

48.4
47.4
4.2

luu.o
67.4
31.5
1.1

9
77
1
74
2

3x
310
37
261
12

42
379
15
353
11

-
100.0
1.3
96.1
2.6

100.0
11.9
X4.2
3.9

100.0
4.0
93.1
2.9

7      -
53     100.0
4      7.6
46     86.8
3      6.7

31      -
256     100.0
74     28.9
178     69.6
4      1.6

24      -
213     100.0
117     64.9
93     43.7
3      1.4


i\. ,411 ages  ................   III
  Tt,t:tl section-; I  ...............   7x7
  NC, atypirnl nuclei  ..............   733
  Some but *<fill percent ntsuical  .....   52
  60 percent or more atypical  ........    2

8. Men under ax-c 50:
  Number me,,  .................   26
  Total srrti<,nr '  ...............   221
  No ntypirnl nurlei  ...............   190
  S,,",? bill <:c;u p,`l'rcrlt atYJlicnl  .....   33
  611 perrrnt or mc,rc atypical  ...........

(' Mm agml 6O-G!1:
  Numbc, men  .................   44
  Total sections '  .................   379
  NC, atypical nuclei  ................   373
  S,,mc but <GO pcrccnt atypical  .....    4
  GO lw~`rent 0~ mow atypical  ........    2

D. MWl a$RYl in ,)1` Clldc~r:
  N,,mkr~ rncn  ............    21
  Total secti<,ns '  ...................   lR5
  No atypical nuclei  ...............   170
  Some but `:Gn peK!ent atypical  ....   15
  GO pr,`cent 01 m,rl'e atynicnl  .........

' Sections with some epithelium present.
Source: Auerbnch, 0. et al. (15)

          1 i!)
100.0        1,544
!13.1          x9
6.6        1,341
0.3         114

           !)
100.0         433
85.2          4x
14.x         3x2
. . .           3

           !12                  240                   113        -

100.0         789       100.(1         2.116       lou.u          148      lUU.0
9x.4          30        3.X           1X        O.!)           35        :3.i
1.1         694       R7.0         1.6Oi       75.!1          F14       64.S
0.5          65        8.3          491       23.2          299       31.5

          :3:,
100.0         322
!)I.!)          11
3.1         2G5
           46

            41R        -          137        -
100.0         3.rY20      100.0         1,57!)      100.0
5.x           :i!l        I.1          ,3!l        2.5
X6.X         2,957       Xl.5         1,091       69.1
7.4          6 :3,3       17.4          44!1       2X.4

100.0
11.1
RX.2
0.7

132                   55
l.lti!)      1 lJ(l.0          457
21        1.X           2
I .OX!l       !I3 ."          3h"
50        5.0           73

            41        -           19
1011.0          :14-l      100.0          174
3.4                   _           2
R2.3          "61       iT,.!I           95
14.3           x:5       `24.1           77

100.0
0.4
83.6
16.0

-
100.0
1.1
54.7
44.2


   TABLE AIL-Summaq of methods used in retrospective studirs of sntoking nnd ca~ccr of the i&&k~~
                                          ____
Author.
year,                    CZWZS                                     Contwls
countrY.                   ____.                                   ___~               ___ .-
reference       Sex    Number           Method of selection             Numbrl            Method of selection
                                             _______  ___~              ____I_

Lilienfeld et al.,
1956,
U.S.A. (171).

M.

  F.



M.




M.
F.







--
M.
F.




M.
F.

M.

321

llfi

Admissions to Roswell Park Memorinl Institute.
1945-55 over 45 years of age.
Same as males

Schwartz et al.,
1961.
France (e@)

214

Admissions to hospitals in Paris and a few
large provincial cities since 1954.

337

109
317

214

No disease patients.

Benign bladder conditions.
No disease patients.
      _I-       ~~-
Healthy indi\Gduals admitted to same hospital
because of work or trnffic accident, matched
by 5 year age group.

Lockwood.
1961,
Denmark (175).

-

-

2R2
R7

All bladder tumors reported to Danish Cancer
Register during 1942-56 and living at time
of interview in Copenhagen and Fredericks-
burg. (Includes bladder papillomas).

28'2
x7

A. Fwm election wlls matched with cases ac-
curding to xx, age, marital status. occupa-
tion, and residence.

H. Another control group obtained from sam-
pit, <jf Danish Morbidity Survey (1952. 1953.
.and 1954) compared with respect to smok-
ing historica.

