Data for national and state smoking prevalence are drawn from standard birth certificate data collected by each state. The Pregnancy Risk Assessment Monitoring System (PRAMS) also offers a measure of the prevalence of smoking during pregnancy in some states. Although each data source has its strengths, either may understate the number of women smoking during pregnancy. For example, a CDC study compared the completeness of data collected from PRAMS with that from birth certificates.¹⁹ Among white women in six states, the completeness of ascertainment for maternal smoking rates ranged from 71% to 82% using birth certificate data and 86% to 90% using data from PRAMS questionnaires. If these results apply to all women, then both sources potentially underestimate maternal smoking prevalence. A strength of the birth certificate files, however, is that they are the only source of comparable, population-based measures available for all states over a period of time.

Birth Certificates

Detailed prenatal smoking prevalence information was calculated for each state using birth certificate data. The birth certificate was also the source for the statistics on all births in the state, birth weight measures, and receipt of early prenatal care. Data presented in the national section (Figures 1, 2, 4, and 5) are derived simply by aggregating all available state birth certificate data. Data are presented for each state in Figures 1 and 2.

U.S. birth certificates were revised in 1989 to include more complete information on maternal and infant health.²⁰ The standard tobacco question has a yes/no check box that asks for "tobacco use during pregnancy," and the "average number cigarettes per day." Birth certificate files were available in 1999 from 48 states and the District of Columbia. In 1999, smoking information was not available from California or South Dakota. Details of the reporting areas have been described elsewhere. ⁴

Smoking prevalence from birth certificate data is presented for each state overall and by different demographic subgroups including race/ethnicity, age, and education. Race/ethnicity is categorized into the following groups: Hispanic, white, black, Asian or Pacific Islander, and American Indian or Alaska Native. (The ethnic category Hispanic is mutually exclusive. For example, all persons classified as white are non-Hispanic.) Data on education are presented only for women aged 25 years and older. Data are not shown for subgroups with 30 or fewer individuals. Some of the subgroups, particularly in the race/ethnicity category, had small populations, and data from these subgroups should therefore be interpreted with caution.

PRAMS

PRAMS data are included in the national and state sections as an alternative source for measures of smoking prevalence (Figure 3). PRAMS data also were used to determine the prevalence of WIC participation and Medicaid-covered births. PRAMS data were available in 1998 from Alabama, Alaska, Arkansas, Colorado, Florida, Illinois, Louisiana, Maine, New Mexico, New York, North Carolina, Oklahoma, South Carolina, Washington, and West Virginia.

PRAMS is an ongoing, state-specific, population-based surveillance system used to supplement birth certificate data. It is maintained through CDC's Division of Reproductive Health with the cooperation of participating states. The survey was implemented to monitor certain maternal behaviors and experiences before, during, and after pregnancy. Each month, a sample of 100 to 250 new mothers in each participating state are selected from birth certificates and sent surveys between 2 and 6 months after delivery. Those who do not respond are contacted by telephone.²¹

The PRAMS questionnaire includes several questions about smoking. The new mothers are asked "Have you smoked at least 100 cigarettes in your entire life?" If the answer is "yes," they are asked "In the last 3 months of your pregnancy, how many cigarettes or packs of cigarettes did you smoke on an average day?" Women are considered to have smoked during pregnancy if they reported smoking at least 100 cigarettes during their lifetime and had smoked at least one cigarette per day during the last 3 months of pregnancy.

Data on the prevalence of smoking during pregnancy are presented for the 15 PRAMS states by race, education, and age. Race/ethnicity is categorized into Hispanic, white, or black. Data on education are presented only for women aged 25 years and older. Data are not shown for subgroups with 30 or fewer women.

