The Effects of Tobacco Use During and After on Exposed Children

Relevance of Findings for Research

Marie D. Cornelius, Ph.D., and Nancy L. Day, Ph.D

Alcohol and tobacco use during pregnancy have both been associated with a number of adverse effects on the growth, cognitive development, and behavior of the exposed child. Understanding the effects of prenatal tobacco exposure allows researchers to identify those characteristics that are uniquely related to tobacco and those that are affected by alcohol exposure. This research, along with studies on the effects of alcohol use during pregnancy, has implications for preventing various types of substance use during pregnancy and for treating children affected by prenatal substance use. KEY WORDS: tobacco in any form; ; pregnancy; adverse effect; postnatal AOD (alcohol or other drug) exposure; prenatal AOD exposure; infant; cognitive development; psychobehavioral AODE (effects of AOD use, abuse, and dependence); growth and development

omen who smoke during the National Pregnancy and Health this issue examine the use of alcohol pregnancy are also likely to Survey (National Institute on Drug and tobacco together, this article focuses Wdrink alcohol. In one survey, Abuse [NIDA] 1996), 74 percent of on tobacco use during pregnancy and conducted as part of the Maternal Health women who used illicit during the effects of prenatal tobacco expo- Practices and Child Development pregnancy also reported either smoking, sure. Understanding the effects of pre- (MHPCD) project in Pittsburgh, drinking, or both. The use of either natal tobacco exposure allows the iden- , 76 percent of adult women one of these drugs is, in itself, a risk tification of those characteristics that who reported smoking during their first factor for poorer pregnancy outcome. are uniquely related to tobacco and trimester of pregnancy said that they Although alcohol and tobacco are also drank alcohol during that period frequently used together during preg- (Day et al. 1992). Among pregnant nancy, researchers studying the negative MARIE D. CORNELIUS, PH.D., is an teenagers surveyed, 61 percent of those effects of prenatal exposure to tobacco associate professor of psychiatry and who smoked during the first trimester and alcohol have generally examined epidemiology and NANCY L. DAY, PH.D., also drank alcohol (Cornelius et al. 1995). the effects of each drug separately. is a professor of psychiatry, epidemiology, In addition, tobacco and alcohol use Therefore, it is difficult to discuss the and pediatrics at the University of are both prevalent among women who effects of the combined use of the two Pittsburgh School of Medicine, Pittsburgh, use illicit drugs during pregnancy. In drugs. Although the other articles in Pennsylvania.

242 Alcohol Research & Health Tobacco Use During and After Pregnancy

those that are affected by alcohol expo- Effects of Smoking During prenatal tobacco exposure was signifi- sure. This research, along with research Pregnancy cantly related to reduced , on the effects of alcohol use during birth length, head circumference, and pregnancy, has implications for preventing This section of the article reviews find- chest circumference. These reductions various types of substance use during ings on the effects of maternal smoking were even more pronounced than those pregnancy and for treating children during pregnancy on the exposed chil- found in a similar cohort of the chil- affected by prenatal substance use. dren’s growth, cognitive function, and dren of adult women (Day et al. 1992). Prenatal tobacco exposure has been behavior. The subsequent section focuses For example, in the study of adult moth- reported to be a significant risk factor on the effects of . Because ers and their children, prenatal tobacco for sudden infant syndrome (SIDS) of space limitations, this article does use was significantly associated with a (National Institute [NCI] 1999) not review research on the effects of reduction in birth weight of 158 grams and is estimated to be responsible for up prenatal alcohol exposure. Because per pack per day. In the children of teen- to 4,800 infant as well as 61,000 women who smoke during pregnancy age mothers, prenatal tobacco exposure low-birth-weight (LBW) infants and are also likely to drink alcohol and use was significantly associated with a 26,000 infants requiring neonatal inten- other drugs, many of the studies reviewed reduction in birth weight of 202 grams sive care annually (DiFranza and Lew here controlled for prenatal alcohol per pack per day. The increased prob- 1995). In a national survey of pregnant exposure and other confounding factors, lems associated with young maternal adult women, however, 20.4 percent to determine the unique effects associ- age and poor fetal outcomes (Fraser et reported smoking during ated with prenatal tobacco exposure. al. 1995; Ketterlinus et al. 1990), cou- pregnancy (NIDA 1996). This propor- pled with the high prevalence of smoking tion rises to about one-half for women Effects on Infant Growth among pregnant teenagers (Cornelius in lower socioeconomic populations et al. 1994), magnify the risks to chil- (Cornelius et al. 1995; Day et al. 1992). Maternal smoking during pregnancy dren of pregnant teenagers who smoke. Smoking during pregnancy is more has long been considered an important In another recent study on prenatal prevalent among Caucasian women com- risk factor for LBW. This association tobacco exposure and fetal growth, pared with African-American or Hispanic was first reported in 1957 and has been Zaren and colleagues (2000) reported women (NIDA 1996). Caucasian proven in numerous subsequent studies that the male might be more women also smoke at higher levels than (Stillman et al. 1986; U.S. Department adversely affected than the female fetus. do women of other ethnicities. Women of Health and Human Services In this study, of nonsmoking, who smoke during pregnancy are less [USDHHS] 1980; Floyd et al. 1993). light smoking, and heavy smoking likely to be married, have less education, Birth weight decreases in direct propor- mothers were measured by sonograms have lower incomes, and attend fewer tion to the number of cigarettes smoked at weeks 17, 25, 33, and 37. Boys born prenatal visits compared with women (Persson et al. 1978; Yerushalmy 1971), to heavy-smoking mothers had greater who do not smoke during pregnancy and children of smokers are 150 to weight reductions, lower fat accretions, (Day et al. 1992; Cornelius et al. 1994). 250 grams than are the children and smaller head circumferences when Compared with alcohol, marijuana, of nonsmokers (USDHHS 1980). compared with girls of heavy smoking and other illicit drug use, tobacco use is The reduction in infant weight is not mothers. less likely to decline as the pregnancy attributable to earlier gestation, because Two key ingredients of smoke progresses (Day et al. 2000; Cornelius infants of smokers exhibit growth retar- that are known to affect fetal growth et al. 1995). In the National Pregnancy dation at all gestational ages (NCI 1999). are and . and Health Study (NIDA 1996), approx- In a recent study of neonatal body com- Carbon monoxide causes fetal hypoxia, imately two-thirds of the women who , prenatal tobacco exposure was a reduction in the amount of oxygen smoked prior to their pregnancy con- significantly related to having less fat-free available to the fetus (USDHHS 1980; tinued smoking into the last trimester. mass, as measured by total body electri- Lambers and Clark 1996), whereas In contrast, only one-fourth of the cal conductivity (Lindsay et al. 1997). nicotine can lead to a decrease in the women who used alcohol prior to con- The authors concluded that the LBW flow of oxygen and other nutrients ception continued to drink into the of infants exposed to prenatal smoking across the by constricting uter- third trimester. Women who smoke is primarily attributable to reduced fat- ine arteries (Lambers and Clark 1996). during pregnancy also continue smoking free mass or tissue. Birth length In addition, nicotine itself can cross the after the pregnancy (Cornelius et al. and head and chest circumference are placenta to affect the fetal cardiovascu- 1999a; Leech et al. 1999). Therefore, also reduced in infants who are prena- lar and central nervous systems (CNS) children born to women who use tally exposed to tobacco (Cornelius et al. (Stillman et al. 1986). Other constituents tobacco during pregnancy are likely to 1995; Day et al. 1992; Lindsay et al. of (e.g., and continue to be exposed to tobacco after 1997; Luciano et al. 1998). toluene) have also been shown to cause birth. This environmental, or passive, In a recent study of pregnant teenagers fetal growth retardation (Office of exposure may also affect the children’s (Cornelius et al. 1995, 1999b), more Environmental Health Hazard Assesment development. than one-half of whom were smokers, [OEHHA] 1996).

Vol. 24, No. 4, 2000 243 Long-Term Effects on Growth up at 18 months and 6 years, prenatal children whose mothers smoked dur- tobacco exposure was not related to ing pregnancy, compared with children The effects of prenatal tobacco expo- any growth reductions after controlling whose mothers did not smoke. Re- sure on older children’s growth are not for the appropriate covariates (Day et searchers evaluating the MHPCD cohort as clear as the effects on infants. Using al. 1994). Similarly, Vik and colleagues of 6-year-old children of teenage moth- data from the Collaborative Perinatal (1996) found that the reductions in ers also found a positive association Project, Naeye (1981) detected a small birth weight that were attributed to pre- between prenatal tobacco exposure and difference in height and head circum- natal tobacco exposure were not evident increased skinfold thickness. Prenatally ference in exposed children at age 7. when the children were 5 years old. exposed children also had higher values Rantakallio (1983) found that exposed on the body mass index and weight- children were shorter than nonexposed for-height Z-scores, an indication that children at age 14, and Fogelman and the children were overweight for their Manor (1988) reported decreased height height (Cornelius et al. in press b). at ages 7, 11, and 23. In the latter study, Prenatal tobacco Bottle-feeding was not a significant fac- the differences in height at age 23 were exposure was tor. Thus, several recent studies indi- mediated by birth weight. These studies cate that prenatal tobacco exposure did not control for passive exposure to significantly associated seems to alter the relationship between tobacco smoke or exposure to alcohol. body length and weight. This finding A study of 714 three-year-old children with reduced birth is underscored by two studies that have found that the children of women who length and found that prenatal tobacco exposure quit smoking during pregnancy were reduces the growth of the long bones in heavier and taller than those of women birth weight. the fetus (Lindsay et al. 1997; Luciano who did not quit (Fox et al. 1990). et al. 1998). Adjustment for postpartum exposure to tobacco smoke reduced the differ- Effects on Cognitive Function ence in the children’s weight, but had Prenatal tobacco exposure may not little effect on differences in height. only be related to size deficits at birth, Laboratory research with animals has Other studies have not found growth but may also be associated with dispro- shown that nicotine affects the CNS retardation over the long-term (Fried portionate weight (for height) among at exposure levels below those at which and O’Connell 1987; Hardy and Mellitus both infants and young children. For growth changes are evident (Slotkin 1972). In addition, one study that fol- example, a recent study of more than 1998). For example, animal studies lowed infants from birth through 6.5 200,000 births in Sweden found that have shown associations between fetal months and 13 months found that pre- prenatal tobacco exposure was signifi- nicotine exposure and increased loco- natal alcohol exposure, rather than cantly associated with reduced birth motor activity in male rat pups (Shacka tobacco exposure, was associated with a length and birth weight (Lindley et al. et al. 1997); hyperactivity in rats associ- slower growth rate when the exposed 2000). However, maternal smoking ated with increased nicotine receptors children were compared with unexposed was also significantly associated with an in the brain (Tizabi et al. 1997); lower children during the first 6.5 postpar- increase in ponderal index, an indica- turnover of the brain chemicals tum months. Although maternal smok- tion of higher proportionate weight for and in the rat brain as a result ing was correlated with shorter stature height, when birth weight and gesta- of alterations in the release or removal at 6.5 and 13 months, this effect was tional age were controlled for. Thus, of dopamine and serotonin from the attributable to maternal drinking dur- the children of smokers tended to be synapse (Muneoka et al. 1997); and ing pregnancy (Jacobson et al. 1994), shorter and have a higher ponderal index changes in the morphology of the hip- highlighting the importance of control- than children of nonsmokers. This pocampus in rats (Roy and Sabherwal ling for the effects of other drugs. finding is consistent with studies that 1998). The MHPCD study of adult mothers have followed children after infancy. For In the literature on humans, prenatal and their children (Day et al. 1992), example, Fried and colleagues (1999) tobacco exposure has also been linked which controlled for prenatal alcohol found that prenatal tobacco exposure to CNS effects, including cognitive and and other drug exposures and current was related to an increased rate of obe- neurobehavioral outcomes, although maternal tobacco use, found a significant sity among 6-year-olds. The researchers the reports are inconsistent. At birth, inverse relationship between maternal proposed that this association was prenatal tobacco exposure has been tobacco use during pregnancy and the attributable to a preference for bottle- associated with poorer auditory orienta- infant’s weight, length, and head cir- feeding among mothers who smoked tion and autonomic regulation (Picone cumference at birth. At 8 months, only during pregnancy. Vik and colleagues et al. 1982) and increased tremors and the infant’s length continued to be (1996) also reported a higher ponderal startles (Fried and Makin 1987). In a associated with prenatal tobacco expo- index and increased skinfold thickness recent race-matched study of - sure. When the children were followed (a measure of percentage body fat) in exposed and non-cocaine-exposed infants,

244 Alcohol Research & Health Tobacco Use During and After Pregnancy

neurological exams showed that prena- scores on the Wide Range Assessment at age 10, prenatal tobacco exposure tal tobacco exposure was significantly of Memory and Learning test (WRAML) predicted deficits on neuropsychologi- related to muscle tone abnormalities (Sheslow and Adams 1990) (Cornelius cal tests that measured planning ability when controlling for other variables, et al. 1999c), and these associations and fine motor coordination (Cornelius including prenatal cocaine and remained after consideration of other et al. 1999c). These deficits persisted exposure, head circumference, and pre- factors, including socioeconomic status, after controlling for maternal current natal care (Dempsey et al. 2000). The maternal psychological status, home smoking, prenatal exposure to other authors concluded that maternal cigarette environment, other prenatal substance substances, and covariates of prenatal smoking, rather than cocaine exposure, exposures, and current maternal tobacco and current substance use. might be the major predictor of tone and other substance use. abnormalities. Behavioral and Psychological Effects Studies have also reported adverse Effects on Activity, Attention, effects of prenatal tobacco exposure on and Impulsivity Behavioral and psychological problems cognitive and behavioral development have also been linked to prenatal tobacco in older children. In one study, cogni- Researchers have also reported associations exposure. Orlebeke and colleagues (1997) tive functioning at age 3 was higher between prenatal tobacco exposure and reported a significant effect of prenatal among the children of mothers who increased activity, inattention, and tobacco exposure on externalizing behav- quit smoking during pregnancy than impulsivity. Streissguth and colleagues iors, including oppositional, aggressive, among children whose mothers smoked (1984) reported significant relationships and overactive behaviors in 3-year-olds. throughout pregnancy (Sexton et al. between prenatal tobacco exposure and This study did not control for other 1990). Poor language development and errors of omission and commission, prenatal substance exposures or the moth- lower cognitive scores have also been reflective of inattention and impulsivity, ers’ current smoking habits. Weitzman reported in 2- (Fried and Watkinson respectively, in 4-year-olds. Kristjansson and colleagues (1992) found that women 1988), 3-, and 4-year-old (Fried and and colleagues (1989) found that prenatal who smoked both during and after Watkinson 1990) children prenatally tobacco exposure predicted impulsivity pregnancy rated their children as hav- exposed to tobacco. When those children and increased overall activity among 4- ing more behavior problems, but the were 9 to 12 years old, prenatal tobacco to 7-year-olds after controlling for pre- researchers found no effects on children exposure was negatively associated with natal exposure to other drugs and post- who were only exposed during pregnancy. language and reading abilities (Fried et natal exposure to second-hand smoke. Brook and colleagues (2000) found al. 1997). In another analysis of this In addition, Fried and colleagues (1992) that mothers who smoked during preg- same cohort of 9 to 12 year-olds, pre- reported a significant relationship between nancy were significantly more likely to natal tobacco exposure had a negative, prenatal tobacco exposure and impul- have toddlers who displayed negativity dose-dependent association with visual sivity among 6-year-olds in the same than did mothers who only smoked perception after consideration of other cohort. after delivery. This relationship was potential prenatal risk factors and of Milberger and colleagues (1996) maintained after controlling for a num- pre- and post-natal secondhand smoke found a positive relationship between ber of psychosocial risk factors, includ- exposures (Fried and Watkinson 2000). maternal smoking during pregnancy ing the mother’s distress, socioeco- Other researchers (Baghurst et al. and an increased risk of attention deficit nomic status, and perinatal risk factors. 1992; Fergusson and Lloyd 1991) have hyperactivity disorder in exposed children In the adult cohort of the MHPCD argued that initially significant associa- between the ages of 6 and 17, although project, 3-year-olds who were exposed tions between prenatal tobacco expo- the study did not control for current prenatally to tobacco were significantly sure and cognitive development were maternal smoking or prenatal exposure more likely to display oppositional explained better by differences in social to other substances. In the MHPCD behavior, immaturity, and aggressive class and the home environment. For study of adult mothers, prenatal tobacco behavior, according to the mothers’ example, after controlling for socioeco- exposure significantly predicted increased reports (Day et al. 2000). These rela- nomic and environmental differences, errors of commission on the Continuous tionships persisted after controlling for Eskenazi and Trupin (1995) failed to Performance Test (Lindgren and Lyons socioeconomic status, current home find consistent relationships between 1984) among 6-year-olds (Leech et al. environment, maternal psychological prenatal tobacco exposure and perfor- 1999). However, the mothers’ current status, current maternal tobacco use, mance on the Raven Colored Matrices tobacco use correlated so highly with and other prenatal substance exposures. Test (Raven et al. 1986), a measure of the prenatal exposure levels that these The behavior problems observed in nonverbal reasoning, or the Peabody exposures could not be separated. toddlers prenatally exposed to tobacco Picture Vocabulary Test (PPVT) (Dunn Eskenazi and Trupin (1995) did not persist through the adolescent and adult and Dunn 1981). However, in the find a relationship between prenatal years. Fergusson and colleagues (1993) MHPCD study of adult mothers, pre- tobacco use and activity. followed a birth cohort through age 12 natal tobacco exposure predicted deficits When the children of the adult moth- and reported that prenatal tobacco expo- in visual memory and verbal learning ers in the MHPCD study were assessed sure was significantly related to child-

Vol. 24, No. 4, 2000 245 hood behavior problems, whereas cur- tal exposure to other substances and intelligence, and visual-spatial abilities rent maternal smoking was not. At ages their mothers’ current smoking habits. as well as on the mothers’ ratings of 16 to 18, children in that cohort who behavior, compared with children whose were exposed to prenatal smoking had mothers were active or passive smokers. higher rates of , sub- Effects of Prenatal The performance of children of passive stance use, and depression than did Exposure to smokers was found, in most areas, to nonexposed children (Fergusson et al. Environmental be between that of the children of active 1998). Wakschlag and colleagues (1997) Tobacco Smoke smokers and nonsmokers. also reported a significant relationship between prenatal tobacco exposure and Pregnant women who do not smoke conduct disorder in a clinical sample; but live with or spend time with smokers Effects of Postnatal however, this study did not control for expose their children to environmental Exposure to current exposure. In addition, maternal tobacco smoke (ETS). In a review of Environmental smoking during pregnancy predicted 25 epidemiological studies of the rela- Tobacco Smoke persistent criminal outcomes in adult tionship between fetal growth and ETS male offspring in a Danish prospective exposure, all but one study reported a Postnatal exposure to ETS has been sig- study (Brennan et al. 1999). That study decrement in mean birth weight with nificantly associated with an increased controlled for a number of demographic ETS exposure (NCI 1999). Martin and risk of SIDS. After considering the variables, but it did not control for pre- Bracken (1986) found that passive effects of socioeconomic status, prenatal natal alcohol and illicit drug exposure exposure to smoking during pregnancy care, prenatal tobacco exposure, birth or for environmental tobacco exposure. was significantly correlated with lower weight, breast feeding, and routine infant In another prospective study in Finland birth weight among the children of sleeping position, Klonoff-Cohen and (Rasanen et al. 1999), maternal smoking nonsmoking women. Full-term new- colleagues (1995) reported that chil- during pregnancy was significantly asso- borns exposed only to passive smoke dren exposed to the smoking of more ciated with an increase in violent offenses weighed 61 grams less than newborns than 1 pack of cigarettes per day in a among the adult male offspring. not exposed to passive smoke and had household were 22.7 times more likely A few studies have evaluated the a significantly increased risk of LBW. than other children to develop sudden relationships between prenatal substance Data from the National Health Interview infant death syndrome (SIDS). Blair exposure and subsequent substance use Survey showed that after controlling and colleagues (1996) reported that the in the offspring. Animal researchers for potential confounding variables— risk of SIDS increased with the num- have noted that changes resulting from including race, number of children (i.e., ber of cigarettes smoked per day in the prenatal nicotine exposure might affect parity), income, and maternal age— household, ranging from 2.5 for 1 to susceptibility to later tobacco use (Miao nonsmoking women with high exposure 19 cigarettes per day to 7.6 for 40 or et al. 1998; Nordberg et al. 1991; Smith to passive smoke were 1.6 times more more cigarettes per day. et al. 1991). In a retrospective study of likely to have a LBW infant than were Cognitive and behavioral outcomes humans, Kandel and colleagues (1994) nonsmokers with low exposure (Main- are also affected by postnatal exposure reported a fourfold increased risk of ous and Hueston 1994). to passive smoke. Postnatal exposure to tobacco use among female offspring Studies using biomarkers to measure household smoke was reported to be who were exposed to tobacco prena- passive exposure provide further evi- associated with reduced IQ scores in 3- tally. In a later report, Griesler and col- dence of an adverse effect on growth. year-olds (Johnson et al. 1993). However, leagues (1998) showed that maternal For example, one study examined levels the effects of prenatal exposure were smoking during pregnancy was signifi- of (a product of nicotine not considered in this analysis. Eskenazi cantly associated with higher levels of ) in pregnant nonsmokers and Trupin (1995) reported that 5- child behavior problems and that these (Haddow et al. 1988) and found that year-olds who were environmentally behavior problems increased the likeli- the infants of the passively exposed exposed to tobacco smoke had signifi- hood of smoking among daughters mothers weighed 108 grams less than cantly lower scores on the Raven test between the ages of 9 and 17. The asso- infants of unexposed women, even after and PPVT and were rated as more active ciation between prenatal tobacco expo- controlling for known birth-weight- by their mothers. That analysis con- sure and early tobacco experimentation associated covariates. Other studies trolled for prenatal tobacco exposure. was also found in the MHPCD prospec- have confirmed these findings (Eskenazi Among 6- to 11-year-old children tive study of adult women and their et al. 1995; Rebagliato et al. 1995). of nonsmoking mothers, McCartney offspring (Cornelius et al. 2000). In Makin and colleagues (1991) exam- and colleagues (1994) found that post- this study, 10-year-old children exposed ined the long-term effects of prenatal natal passive tobacco exposure resulted to tobacco at the level of at least one passive exposure on 6- to 9-year-olds in scores on central auditory processing half pack per day during gestation had and found that children of nonsmoking tasks that were similar to scores for chil- a 5.5-fold increased risk for early tobacco mothers generally performed better on dren of mothers who were light smok- experimentation, controlling for prena- tests of speech and language skills, ers during pregnancy. In the MHPCD

246 Alcohol Research & Health Tobacco Use During and After Pregnancy

cohort of adolescent mothers and their have also reported behavior problems, bined effects of tobacco and alcohol 6-year-old children, passive tobacco such as increased activity, inattention, exposure on the developing offspring exposure, measured by the child’s urine impulsivity, opposition, and aggression. and use study designs and methodolo- cotinine levels, was significantly related In addition, prenatal tobacco exposure gies that allow researchers to tease out to poorer scores on subtests of the Test has been associated with higher rates of the effects from both prenatal and post- of Language Development (TOLD) delinquency and criminality in adoles- natal time periods. Without an under- (Hammill and Newcomer 1999), thereby cence and adulthood, an outcome that standing of the exact mechanisms by reflecting lower receptive language abil- is perhaps mediated by earlier behavior which tobacco exposure affects the ities (Cornelius et al. in press a). problems. CNS, the causes of the cognitive and behavior problems associated with pre- natal tobacco exposure will possibly be Summary and Conclusions attributed to another exposure, to envi- ronmental factors, or to the character Smoking during pregnancy has been Compared with of the mother or child. associated significantly with a number Recognition and clarification of the of adverse effects on the growth, cogni- alcohol and other effects of tobacco exposure on the devel- tive development, and behavior of the drug use, tobacco use opment of the child may also help exposed child. However, because women improve understanding of the effects of who smoke during pregnancy are also is less likely to prenatal exposure to alcohol and other likely to use alcohol or other drugs, drugs. In addition, this research will researchers must account for these con- decline during facilitate the development of interven- founding factors in order to identify pregnancy. tions to prevent substance use during accurately the specific and unique role pregnancy and to treat children prena- of tobacco exposure. In addition, even tally exposed to tobacco, alcohol, and nonsmoking mothers can expose their other drugs. children through environmental tobacco exposure. Compared with alcohol and Heredity is an important factor to other drug use, tobacco use is less likely consider in the interpretation of these References to decline during pregnancy, and women findings (Heath et al. 1995). A shared who smoke during pregnancy are more genetic component between the mother BAGHURST, P.; TONG, S.; WOODWARD, A.; AND likely to continue to smoke after delivery. and child may represent a vulnerability MCMICHAEL, A. Effects of maternal smoking upon neuropsychological development in early child- This means that children who are pre- to the characteristics that are associated hood: Importance of taking account of social and natally exposed to tobacco are at higher with tobacco use. For example, prena- environmental factors. Pediatric and Perinatal risk for continued exposure to environ- tal tobacco exposure may result in more Epidemiology 6:403–415, 1992. mental tobacco smoke from the mother impulsive offspring, or women who are BLAIR, P.; FLEMING, P.; BENSLEY, D.; ET AL. and from other household smokers. impulsive may be more likely to smoke Smoking and the sudden infant death syndrome: Prenatal tobacco exposure has con- and to produce more impulsive chil- Results from the 1993-1995 case-control study for sistently been associated with deficits in dren. Data from animal studies demon- confidential inquiry into and deaths in weight, height, and head circumference strate specific CNS changes resulting infancy. British Medical Journal 313:195–198, 1996. at birth. In general, long-term studies from prenatal nicotine exposure that BRENNAN, P.; GREKIN, E.; AND MEDNICK, S. Maternal that have controlled for other factors may affect offspring behavior. There- smoking during pregnancy and adult male criminal that affect growth, particularly prenatal fore, both genetic and teratological outcomes. Archives of General Psychiatry 56:215–219, 1999. alcohol exposure, have reported that etiologies are most likely involved these growth deficits are corrected by in the observed adverse outcomes. BROOK, J.; BROOK, D.; AND WHITEMAN, M. The “catch-up” growth in early childhood. The neurobehavioral effects of prena- influence of maternal smoking during pregnancy on the toddler’s negativity. Archives of Pediatric and Other studies have indicated a dispro- tal and postnatal tobacco exposure are Adolescent Medicine 154:381–385, 2000. portionate weight-to-height ratio with subtle. They are not easily identified, higher ponderal indices in infants and and difficulties arise in demonstrating CORNELIUS, M.; GEVA, D.; AND DAY, N. Patterns and covariates of tobacco use in a recent sample of body mass indices in older children. that many of the outcomes discussed in pregnant teenagers. Journal of Adolescent Health Recent research has noted a higher this review are “caused by” tobacco expo- 15:528–535, 1994. rate of behavioral problems among sure (Ramsay and Reynolds 2000). CORNELIUS, M.; TAYLOR, P.; AND GEVA, D. children who were prenatally exposed Nevertheless, we must continue identi- Prenatal tobacco and marijuana use among adoles- to tobacco. Higher rates of cognitive fying both short- and long-term effects cents: Effects on offspring , growth deficits, specifically in language, read- of prenatal and postnatal tobacco expo- and morphology. Pediatrics 95:438–443, 1995. ing, and vocabulary, as well as poorer sure on the growth and neurobehavioral CORNELIUS, M.; DAY, N.; RICHARDSON, G.; AND performances on tests of reasoning and development of children. Future studies TAYLOR, P. Epidemiology of during memory have been reported. Researchers should consider the separate and com- pregnancy. In: Ott, P.; Tarter, R.; and Ammerman,

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