Wynder,
1963,
U.S.A. (326)

200
50




100
20

First phase:
  Admission to several hospitals in New
   York City during January 1957-Decem-
   ber 1960.
Second phase:
  Admission to same hospitals during 1!161.

Admissi(m to same hospitals (excluded cancel
of w'ipiratow system, upper alimentary tract,
myornrdinl infarction) matched by sex and
age.
Snrnc ns above.

Cobb and Ansell,
1965.
U.S.A. (57)
_I~__

136

Patients admitted to VA Hospital in Seattle
1951-61.

120 patient; with cancer of sigmoid colon, 222
pntirnts with non-neoplnstic pulmonary dis-
c':ise.


     TABLE AXi.-Summary of methods used in retrospective stltdies of s~tloking and carwe)' of the bladder (cont.)

    Author,
     war.                    Cases                                     COllt~OlS
    country.
    reference       Sex    Numhe:           Method of selection             N umbw            Method of selection
-
Staszewski.          M.     159    Patients with histologically confirmed bladder     750     Undefined srnnw age-matched.
1966.                          carcinoma.
Poland (201).

D~elry nnd Cohen.                                                     -
                M.     127    Patients with histologically confirmed bladder                                 -___
                                                             127      Patients in same hospital with non-cancerous
1966,                          carcinoma.                              or pulmonary disease matebed ior age.
England (66).

Yoshida et al.,         M.     163     Patients with bladder cancer.                163   "Compa&on cases."
196X,             F.      29                                      59
Japan (390).
-__~
Kidn et al..           M.      88    Admissions to 15 hospitals in North Fukuoka      xx
1968,                                                          Selected from patients hospitalized in fame re-
                E`.      26      prefecture.                          26     &ion for non-urinary ailments and we-
Japan (144).                                                            matched

Dunham et al.,      -if.     334    Admissions to New Orleans hospitals with his-     350     Admissions tu same hospitals with non-ncoplas-
1968.             E'.      150    tologic diagnosis of bladder carcinoma.          177
U.S.A. (85).                                                         tic diseases and diseases unrelated to peni-
                                                                   tourinary tract.

Anthony and Thomas.    M.     ax1    Patients with papilloma and esncer of bladder     275     Surgical patients without ~aneer previously in-
1970.                          at Leeds betweeen 1958-67.
England (9).                                                         ten&wed for lung cancer study.


     TABLE A35a.Summary of results of retrospective stzldies of smoking and cancer of the bladder
-... __        -                                                            -~ ._

Author,           Percent nonsmokers
veal-.           ___~

Percent heavy smokers

Percent cigarettes    Relative risk ratio:
  smoked     All smokers to nonsmokers
           ~.____~

  cointr;.
  reference      sex

Lilienfeld et al., M.
1956. F.
U.S.A. (171).

                                           All
ClW?S   Controls      CCW3   Controls     C*SeS              Heavy Cigarette          Comments
                                   Controls smokers smokers smokers
                                        -__I_                      ___-
15.0     29.0       .            61.0    44.0       2.3    . .   .2.7     Cigarette and other.
37.0     83.0             . .                     1.4          

                                                       ~~__                       -______
Schwartz et al., M.      11.0     20.0                    x3.0    70.0       2          2.2     Cigarette only.
1961,
Fr*nce (249).

Lockwood. M.
19G1. F.
Denmark (175).

9:o
66.0

13.4
66.0

30.0
4.0

15.0
4.0

--__  ~- - --__  ---~~~  ~___
30.0     1.5.0       1.6     8.0    3.0     Cigarettes main mode of
            1.5     1.2          smoking.

wynder et al.. M.
19GR. F.
U.S.A. (326).

7.0     18.0
61.0     86.0

47.0    23.0
6.0     ._.

85.0


     ~___- ___-- ~~ ~--__ ____~. ___
63.0       2.9     5.2    3.3     Phases A and B eom-
       3.9    .           bined.

    -                                                                           _____
Cohb and Ansell. M.      4.6     25.8       79.4    43.3       .            7.3    10.3    
llfl.5.
U.S.A. (57).

Stnsruwski, M.
1%X.
Poland (261).

                                       .~~~__~~_
6.7     16.0       86.7    65.7       X7.1    72.2       2.7     3.1     2.9     CiKWettC4 0,-h'.

De&y and Cohen, M.
1966.
Enalnnd ( 66 ) .

                                         ~~_I_ ._
2.4      7.1        .     . . .        . .            3.1         . .


     TABLE A3Sa.-Summaw~ of results of retrospective studies of smoking and cancer of the bladder (cont.)


   Author.                     Percentnt~rettes    Relative risk ratio:
                  I'crrmt nonsmokers    Percent heavy smokers               All smokers to nonsmokers
   YCBI',                  ~~                               ___ .-
  country.                                                       All   Heavy Cigarette          Comments
  rrfermce     SC\    Casrs   contrkJs      Cases   controls     Cases   Controls smokers smokers smokers
                                                     .-
Yn-hirln et al      M       R.O     22.7     43.4 - 33.0        _~     -       3.4     3.7 -
19GS.         2,`      62.1     8G.4        -     -              -
Japan (.?.%I).
_--
Kida et al.,                                             .-
            M.      11.0     11.0     32.0    29.0        -             1.0          -
1968,         F.      16.0     21.0              -                      1.4 -
Japan (144).                                                                           .-~
Dunham et RI..     iv.      X.6     14.5        -     -       49.4    45.4       1.R          1.8     Cigarettes onb.
19GR,         F.      62.2     61.5              -       32.0    2R.2       1.0 -    1.1
U.S.A. (85).
__~
Anthony and      F.      fi.3    6.3 - -     -       36.6   29.1 --  1.0 -    1.3     Cigarettes only.
Thomas,                                                                          More than 16 a day.
1870,
England (3)


CHAPTER 5

                  Pregnancy


Contents

Introduction   .......................................
Effect on birthweight  ................................
Effect on outcome of pregnancy  ........................
Experimental studies  ................................
Summary  ..........................................

References  .........................................

LIST OF TABLES

1. Summary of methods used in study of smoking and human
pregnancy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Maternal smoking and infant weight . . . . . . . , . . . . . .
3. Maternal smoking and prematurity . . . . . . . . . . . . . . , . . ,
3. Comparison of abortion, stillbirth, and neonatal death in
smoking and nonsmoking mothers . . . . . . . . . . . . . . . . . . .
5. Human experimental data on smoking and pregnancy , .
6. Animal experimental data on the effect of smoking and
nicotine on pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I'flp?
389

389

390

407

415

415

391
397
400

405
408

411

387


INTRODUCTION

In recent years, there has been increased research on environ-
mental factors which may adversely affect the unborn child. The
potential effect of maternal smoking on the fetus has been of par-
ticular interest because of the large number of pregnant women
who smoke and because smoking is an environmental influence
which could be controlled. Based on 1970 surveys of smoking
habits in representative samples of the U.S. population, it is
estimated that one-third of American women in the child-bearing
age group of 15 to 44 years are cigarette smokers. What propor-
tion of these give up smoking or cut down substantially on their
smoking during pregnancy is not known.

EFFECT ON BIRTHWEIGHT

Epidemiological and experimental studies have supported the
view that maternal smoking during pregnancy exerts a retarding
influence on fetal growth (tables 2, 6). Analysis of over 100,000
births shows that the infants of mothers who smoke during preg-
nancy have a mean birthweight of 6.1 ounces less than the infants
born to nonsmoking mothers (table 2). Several studies have docu-
mented that this effect is independent of other factors known to
exert a negative influence on infant birthweight, such as elevated
maternal blood pressure and small maternal size (1, 36, 39). The
reduction in infant birthweight is greater among heavy smoking
mothers than light smoking mothers (12,21,,03,30,~1,50,58), and
has been found in pregnancies terminating in each trimester (12,
16,23,40,51,54). In a study of more than 48,000 women, Under-
wood, et al. (51) demonstrated that infants born to women who
smoked during part of their pregnancy were significantly smaller
than infants born to nonsmokers, and that infants born to women
who smoked throughout their pregnancy were significantly smaller
than the infants born to women who smoked during part of their
pregnancy. Russell, et al. (39) have presented evidence that al-
though infants born to smoking mothers weighed less than those
of nonsmoking mothers, they grew more rapidly during the first
six months of life. At one year of age, children born to smoking
mothers weighed nearly the same as those born to nonsmoking
mothers. They concluded that smoking exerts a retarding influence

389


on fetal growth and that after delivery this is largely compensated
for by a period of more rapid growth.

As documented in more than 15 prospective and retrospective
studies, smoking mothers have significantly more infants who are
premature, as delined l)y wlzight alone (<2,500) grams, than do non-
smoking mothers (table 3). Buncher (4) studied the mean dura-
tion of pregnancy in smokers and nonsmokers in a survey which
included 49,897 live births. He found that women smoking 20
cigarettes a day had a mean length of gestation which was approxi-
mately one day shorter tha.n that of nonsmoking women. He calcu-
lated that this shortening of gestation is enough to account for only
10 percent of the known reduction in birthweight that is associated
with maternal smoking.

EFFECT ON OUTCOME OF PREGNANCY

Some controversy has surrounded the question of whether ma-
ternal smoking during pregnancy is associated with an increased
risk of spontaneous aborti'on, stillbirth, and neonatal death. Table
4 summarizes the studies which have dealt with this question. Some
of the studies did not dem.onstrate such an increased risk (7, 34,
*SO, 51)) while others did (1.2, 23, 33, 58). Many of these reports
(7, 23, 33, ,34, i 7, 3.9, 58) .were based on retrospective studies and
included women delivering their infants in hospitals and infants
whose names appeared on listings of newborn children (table 1).
As Russell, et al. (3.9) ha1.e pointed out, such studies may be sub-
ject to selective bias since they tend to underrepresent women who
have aborted. These retrospective studies also did not systemat-
ically control for maternal social class, parity, and maternal age,
all of which are related to the outcome of pregnancy and also are
related to smoking in some populations. In a prospective study of
more than 2,000 pregnant women, Russell, et al. (39) have demon-
strated a significantly higher percentage of unsuccessful pregnan-
cies (that is, abortion, stillbirth, or neonatal death) among women
who smoked during their pregnancy than among those who did
not. He interpreted his findings to mean that 20 percent of ". . . un-
successful pregnancies in women who smoke regularly would have
been successful if the mother had not been a regular smoker" (38).

The Second Report of the 1958 British Perinatal Mortality Sur-
vey published in 1969 is one of the largest prospective studies to
deal with this question (.5) . It included 98 percent of the total births
registered during one welzk in March 1958 throughout England,
Scotland, and Wales. In this study, a large amount of obstetric and
sociobiologic information was obtained on 17,000 singleton births.
This study reported that "the mortality in babies of smokers was
significantly higher than in those of nonsmokers." The increase in

390


TABLE l.-Summary of methods used in study of smoking and hzman pregnancy

-                                                   ______
Author.
  Year,    Retrospective
country,      or    N"zber          Data collection                  Case selection
reference   orosrxctive "ersons

Simpson,
1957.
U.S.A. (44).

R.

7,499

Questionnaire was filled out 48 hours
after delivery for all patients at
San Bernardino County Hospital
for 3 wars. Same form used for
2 years at St. Bernardines Hos-
pital and Loma Linda Hospital.

Multiple births excluded.

LOW,
1959,
England (29).

It.

2,042

Questionnaire was filled out for every
woman delivering at one of six
Rirmingham hospitals over a 5-
month period.

Non-Europeans and women  with    Social workers performed
twin births were rxcluded.          interviews.

Frazier et al.,      F.       2,736     (al Interview.                 All Neur<r women seen at Raltimwe
1961,                       (bl Prenatal clinic history.           Maternity Interviewing Service in
U.S.A. (12).                   (c) Birth and stillbirth certificates.       1!16!1 who WCL`C scheduled fop de-
                                                livery at HaItimore City Hosl,ital
                                              and who received prenatal care in
                                                  clinic "f Baltinwre City Health
                                                    Ikrlartme"t.
___~
Herriot et al..      K       2,745    Questionnaire filled out for Aber-
1962.                       deen city residents who were de-
Scotland (16).                   livered in Aberdeen City Hospital
                           over a l-year period.

Nonsxwkers include occasional
smokers.

Save1 and
Roth,
1962.
U.S.A. (41).

K.

I.416

1.500 consecutive patients admitted
to Newark Beth Israel Hospital
were interviewed.

Comments

The county hospital population
was different. with 50.6 per-
cent of the births being
"Mexican".


TABLE L-Summary of methods used in study of smoking and human pregnancy (cont.)

Author.
  war,    Retrospective   NU"lblS-
CountrY.      or        of            Data collection                  Case selection                 C""l"W"tS
reference   prospective    PCI'S""E

Yerushalmy,      P.        9X2     Form questionnaire.             Pregnancies terminating in abortion
1962,                                                  WPR excluded.
U.S.A. (53).

Murdoch.
1963.
U.S.A. (SO).

O'Lane,
iYb&,
U.S.A. (33).

1~.




R.

500




1.031

Personal interview by sothov.




Standard U.S. Naval Obstetrical Code
Sheet was used with supplemental
questions. Additional information
was obtained from prenatal his-
tory.

All mothers delivering at Nebraska
Methodist Hospital from Septem-
her 1962 to January 1963.

1,031 Caucasian women who had
single pregnancies delivered WI-
ginally over n B-month period.

"Smokers" defined as those
smoking regularly each day.

Zabriskie.
1963.
U.S.A. (58).

R.

2.000

History was obtained during the
postpartum period from 2,000 con-
secutive births  over a B-month
period.

Twin deliveries were omitted.

Yeruuhalmy,
1964.
U.S.A. (51).

P.

6,X00

Personal interview.

All women were members of Kaiser
Foundation Health Plan. Only
pregnancies terminating in single,
live births included. All races ex-
cept whites and Negroes were ex-
cluded.

5,3X1 whites 1,419 Negroes.

MacMahon et al.,
1965.
U.S.A. (24).

R.      12,192     Mnil questionnaire.

Mothers of single. white, legitimate
live births. Mothers were residents
of Massachusetts and delivered in
May or June of 1963.

Birthweight based on birth
certificate.


TABLE L-Summary of methods used in study of smoking and human pregnancy (cont.)

Author,
ye*=.    Retrospective   Number
country,      or        of            Data collection                  Case selection                 C"mme"ts
reference   prospective    persons

McDonald and
Lanford.
1965.
U.S.A. (96).

I'        177     Interview

White, unmarried primigravidas re-
ceiving obstetric care over a 2-
year period.

Peterson et al.,
1965,
U.S.A. (34).

R.

7,740

Cooperative study involving 17 hos-
pit& in 13 states, using U.S. Air
Force obstetrical code.

Includes only those multiparss whose
prior  infants  weighed >2.500
grams (Caucasians). All preg-
nancies  with  B"Y  complicntion
were excluded. Ceserean sections
and induced delivery were ex-
cluded.

Robinson,
1965.
Burma (37).

P.       1,614     Interview.

Regular attendees at prenatal clinic.

46.X percent of women smoked
cheroots.

Underwood et al.,
1965,
U.S.A. (50)

R.       4,440

interview by obstetrical resident.
Data was obtained on 16.158 preg-
nancies from the 4,440 women.

Puerperal wonw" from Roper Hos-
pital and Medical College Hospi-
tal. Only infants weighing >I,000
rrams WEI`P included.

Women from Roper Hospital
were of above average eco-
nnmic status. Women from
Medical College Hospital in-
cluded Negro and white
patients.

Downing and
Chapman.
1966.
U.S.A. (7).

R.

5,659

Review of clinic records from 1952
to 1958.

Six-year tot"1 of obstetrical patients
at clinic.


TAULE l.-Szcmmar~/ of ~trclhock used tn study of smoking and huwlan pregnancy (cont.)

Number
of
*erson':

2.02:1

      Data collection


Epidemiologic questionnaire. Much
data collected uver telephone. Ad-
ditional datn obtained from birth
certificates.

Rcinkr nnrl
Hrndrrso"
14fX.
U.S.A. (SG).

Ii.

3.151;    Registration data of prenatal clinic.

       Case selection


Study population was identified by
the listing of newborn infants in
ii Seattle newspaper during May.
June.  and July of 1964. Twins
were excluded.

      Comme"ts


95.4 percent of mothers were
white.

Negru women who delivered single,
live infant- from 1962-64.

Patients receiving care at "concep-
cion palncias" in Caracas.

Underwood et al..
Illfii.
U.S.A. (51).

I'

4X.605

Code sheets submitted from 44 world-
wide  navel  installations. Code
sheets were completed by the at-
tending physician upon the mo-
ther's admission to the labor room.

Women with single pregnancies de-
livered of infants weighing more
than 500 grams between July 1,
1963, and June 30, 1965.

Duffw and
MacCillivray,
I'JFX.
Scotland, (8).

Mulcahy and
Knaugs,
1YliP.
Ireland (28).   .-

II

2,543

Antenatalclinic records.

All "booked" marriezl city primi-
gravidae attending the antenatal
clinics during 1960. 1964. and
1965.

The number of cigarettes
smoked was not considered.

3.6X1

Mothers admitted to the Coombe
Hospital from April 1963 to Oc-
tober 1964.


Author.

TABLE I.-Summary of methods used in study of smoking and human pregnancy (cont.)

  year,   Retrospective   Number
country.      Or        of            Datn collection
reference                                                     Case selectio"                 Comments
        prospective    persons
-

Russell et al.,      P
1968,
England (89).

Tokuhata,
1968,
U.S.A. (49).

R.

Ihmcher,
1969,
U.S.A. (4).

R.

Butler and       1'
Alberman,
1969.
Great Britain (5).

      ~~~-__
Terris and       R.
Gold,
1969.
U.S.A. (47).

2.110

2.016

49.R97

17.000

197

-









-

Data collected by Senior resesrch
midwives over  a 4- to fi-year
period.

Women attending the two main ma-
ternity units in Sheffield, who
"comprised n reasonably repre-
sentative sample." Multiple preg-
nancies were omitted.

Personal interview or mail question-
naire of surviving family members.

Women selected from Memphis and
Shelby County death registry who
died of cnncer of genitalia or
breast since 1950 and who had
been married.

Included some threatened abor-
tions and some with "bad"
obstetrical histories.

Control group taken from same
registry. They died of causes
other then cancer and were
matched for rnce, age at
death, and year of death.

Data obtained from U.S. Naw ob-
stetrical study from 1963 to 1965.
Smoking dats obtained by physician
at the time of mother's admission
to labor room.

Women with single pregnancies de-
livered of infants weighing more
than 500 grams between July 1.
1963, and June 30, 1965.

Includes cases reported by
Underwood et al. (47) in
1967.

The British Perinetal Mortality Sur-
vey of 1958 when n large amount
of obstetric and sociobiologic in-
formation wns obtained from birth
sttendants, records, and nt inter-
view with the mothers.
        --

Public Health Nurse interviewed each
mother on first or second post-
partum day.

98 percent of the total births reg-
istered during 1 week in Msrch
1958 throughout England, Scot-
land, and Wales.

Another 7,000 perinatal deaths
were surveyed by identical
methods over a &month
period.

Premature   Negro   ward   births
(<`&SO0 grams) with no known
cause of prematurity. Controls
were matched by sex, birth order
of infant, nge, and marital status
of the mother.


         TABLE I.-~Summary of methods used in study of smoking and Izunlan pregnancy (cont.)

Author.
  year,    Retrospective   Nlllllber
coontry,               ;f            Data <o::ei:i"i,                  Case seiection
            3r
refewnce   prospective    T)PI`SO"S                                                             Lommcnts
                       ~___
Mulcahy et al.,     I'        100     lntcwiew by physician.
1970,                                                 100 mothers of term infants who

Ireland (28).                                            wew free from all sianifirent medi-
                                                  ical and obstetrical complications.
                                                  All were between 20 and 30 years
                                                    of age and were Para III or less.
                                                     All had normal deliveries. Half
                                                  were smokers of 10 or more ciga-
                                                     rettes per day.


    TABLE 2.-Maternal smoking and infant weight
(Numbers in parentheses indicate absolute number of infants in respective groups)

Author,
reference

Nonsmoker

Infant weight                    Difference in mea" weight
                             of infant of smoker             Comme"ts
          Smoker                versus nonsmokrr

Lowe (29)                       <lO cigarettes       >I0 cigarettes                 Effect on infant weight WBS independent
                               per day            Per day                     of maternal sge, parity, or complica-
        Male . . . . . 7.43 lbs.   (607)   7.1x (187)          7.05 (165)                      tions of pregnancy.
        Female  7.23 Ibs.   (539)   6.74 (163)          6.67 (147)
        Total  7.33 lbs.  (1,146)   6.38 (350)          6.87 (312)   170 g.   (6 oz.)

Frazier              3,osog. (1.717)               2,924 g. (1.019) 156 8. (5.5 OZ.)         Nonsmokers include occasional smokers.
et al..
(12).

Herriot     No data  (1,473)               No data (1.272) 160 g. (6.6 oz.)        Effect on infant weight was independ-
et al..                                                               ent of maternal age, parity. height,
(16).                                                                     or social class.

Save1 and    White  . 3,374 g.   (383)                3,141 g.   (428) 233g. (8.2 oz.)         Ciy*Tc.ttC#
Roth     Negro .._... 3,173g.   (364)                3.031g.   (240) 142 g. (5.002.)          per day        Infant weight
(41).                                                                    White smokers:
                                                                         l-10 3,ZlOg.  (161)
                                                                          11-20  ._ 3,198g.  (184)
                                                                          >zo  . . 3,OlOg.  (83)
                                                                      Negro smokers:
                                                                      l-10 3,042g.  (169)
                                                                          11 20  3.012g.   (57)
                                                                           >ZO  ._ _. _. _. 2,968 g.  (14)

Murdoch            7 Ibs. 7.5 oz.   (243)              6 Ibs. 15 oz.   (258)       8.5 oz.          Cigasrttce
(30).                                                                    PCT duy        Infant weight
                                                                           l-10  t.. 7 lbs. 2 oz.
                                                                          11-20  _. 6 lbs. 11 oz.
                                                                      >20 .._........ 6lbs.lOoz.
                                                                           >40  . . . 61bs. $02.

     O'Lane               2.9'78 g.   (666)               2,938 g.   (465)  40 g. (1.4 OZ.)
li:       C-w).
-4


TABLE 2.-Maternal smoking and infant weight (cont.)

(Numbers in parentheses indicate absolute number of infants in respective groups)

                           Infant weight                   Difference in mea" weight
Author,                                                    of infant of smoker             Comments
reference         Nonsmoker                 Smoker                versus nonsmoker

Zabriskie             3,320 g. (1,043)                3,091 g.   (967) 229 8. (8.1 OZ.)         Cigarettes
(58).                                                                  per day        Infant weight
                                                                           <lo  . 3.205g.  (260)
                                                                          10-20 3,090g.  (396)
                                                                     20-30 ._ ._ __ __ __ 2.9'7Og. (264)
                                                                         >30  3,190s.  (38)

MacMahon   Male  124.00~. (3,063)               116.3 oz. (3,173)       7.1 oz.         Cigarettes      Infant weig%t
et al.,     Female  . . . 119.9 oz. (2.906)               111.9 oz. (3,011)       8.0 oz.          ,WT day         ( oumx?s )
(24).                                                                           Male      Fe"l&
                                                                           /In
                                                                           1."  Y21.2 ($59) ??C,.E (595)
                                                                          lo-20 115.2 (1.262)   112.2 (1.259)
                                                                        20-40 114.6( 1,166)   108.9 (1,088)
                                                                          >40 113.2 (66)   111.7  (49)

McDonald

Light smoker

Heavy emoker

No significant difference be-

and
Lanford
(26).

111.68 oz.   (81)    110.83 oz.(42)   109.38 oz.(48)     tween mea" birthweights.

Underwood
et al.,     Group:
(50).        I 3,622g. (2,406)

Cigarettes
pe+ day
  <lO
10-20
  >20
  <lO
l&20
  >20
  <lO
10-20
  >20

           Fm >20 cigarettes per day
 3,349 g.       353 g. (12.5 oz.) (p<O.OOl)
 3,236 g. t (1.720)
 3.169 g.
. 3.171 g.       212 g. (7.5 oz.) (p<O.OOl)
 3.146 g.  t (660)
 3,092 g.
 2,936 g.      115 8. (4.1 oz.) (p<o.ool)
 2,965 s. t (3,040)
 3,011 g.

II  . 3,304 g.   (661)

III ___ __ 3,126g. (7,776)






.

Patients were divided into 3 grows:
   I. .Private patients of above av-
       erage economic status.

II. .White patients of average
    economic .status.

  III. .Negro patients of low eco-
       nomic status.
t Total for all smokers in each grwp.

Ravenholt   Male . . `7.80 lbs.   (171)              7.21 lbs. t(167) 59 lbs. (9.4 oz.)         t Smoked >4.000 cigarettes during preg-
et al..     Female  . 7.60 lbs.   (160)              7.05 lbs. t(171) .46 lbs. (7.2 oz.)          "*"W.
(35).


   TABLE 2.-Maternal smoking and infant weight (cozt.)
(Numbers in parentheses indicate absolute number of infants in respective groups)

                           Infant weight                   Difference in mea" weight
Author,                                                    of infant of smoker             Comme"ts
reference         Nonsmoker                 Smoker                versus nonsmoker
Reinke and            3.135 g. (1,542)               2.987 8. (1.614) 14R g. (5.2 oz.) (p<O.OOl)
Henderson
($6).
~-                                                                     ~___             -
Kizer (19).   Data not svailable           Deta not available               97 g. (3.4 oz.)        Total number of patients-2,095.

Underwood                        Cigarettes
et al..                           per day
(51).              3.396 g. (24,665)    l-10 . . . . . 3.286g. (7,609) 109g. (3.80~)
                                11-30  . 3,196 g. (14.450)  199 8. (7.Ooz.)
                                >30  3,182g. (1,570) 213 g. (7.502.)                           .___
Mulcahy              113.3 oz.        Cigalettee
and                            per day
Knaggs                           l- 4  111.4oz.            1.9 oz.
(28).                             5- 9  102.30%.           11.0 oz.
                                10-14  . 102.0 oz.           11.3 oz.
                                16-19  I.. 102.9 oz.           10.4 oz.
                                >20  . 102.40%           10.9 or..

Russell      BP                                         The effect of ma&al smoking on fetal
et al.,    <140/ 90 117.2 2 .7 oz.   (9R4)            107.2 !I 1.0 oz.   (496)      10.0 oz.          weight ~8s independent of maternal
(39).      140/ 90 114.2 3- 1.2 oz.   (340)            103.9 & 2.4 oz.   (117)       5.3 oz.          parity. age. height, educational level,
        >150/100 99.3 -c 2.6 oz.   (138)             90.8 15.3 oz.    (35)       8.5 07..          attitude to pregnancy or work during
                                                                  pregnancy, father's social class, con-
                                                                  sort's social class. and sex of the child
                                                                       or premature delivery.

Butler and
Alberman
(5).

3,375 g. (11,146)           3,205 g. (4.660) 170 g. (6;~)

fieductio" of mean birthweight of babies
born to smokers WBS independent of
unduly high proportion of babies born
preterm, and maternal factors includ-
ing social class and maternal height.

     Mulcahy              3.83 kg.   (50)                3.43 kg.    (50) 396 g. (14 oz.)
2      et *I.,
       (29).
9


TABLE 3.-Maternal smoking and prematurity (cont.)
(Figures in parentheses are the absolute number of premature births)

Author.
reference


Simpson
(44).









Lowe
(43).

   Premature by                Percent of premature infants         Mean duration of pregnancy
       Duration of ~ ~----        Comments
Weight    gestation                Nonsmokers   Smokers             Nonsmokers    Smokers

<2.600 B.          Name of hospital:                                             Number and percent of
                 County 7.77  (144)  11.48   (96)                             premature infants:
                 Loma Linda  6.16   (86) 12.13   (49)                              Nonsmokers 6.39 (328)
                 St. Bernnrdines 5.21   (98) 10.50 (119)                              Cigarettes per day:
                                                                           l-5 . . 7.06 (47)
                                                                           6-10 .11.18 (89)
                                                                         11-15 .11.36 (31)
                                                                           lfi-20  .13.6
                                 21-m ._ ._ .25.0 I::;
                                                                           >30 .33.3   (9)
                                            ___-
      <260 days                 6.4   (57) 10.6   (58)           279.9 days    278.5, days   At each week of gestation, the
                                                                        mean birthweight was lower
                                                                          in babies of smokers.

Frazier
et al..
(12).

<2,500 8.

11.2   (175) 18.6   (179)            38.7 weeks   3X.4 weeks Infants of smokers weighed less
                                             than infants of nonsmokers
                                             for a wide range of preg-
                                             nancy duration.

Herriot    No data    No data    Social class:                                                   2,745 patients in the study.
et al ..                      I and II  ......... 4.0        4.8                                At each week of gestation, the
(16).                      III  .............. 3.5        6.8                                  mean birthweight was lower
                         IV andV  ........ 6.3       12.6                                   in babies of smokers.

Save1 and          36 weeks   White  ............... 2.6    (10)   4.9   (21)       White .39.8       39.4
Roth                   Near,,  .............. .13.7    (50) 11.3   (27)      Negro .38.X       38.8
(41).
       t<zsoo g.          White  ............... 1.8    (7)   3.7  (16)-                           t Premature by weight but ma-
                      Negro  ............... 3.6   (13)   8.3   (20)                            ture by date (>37 weeks).