California Maternal and Infant Health Assessment

The California Maternal and Infant Health Assessment (MIHA) is a collaborative project of the Maternal and Child Health Branch of the California Department of Health Services and researchers at the University of California, San Francisco. MIHA is an ongoing, population-based, mail/telephone survey of English- or Spanish-speaking mothers who gave birth to live infants in California during February through May of each survey year. The MIHA sampling frame consists of women who are California residents aged 15 years and older with singleton, twin, or triplet births. The MIHA sample is stratified by region of residence in California and maternal education to ensure a representative sample and by maternal race/ethnicity to permit over-sampling of black women, who are of special interest because of their high rates of adverse pregnancy outcomes. MIHA data are weighted to adjust for the stratified sampling design, over-sampling of black women, and differential nonresponse so that results can be generalized from the sample to the statewide population of eligible women with live births each year.

MCH SAMMEC

The basic structure of the Maternal and Child Health Smoking-Attributable Mortality, Morbidity, and Economic Costs (MCH SAMMEC) software package, which was developed by CDC, has been described previously.¹² MCH SAMMEC estimates the number of SIDS deaths caused by smoking, using estimates of relative risks of SIDS deaths to infants of mothers who smoke during pregnancy. The total number of SIDS deaths by state were derived from CDC's National Center for Health Statistics' Linked Birth/Infant Death Database, which is available at http://wonder.cdc.gov/lbd.html. Smoking-attributable SIDS deaths are presented for states reporting 30 or more total SIDS deaths in 1997.

Data on smoking-attributable morbidity (percent low birth weight [<2500 grams], admission to a NICU, length of infant hospital stay following birth, and neonatal health care dollars) are based on models previously estimated and published.^2,22 These models were completed using PRAMS data from 13 states, and the results were applied to birth certificate data from 1997 to derive estimates of smoking-attributable fractions for the above indicators. For those states whose birth certificate data from 1997 were not available (California, Indiana, and New York State), the results were applied to PRAMS data from 1995. The smoking-attributable fraction of neonatal health care dollars was also derived in this manner, and 1996 data from private-sector health care claims were used to formulate the actual dollar amounts presented in this databook.

National Governors Association

Data on Medicaid income eligibility levels for pregnant women in 2000 were obtained from the National Governors Association (NGA) Maternal and Child Health Update*. Current levels of eligibility are provided in the databook, but information for earlier years is available from the NGA source. The percentage of births covered by Medicaid in 1998 was also derived from the NGA for most states. PRAMS data on this variable were used when available.

United States Department of Agriculture

The United States Department of Agriculture funds the WIC program, a special supplemental food program for women, infants, and children deemed to be at nutritional risk. It is limited to pregnant and nursing women and children up to 5 years of age. Participants in WIC receive nutrition education, diet counseling, and vouchers to buy approved food that is high in growth nutrients.

Association of Maternal and Child Health Programs

Data on federal grant dollars for Title V programs were obtained through the Association of Maternal and Child Health Programs (AMCHP). AMCHP is a national organization located in Washington, D.C., that advocates for the health and well-being of mothers, infants, and children.

The general purpose of the Title V block grant program is to improve the health of all mothers and children. Its specific purpose is to create partnerships that include federal, state, and local governments to develop community systems that can address challenges to women's and children's health. The Title V block grant dollars reported here are only the federal dollars allocated and, hence, do not represent the total amount spent through these partnerships. For every $4 of federal funds, at least $3 must be matched by state and local funds, and most states over-match.

The data in the section on MCH smoking cessation programs were gathered through a special AMCHP* survey of state MCH staff in the states and territories. Of 59 states and territories surveyed, 50 responded. A full copy of the survey and results is available from AMCHP. This databook presents a summary of the states' responses on whether they screen clients for tobacco use and provide cessation counseling and materials. Also summarized is the information on media campaigns targeted to pregnant women, training on delivery of cessation interventions for MCH professionals, and Medicaid reimbursement for smoking cessation interventions aimed at pregnant women.

Office on Smoking and Health, Centers for Disease Control and Prevention

The data on tobacco excise taxes and bans on public smoking in each state were obtained from the Web site of CDC's Office on Smoking and Health (OSH). The data on the amount of each state's tobacco settlement allocation for 2001 were obtained from a recent OSH publication, Investment in Tobacco Control: State Highlights—2001, which is also available on the Web site.

Date last reviewed: 11/09/2006
Content source: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion