, , _ _ , NTATION __.._____— Center for Health Statistics 0 " a‘ El Smoking and lb od Morbidity ,1; .w ,J MJss. Mary D. 6verpeck Gerry E. Hendershot, Howard J. Hoffman and Heinz W. Berendes . US. DEPARTMENT OF HEALTH AND HUMAN SERVICES 0 Public Health Service 0 National Center fpr Health Statistics ' W , W W ”mam” .mfi m .Mhug‘a ”ham, of)», ‘ Q PRESENTATION National Center for Health Statistics L Prenatal Smoking and Childhood MorbidityN, Abigail J. Moss, Mary D. Overpeck Gerry E. Hendershot, Howard J. Hoffman and Heinz W. Berendes Presented at the International Conference on Smoking and Reproductive Health San Francisco, California October 15-17, 1985 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Center for Health Statistics Hyattsville, Maryland July 1987 Hafizow PuBL W7" (W0) pufi» PRENATAL SMOKING AND CHILDHOOD MORBIDITY Heinz H. Berendes INTRODUCTION Smoking during pregnancy and its adverse effects on infant health have been addressed in numerous research studies over the past 25 years. The first large-scale study was conducted in California in the late 1950's. In that retrospective study of 7,000 mothers, the researchers found that mothers who smoked during pregnancy gave birth to babies weighing less than 2,500 grams twice as often as did nonsmokers.1 Since that time, many other researchers have replicated these findings.2 Other adverse effects associated with smoking during pregnancy have also been identified, including increased incidence of spontaneous abortion complications of pregnancy and labor, and an increase in perinatal mortality.3'14 This paper, which describes results from the 1981 National Health Interview Survey (NHIS), looks beyond the effect of maternal smoking on the fetus and the newborn to subsequent health status of surviving children at later stages of development. BACKGROUND A number of studies, conducted since the early 1970's, indicate maternal smoking may have long-lasting adverse effects on a child's health. In 1973, British researchers Butler and Goldstein found that there was a significant impact on physical growth and school-related taiks in the children of mothers who smoked after the fourth month of pregnancy. 5 These findings were obtained from the National Child Development Study, a followup study of over 13,000 British children born in 1958, and retested at 7 and 11 years of age. Butler and Goldstein further found that the effect of maternal smoking increased with the number of cigarettes smoked. Specifically, at 7 and 11, the children of mothers who smoked 10 cigarettes or more a day during pregnancy were, on the average, 1 centimeter shorter and between 3 and 5 months slower in reading, mathematics, and general ability compared with children of nonsmoking mothers. Some have since questioned whether all of these findings necessarily imply effects of maternal smoking. Several other studies conducted in California, Canada, and elsewhere have substantiated many of the above findings. Results almost identical to the British study were obtained from the California “Child Health and Development Study" which followed about 3,700 children born It the Oakland Kaiser- Permanente Medical Center between 1959 and 1967. 5 It showed children of nonsmokers at 5 years of age to be almost 1 centimeter taller than children of heavy smokers. Similarly, it was discovered in the Canadian study that 6 1/2 year-old children whose mothers did not smoke during pregnancy had greater mean weight and height than did children whose mothers smoked.1 In another study from Israel, infants of mothers who smoked during pregnancy had significantly more hospital admissions for bronchitis and pneumoni . 3 There was also a direct relationship found between hospital admission rates - 1 - “a .‘ Abigail J. Moss, Mary 0. Overpeck, Gerry E. Hendershot, Howard J, Hoffman, and re. and quantity of cigarettes smoked. Similiar findings were also obtained in a study from Northern Finland where effects of matsrnal smoking on morbidity and mortality up to the age of 5 were investigated. These and other researchers have since revealed that, even after adjusting for socioeconomic status and other confounding variables, maternal smoking during pregnancy is significantly related to signs of poorer physical, intellectual, and neurological status in the school-aged child.20 In 1980, further analysis of data from the British National Child Development Study showed that: (1) mother's smoking during pregnancy was still related to the child's reading and mathematics attainment at age 16; and (2) among boys, there was an associatign with height, even after allowing for a number of related background factors. 1 Data obtained from The Collaborative Perinatal Study of he National Institute of Neurological and Communicative Disorders and Stroke 2 were used in another study published in 1984 by Naeye and Peters. Siblings whose mothers had smoked in only one of their pregnancies were compared in this study. While the mother's smoking habits during pregnancy differed, the siblings were similar in heredity and socialization thus controlling many parental factors affecting children's mental development. The researchers concluded that "hyperactivity, short attention span, and (slightly) lower scores on spelling and reading tests were more frequent for children whose mothers had smoked throughout pregnancy," although the differences were small. Not all research studies examining the issue of long-term effects of maternal smoking have produced similar results. Researcher Yerushalmy raised the question of whether differences might be due to the characteristics of smokers rather than the smoking per se.2 Researchers from Johns Hopkins University Hospital concluded that, after controlling for birth weight, children had the same average weight regardless of mother's smoking practices during pregnancy, and they differed in height only in the first year. Further, neurological status at 1 year and psychological development up to the age of 7 did not differ significantly between children born to mothers who smoked and those born to mothers who did not smoke. They concluded that "if the child survives the neonatal period, no significant differences beyond the first year are d monstrated in either physical or mental development to 7 years of age."2 These findings have been disputed because of the small sample upon which they were based.2 Canadian researchers in another study also investigated differences in childreng' neurological, behavioral, and intellectual development at 7 years of age.2 Given the many variables affecting a child's development and the different characteristics of smoking and nonsmoking parents, however, the authors were unable to find a strong relationship between maternal smoking and intellectual and behavioral development. The intent of this paper is to add to the knowledge which now exists on the effects of maternal smoking on the post-neonatal health of the child by looking at several measures of health status obtained from a population-based survey. These are the most recent data available on this subject from a large, nationally representative sample. This data set is distinguished from other studies which primarily used samples drawn from medical records or other small-area data bases, not representative of the entire at-risk population. - 2 - SOURCE OF DATA The data presented in this paper are derived from the 1981 National Health Interview Survey, which has been conducted since 1957. A national probability sample of households, representing the civilian, noninstitutionalized population of the United States, is utilized in the Survey. Face-to-face interviews are conducted by U.S. Bureau of the Census interviewers in about 41,000 households each year. In 1981, a major component of the Survey was designed to address health issues of children from before birth through 17 years of age. The Child Health Supplement selected one child at random from every household with children. About 15,300 supplements were completed yielding a 95 percent response rate. (See Vital and Health Statistics Series 1, No. 18 for a description of the sample selection, survey design, and implementation of the National Health Interview Survey.) The questions about smoking practices of mothers dUring pregnancy were asked of biological mothers for children up to 6 years of age. Therefore, this paper includes data for that age group only. Further, the results are based on those questionnaires where prenatal maternal smoking status was known. Data represent over 98 percent of all families in the Survey with children under 6 years of age. The sample for this analysis numbers 4,631 children. The data are weighted so that the estimates presented will be more representative of the noninstitutionalized children in the United States under 6 years of age. RESULTS This analysis is based on mothers' reports of measures of a child's overall health. Since data are derived from household interviews and not based on physical examination, they reflect only the mother's perception, knowledge, and recall of a child's health. The health measures used to compare groups of children according to mother's smoking practices during pregnancy were: (1) child's general health as perceived by the respondent, (2) number of bed days in the past year for health reasons, (3) number of chronic conditions and chronic respiratory conditions since birth, (4) number of hospitalizations since birth, and (5) number of disability days per year. The question used to determine mother's smoking practices during pregnancy was: "During your pregnancy with (child's name), about how many cigarettes a day did you usually smoke?" The questionnaire did not contain a followup question to determine whether the mother had quit smoking during any part of the pregnancy. It also did not address the impact of the home and outside environment on the child's health. Further, information about the current smoking practices of family members is not known. About 26 percent of mothers reported that they smoked during their pregnancy. This estimate is about the same for those with children under 3 years of age compared with mothers of 3 to 5 year olds, and is consistent with the 1980 National Natality Survey which also found the same percent smoking during pregnancy among married mothers of live-born infants.28 In this Survey, mothers' smoking practices during pregnancy were unknown for about the same proportion of persons with children under 3 and 3 to 5 years (3 percent compared with 4% percent.) - 3 _ PERCEIVED HEALTH STATUS Respondents, usually mothers, were asked whether they considered the child's overall health to be excellent, good, fair, or poor, compared with other children. About two-thirds (64 percent) of all children under 6 years of age were reported in excellent health (table 1). The likelihood of a child being classified in excellent health was reduced by about 8 percent, however, if the mother smoked durin pregnancy (p<.05), and was further reduced if she was a heavy smoker (p<.01). For purposes of this analysis, mothers smoking an average of more than 15 cigarettes a day were classified "heavy" smokers. Those who said they averaged less than this number were considered "light" smokers. While this classification scheme differs from studies which grouped smokers according to less than one-half pack, one-half to one pack, and one pack or more a day, the categories used in this analysis (and other NCHS reports containing data on smoking patterns) were purposely chosen to minimize misclassifying respondents that reported smoking "about a one-half pack", or "about a pack," instead of an actual number of cigarettes smoked per day. The differences in the percent of children in excellent health, according to the mother's smoking practices during pregnancy, only occur for children under 3 years of age. Above this age, the proportion of children in excellent health is about the same regardless of whether the mother smoked. As shown in figure 1, one out of two children under 3 years of age (51.8 percent) whose mothers smoked more than 15 cigarettes a day were reported in excellent health, compared with two out of three children (67 percent) whose mothers who did not smoke at all (p<.01). Data on perceived health and mother's smoking status were also examined within roups classified according to the child's race, mother's education and age €at the birth), parity, and birth weight (table 2). while the percentages of children in excellent health were different for these subgroups, nevertheless, children up to the age of 3 whose mothers did not smoke during pregnancy fared better than did other children. DAYS IN BED DURING THE YEAR Another health status measure assessed was the number of days children stayed in bed during the year because of illness or injury. These data were obtained by asking: "During the past 12 months, about how many days did illness or injury keep (your child) in bed all or most of the day?“ For this analysis, data were grouped into three categories -- no days spent in bed in the past 12 months, 1 to 7 days, and more than 7 days. Table 3 shows the percent of children that spent more than 1 week in bed during the year for health reasons. The data show about 8 percent of all children had to stay in bed for this length of time. Clearly, though, proportionately more children whose mothers smoked during pregnancy (11 percent) experienced illnesses that required them to stay in bed for this duration than did other children (7 percent) (p<.05). Children whose mothers were classified as heavy smokers were almost twice as likely to have this voluge)of bed days as were children of nonsmokers (13 compared with 7 percent) p<. . _ 4 _ As with perceived health status, this finding only applies to children under 3 years of age. For this younger age group, almost twice as many children whose mothers smoked spent over a week in bed as did children whose mothers did not smoke (13 percent compared with 7 percent) (p<.01). Young children of heavy smokers were at greatest risk -- with 16 percent having 8 or more days in bed because of health. Corresponding estimates of 7 and 9 percent for the 3-to-5- year age group are within sampling variation (figure 2). The proportion of children having eight or more bed days differed by race, birth weight, mother's education and age (at the birth), and parity. More young children (proportionately) of mothers who smoked experienced "excessive" bed days in many of these categories (table 4). For example, about twice as many children under 3 years of age who were not "first born" and whose mothers smoked, stayed in bed 8 days or more as did similar birth order children of nonsmoking mothers (14.5 percent and 7 percent) (p<.01). NUMBER OF CHRONIC CONDITIONS The reporting of one or more chronic conditions was another variable used as an indicator of a child's state of health. Mothers were read a list of conditions that can affect children, and were asked to report those which the child ever had. The list yielded about 100 conditions and impairments of the respiratory, circulatory digestive, musculo-skeletal, skin, sensory, and genito-urinary systems. 9 In this Survey, a chronic condition is any condition which lasted 3 months or longer or is on the Survey's list of conditions always classified as 'chronic'. Conditions on this latter list are considered chronic, regardless of when they occurred or how long they lasted. The results show that about one out of three children under the age of 6 have had at least one chronic condition (table 5). Again, children whose mothers smoked during pregnancy were more likely (proportionately) to have one condition or more reported -- 38 percent compared with 33 percent of children whose mothers did not smoke (p<.01). When the chronic condition estimates of children were compared with mothers who did not smoke and those who were heavy smokers, significant differences (at the .05 level) were found only for those under 3 years of age (figure 3). ,Although the percent of children under 3 years with 1 or more chronic conditions appears higher for the group whose mothers were heavy smokers than for light smokers, the difference is not significant (p>.10). When these data were further examined by race, mother's age (at the birth) and education, birth weight, and parity, the pattern of more children with one or more chronic conditions was observed among the groups with mothers who smoked (table 6). However, for the most part, the differences were not statistically significant. RESPIRATORY CONDITIONS Among the most frequently reported types of chronic conditions were those of the respiratory system. The respiratory conditions specifically asked about included asthma, hay fever or allergies, tonsillitis or enlargement of the tonsils or adenoids, tuberculosis and pneumonia, and “any other respiratory, _ 5 - lung or pulmonary condition". For this last category, conditions were considered chronic only where mothers reported that they had lasted for at least 3 months. Tables 7 and 8 show the percent of children ever having one or more chronic respiratory conditions by mother's smoking status. For this study, estimates also were obtained for chronic conditions of the cardiovascular and digestive systems, but the relatively small sample upon which these estimates were based precluded making a similar comparison. Children of mothers who smoked are more likely to have had a chronic respiratory condition than other children (14 compared with 10 percent) (p‘.01). The difference in the estimates of mothers who smoked heavily compared with mothers who were light smokers is also significant at the .05 level (16 and 13 percent, respectively). This pattern occurred among children of smokers for three of the four selected respiratory conditions reviewed, that is, asthma, pneumonia, and tonsillitis. However, the difference was significant at the .05 level only for asthma. There are several differences between the respiratory condition estimates for children under 3 years of age compared with 3 to 5 year olds. In the younger age group, over twice as many children whose mothers smoked an average of 16 or more cigarettes daily had respiratory conditions as did children whose mothers did not smoke at all (15 percent compared with 6 percent, p<.01) (figure 4). However, the percentages of children with respiratory conditions were not significantly different among those whose mothers smoked fewer than 16 cigarettes a day and those who did not smoke at all (9 percent and 6 percent, respectively, p>.10). In contrast, among 3 to 5 year olds, the percentages of children with one or more respiratory conditions were about the same, regardless of the mother's smoking practices during pregnancy (about 15 to 18 percent, p>.10). HOSPITALIZATIONS SINCE BIRTH Another questionnaire item used to assess children's health was the total number of hospitalizations. This estimate includes only hospitalizations during which the child had to stay overnight or longer and excludes the hospitalization associated with birth. Twenty percent of all children under 6 years of age had experienced at least one hospitalization (tables 9 and 10). When these estimates are compared by mother's smoking status, the data show higher proportions of hospitalized children whose mothers smoked (25 percent compared with 18 percent, p<.01). Significant differences were also found when a similar comparison was made for children havin two or more hospitalizations (8 percent compared with 4 percent; p<.01g. There were over twice the percentage under 3 years of age with hospitalizations in the group whose mothers smoked heavily as there were in the group of children whose mothers reported not smoking at all--about 26 percent compared with 12 percent (p<.01)(figure 5). Children whose mothers smoked more than 15 cigarettes daily were more likely to have been hospitalized than were children of light smokers, 26 compared with 16 percent p<.05 . - 5 - Among 3 to 5 year olds, about one-third of children with mothers who smoked had been hospitalized compared with one-fourth of children whose mothers were ‘ nonsmokers (p .05). RESTRICTED ACTIVITY AND BED DISABILITY DAYS The final health status indicators examined in this study were disability days. These are days when people have to cut down or restrict their usual activities, stay in bed or, depending on their age, miss work or school because of illness or injury. The Survey's average annual number of disability days are obtained through questions about the 2-weeks before the interview; days that are reported for the 2 weeks are then weighted to represent an annual estimate. Survey results show children under 6 years of age cut down on the things they usually do because of health an average of 12 days a year, and they stay in bed about 6 days (table 11). Estimates of the average number of bed days were significantly higher for children with mothers who smoked (9 compared with 5 days; p .01). However, the difference in the restricted activity estimates of 11 days and 14 days for children of nonsmokers and smokers was not statistically significant (p .05). Similarly, sampling variation may account for the somewhat lower restricted activity and bed day estimates among children whose mothers smoked more than 15 cigarettes daily (p .10). Differences in the disability day estimates by age group were found only for children under 3 years of age (figure 6). Children with mothers who smoked during pregnancy had to restrict their activities about 5 more days a year and stay in bed about 7 more days than other children, but again, only the diffeggnces for the estimates for bed days were statistically significant at the . evel. Because the Survey's average annual number of restricted activity days and bed days are obtained through questions that use a 2-week recall period, variances are large. Consequently, detecting significant differences between estimates that are based on relatively small population groups, such as is the case with these data, only occurs with very large differences. This may explain the lack of significant differences with some of the disability day estimates (table 12). SUMMARY OF FINDINGS Estimates for five NHIS health status indicators were compared for children according to mother's smoking status during pregnancy. These measures included: (1) respondent's personal assessment of the child's overall state of health; (2) total days children stayed in bed during the year for health conditions; (3) number of chronic conditions and respiratory conditions children had since birth; (4) total hospitalizations; and (5) average number restricted activity days and bed days per child per year. Based on the five health status measures used for this analysis, the Survey's data indicate an association between a mother's smoking habits during pregnancy and a young child's subsequent health after birth. Specifically, the study findings showed that: _ 7 _ (1) Children under 3 years of age of mothers who smoked during pregnancy were perceived to be in poorer health, and had higher incidences of bed days, chronic conditions, respiratory conditions, and hospitalizations than children whose mothers did not smoke. 2) When these data were tabulated by race, mother's education and age (at the birth), child's birth weight, and child's birth order (parity), the same patterns generally appeared. Under 3 years of age, children of mothers who smoked during pregnancy were more likely than other children to have (a) experienced greater bed disability during the past year, (b) had one or more chronic respiratory conditions, (c) had one or more hospitalizations, and (d) were less likely to be in excellent health. However, differences at the .05 level of significance most often occurred in the categories which contained the largest number of sample children. The relatively small size of some of the groups did limit certain comparisons where significant differences were detected. (3) There is a direct relationship between the amount of cigarettes that are smoked and the impact which smoking has on some of the resulting health conditions of the child. Young children whose mothers were classified as heavy smokers were more likely to be hospitalized or have one or more chronic respiratory conditions than were children whose mothers smoked fewer cigarettes. They were also less likely to be in excellent health. (4) The effects which maternal smoking has on children's health appear to diminish as they age. Except for hospitalizations, the estimates for all health indicators were similar for 3 to 5 year-old children of smoking and nonsmoking mothers. Similarly, no significant differences were found for this age group in the health status estimates between children whose mothers were light or heavy smokers. In conclusion, most of these National Health Interview Survey findings are consistent with results from other studies and clearly provide further evidence that the practice of smoking in pregnancy adversely affects the health of young children later. REFERENCES 1. 10. 11. 12. 13. W. J. Simpson: A Preliminary report on cigarette smoking and the incidence of prematurity. Am. J. Obstet. Gynecol. 73:808, 1957. Health Services and Mental Health Administration: The Health Conse uences of Smokin . A Report of the Surgeon General: 1971. DREW Bub. No. (HSM57I-9513. Public’Health Service. Washington. U.S. Government Printing Office, 1971. Health Services and Mental Health Administration: The Health Consequences of Smoking. DHEH Pub. No. (HSM) 73-8764. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1973. D. Rush and E.H. Kass: Maternal smoking: A reassessment of the association with perinatal mortality. Am. J. Epidemiol. (96)3: 183-196, 1972. S. Kullander and B. 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Naeye: Causes of perinatal mortality in the U.S. Collaborative Perinatal Project. JAMA. 238(3):228-229. July 18, 977. Ontario Department of Health: Second Report of the Perinatal Mortality Study in Ten University Teaching Hospitals. Volume 1. Toronto, Canada, Ontario Department of Health, Ontario Perinatal Mortality Study Committee 1967. M. B. Meyer, and J. A. Tonascia: Maternal smoking, pregnancy complications, and perinatal mortality. Am. J. Obstet. Gynecol. 128(5):494-502, July 1, 1977. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Office of the Assistant Secretary for Health: Smokin and Health. A Report of the Surgeon General. DHEH Pub. No. {PHSS 79-55666. Public Health Service. Washington. U. 5. Government Printing Office, 1979. N. R. Butler and H. Goldstein: Smoking in Pregnancy and subsequent child development. Br. Med. J. 4:573-575, 1973. J. Wingerd and E. J. Schoen: Factors influencing length at birth and height at five years. Pediatrics 53:737-741, 1974. H. G. 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Table 1: Percent of children under 6 years of age in excellent health by age, mother's smoking status, and amount smoked: United States, 1981 All Smoking status ' children and amount smoked under 6 Under 3 to 5 years 3 years years Percent in excellent health All statuses 63.7 (0.9) 64.8 (1.2) 62.6 (1.3) Mother did not smoke 65.0 (1.0) 67.0 (1.4) 62.7 (1.5) Mother smoked 60.1 (1.8) 58.3 (2.5) 62.1 (2.6) 15 cigarettes or less 62.5 (2.3) 62.6 (3.2) 62.4 (3.4) 16 cigarettes or more 56.7 (2.9) 51.8 (4.1) 61.8 (4.0) NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Table 2: Percent of children under 6 years of age in excellent health by age, mother's smoking status, and selected characteristics: United States, 1981 All Selected characteristic children under 6 Under 3 to 5 years 3 years years Race Percent in excellent health White smoker 61.3 59.4 63.2 nonsmoker 66.3 68.4 63.9 p= <.05 p= <.01 p= >.10 Black smoker 51.4 50.8 52.2 nonsmoker 58.3 60.9 55.5 p= >.10 p= >.10 p= >.10 Mother's education Under years smo er 52.7 51.4 54.3 nonsmoker 55.3 59.0 51.4 p= >.10 p= >.10 p= >.10 12+ years smoker 64.1 62.2 66.0 nonsmoker 67.5 69.2 65.6 p= >.10 p= <.05 pa >.10 Birth weight Low smoker 53.5 53.9 52.8 nonsmoker 58.2 66.5 51,9 p= >.10 p= >.10 p= >.10 Normal/High smoker 61.0 59.2 62.9 nonsmoker 65.6 67.4 63.5 p= <.05 p= <.01 p= >.10 Parity One smoker 65.2 65.7 64.0 nonsmoker 68.8 70.6 64.2 p= >.10 p= >.10 p= >.10 Two or more smoker 58.5 54.1 62.1 nonsmoker 63.5 64.7 62.5 p= <.05 p= <.01 p= >.10 Mother's age (at birth) Under 20, smoker 54.0 47.8 61.7 nonsmoker 63.0 67.8 57.8 p= >.05 p= <.01 p= >.10 20+ years smoker 61.5 60.8 62.2 nonsmoker 65.3 66.9 63.5 p= >.05 p= >.05 p= >.10 Source: NCHS, National Health Interview Survey. Tabie 3: Percent of children under 6 years of age with 8 or more bed days in past year by age, mother's smoking status and amount smoked: United States, 1981 A11 Smoking status chiidren and amount smoked under 6 Under 3 to 5 years 3 years years Percent with 8+ bed days- All statuses 8 4 (0.5) 8. 9 (0. 7) 7.8 (0.7 Mother did not smoke 7 4 (0.6) 7. 4 (0. 8) 7.4 (0.8 Mother smoked 11.2 (1.2) 13. 3 (1.7) 8.9 (1.5 15 cigarettes or less 10.2 (1.5) 11.4 (2.1) 8.9 (2.0 16 cigarettes or more 12 6 (1.9) 16. 2 (3.0) 9.4 (2.3 vvvvv NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Table 4: United States, 1981 Percent of children under 6 years of age with 8 or more bed days in past year by age, mother's smoking status, and selected characteristics: All Selected characteristic children under 6 Under 3 to 5 years 3 years years Percent in excellent health White smoker 11.2 13.7 8.7 nonsmoker 7.9 7.9 7.8 p= <.05 p= <.01 p=i> .10 Black smoker 12.0 12.6 11.1* nonsmoker 5.7 5.3 6.2* p= >.05 p= >.10 p= >.10 Mother's education Under 12 years smoker 9.9 12.0 7.2* ‘ nonsmoker 5.7 4.7* 6.7 P= >~05 p= <.05 p= >.10 12+ years smoker 11.8 13.9 9.7 nonsmoker 7.8 8.0 7.7 p= <.05 p <.05 p >.10 Birth wei ht Low smoker 21.0 24.4 16.0* nonsmoker 11.6 15.9* 8.3* = >.05 p= >.10 p= > 10 Normal/High smoker 9.8 11.2 8.3 nonsmoker 7.1 7.0 7.2 p= <.05 p= <.05 p= >.10 Parity One smoker 10.6 11.1 9.2* nonsmoker 8.4 7.8 10.0 p= >.10 p= >.10 p= >.10 ‘Two or more smoker 11.2 14.5 8.4 nonsmoker 7.1 7.2 6.9 p= <.01 p= <.01 p= >.10 flgther's age (at birth) Under 20 smoker 9.6 11.9* 6.6* nonsmoker 5.3 5.5* 5.0* p: >.10 p= >.10 p= >.10 20+ years smoker 11.6 13.7 9.4 nonsmoker 7.8 7.7 7.8 p= <.01 p= <.01 p= >.10 *Figure does not meet standards of reliability or precision (more than 30-percent relative standard error). Source: NCHS, National Health Interview Survey. Table 5: Percent of children under 6 years of age with one or more chronic conditions by age, mother's smoking status, and amount smoked: United States, 1981 Smoking status and amount smoked All children under 6 years Under 3 years 3 to 5 years All statuses Mother did not smoke Mother smoked 15 cigarettes or less 16 cigarettes or more Percent with 1+ chronic conditions 34. 2 (0.9) 32. 8 (1.0) 81 (1.8) 74 (2. 3) 92 (2.8) 40.7 (1.3) 39.1 (1.6) 44.9 (2.7) 46.3 (3.5) 43.0 (4.1) NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Tabie 6: Percent of children under 6 years of age with one or more chronic conditions by age, mother's smoking status, and amount smoked: United States, 1981 A11 Smoking status children and amount smoked under 6 Under 3 to 5 years 3 years years Race Percent with 1+ conditions White smoker 38.5 32.0 45.3 nonsmoker 34.6 29.1 40.9 p= >.05 p= >.10 p= >.10 Black smoker 37.5 31.1 46.6 nonsmoker 28.1 20.7 36.1 p: >.05 p= >.10 p= >.10 Mother's education Under 12 years smoker 42.5 36.1 50.2 nonsmoker 27.0 23.5 30.7 p= <.001 p= <.05 p= <.001 12+ years smoker 35.6 29.1 42.3 nonsmoker 34.2 28.1 41.2 p= >.10 p= >.10 p= >.10 Birth weight Low smoker 43.9 42.7 45.7 nonsmoker 35.3 26.3 42.2 p= >.10 p= >.05 p= >.10 Norma], high smoker 37.2 30.0 44.6 nonsmoker 32.8 27.4 39.2 p= <.05 p= >.10 p= >.10 Parity One smoker 31.9 26.5 44.8 nonsmoker 28.9 24.2 40.6 p= >.10 p= >.10 p= >.10 Two or more smoker 40.4 34.9 44.9 nonsmoker 34.4 29.0 39.0 p= <.05 p= >.10 p= >.05 Mother's age (at birth) Under 20 years smoker 35.4 28.4 44.3 nonsmoker 29.5 26.4 32.8 p= >.10 p= >.10 p= >.05 20+ years smoker 38.7 32.7 45.0 nonsmoker 33.3 27.3 40.2 E <.05 p= >.05 p= >-10 Source: NCHS, Nationai Health Interview Survey. Table 7: Percent of children under 6 years of age ever having one or more chronic respiratory conditions by age, selected respiratory condition, mother's smoking status, and amount smoked: United States, 1981 All Smoking status children and amount smoked under 6 Under 3 to 5 years 3 years years Percent with 1+ Respiratory conditions All statuses 11. 4 (0. 6) 7.4 (0.7) 15.8 (1.0) Mother did not smoke 10. 3 (0. 7) 6.1 (0.7) 15.1 (1.1) Mother smoked 14. 4 (1. 3) 11.2 (1.6) 17.8 (2.0) 15 cigarettes or less 13.0 (1. 6) 8.9 (1.9) 17.5 (2.7) 16 cigarettes or more 16. 4 (2.1) 14.7 (2.9) 18.2 (3.2) Percent with Asthma A11 statuses 4.3 (0.4) 2.7 (0.4) 6.1 (0.7) Mother did not smoke 3.8 (0.4) 2.3 (0.4) 5.5 (0.7) Mother smoked 5.8 (0.9) 3.9 (1.0) 7.7 (1.5) 15 cigarettes or less 4.4 (1.0) 2.7 (1.1)* 6.3 (1.7) 16 cigarettes or more 7.7 (1.5) 5.8 (1.9)* 9.7 (2.4) Percent with Pneumonia All statuses 7.8 (0.5) 6.1 (0.6) 9.8 (0.8) Mother did not smoke 7.4 (0.6) 5.8 (0.7) 9.1 (1.0) Mother smoked 9.2 (1.1) 6.8 (1.3) 11.7 (1.8) 15 cigarettes or less 7.4 (1.3) 5.3 (1.5) 9.8 (2.2) 16 cigarettes or more 11.7 (2.0) 9.1 (2.4) 14.4 (3.1) - Percent with Tonsillitis All statuses 6.1 (0.5) 2.2 (0.4) 10.4 (0.9) Mother did not smoke 5.5 (0.5) 1.7 (0.4) 9.9 (1.0) Mother smoked 7.7 (1.0) 3.7 (1.0) 11.9 (1.8) 15 cigarettes or less 6.6 (1.2) 1.5 (0.8)* 12.3 (2.4) 16 cigarettes or more 9.2 (1.8) 7.1 (2.2)*- 11.5 (2.8) Percent with Respiratory Allergies All statuses 2.6 (0.3) 1.9 (0.4) 3.5 (0.5) Mother did not smoke 2.6 (0.4) 1.6 (0.4) 3. 8 0.6) Mother smoked 2.7 (0.6) 2.7 0.8)* 2. 6 (0. .9)* 15 cigarettes or less 3.2 (0.9) 3.1 1.2)* 3. 3 (1.3 * 16 cigarettes or more* 1.9 (0.8) 2.1 (1.2)* 1. 7 (1.1)* *Figure does not meet standards of reliability or precision (more than 30 percent relative standard error). NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Table 8: Percent of children under 6 years of age ever having one or more chronic respiratory conditions by age, mother's smoking status, and selected characteristics: United States, 1981 All Smoking status children . and amount smoked under 6 Under .3 to 5 years 3 years years Race Percent with 1+ Respiratory conditions White smoker 13.9 10.8 17.2 nonsmoker 10.6 6.4 15.5 p= <.05 p= <.05 p= >.10 Black smoker 17.1 12.9* 23.3* nonsmoker 10.0 5.6 14.8 p= >.05 p= >.10 p= >.10 Mother's education Under 12 years smoker 16.6 13.9 19.9 nonsmoker 10.2 9.0 11.5 p= <.05 p= >.10 p= >.05 12+ years smoker 13.1 9.6 16.7 nonsmoker 10.4 5.4 16.1 p= >.10 p= <.05 p= >.10 Birth weight Low smoker 16.5 15.1* 18.5* nonsmoker 12.7 10.2* 14 7* p= > 10 p= >.10 p= >.10 Normal, high smoker 14.3 10.7 18.0 nonsmoker 10.2 5.8 15.4 p= <.01 p= <.01 p= >.10 Parity One smoker 9.4 4.3* 21.5 nonsmoker 7.8 4.3 16.5 p= >.10 p= 1.00 p=>.10 Two or more smoker 16.3 15.3 17.2 nonsmoker 11.3 8.5 14.9 p=<.01 p=<.01 p= >.10 Mother's age (at birth) Under 20 years smoker 13.4 7.2 21.3 nonsmoker 10.0 7.9 12.3 p‘ >.10 p= >.10 p= >.10 20+ years smoker 14.6 12.2 17.1 nonsmoker 10.4 5.8 15.6 p: <.01 p= <.01 D: >.10 *Figure does not meet standards of reliability or precision (more than 30-percent relative standard error). Source: NCHS, National Health Interview Survey. Table 9: Percent of children under 6 years of age ever having a hospitalization by age, mother's smoking status, and amount smoked: United States, 1981 All Smoking status children and amount smoked under 6 Under 3 to 5 years 3 years years Percent with 1 or more hospitalizations All statuses 19.8 (0.8) 13.7 (0.9) 26 7 (1.2) Mother did not smoke 17.9 (0.8) 11.6 (1.0) 25.0 (1.4) Mother smoked 25.4 (1.6) 19.9 (2.1) 31 3 (2.5) 15 cigarettes or less 23.3 (2.0) 16.2 (2.4) 31 3 (3.3) 5 (2.6) 25.6 (3.6) 31.4 (3.8) 16 cigarettes or more 28. All statuses 5.2 (0.4) 3. 7 (0. 5) 6.9 (0.7) Mother did not smoke 4.4 (0.4) 2. 7 (0.5) 6.2 (0.8) Mother smoked 7.5 (1.0) 6. 4 (1.3) 8.7 (1.5) 15 cigarettes or less 6.0 (1.1) 4. 6 (1. 4) 7.5 (1.9) 16 cigarettes or more 9.8 (1.7) 9.1 (2. 3) 10.5 (2.5) NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Table 10: Percent of children under 6 years of age ever having a hospitalization by age, mother's smoking status, and selected characteristics: United States, 1981 All children Selected Characteristic under 6 Under 3 to 5 years 3 years years Race Percent with 1+ hospitalizations White smoker 26.2 20.3 32.2 nonsmoker 17.6 12.0 24.2 p: <.01 p: <.01 p= <.01 Black smoker 22.2 18.4 27.8 nonsmoker 19.7 9.0 31.0 p= >.10 p= >.05 p= >.10 Mother's education Under 12 years smoker 25.9 19.2 34.0 nonsmoker 18.5 12.1 25.5 p= <.05 p= >.05 p= >.10 12+ years smoker 25.1 19.3 29.9 nonsmoker 17.8 11.6 24.8 p: <.01 p= <.01 p= >.10 Birth weight Low smoker 32.0 24.4* 43.7 nonsmoker 27.9 16.3 36.6 p= >.05 p= >.10 p: >.10 Normal, high smoker 24.2 18.9 29.8 nonsmoker 17.2 11.2 24.2 p= <.01 p= <.01 p= >.05 Parity One smoker 20.2 16.6 28.6 nonsmoker 14.7 10.3 25.6 p= >.05 p= >.05 p= >.10 Two or more smoker 27.3 21.9 31.7 nonsmoker 19.2 12.5 25.0 p= <.01 p=-<.01 p= <.05 Mother's age (at birth) Under 20 smoker 27.6 18.4 39.4 nonsmoker 21.3 13.9 29.3 p= >.10 p= >.10 p= >.10 20+ years smoker 24.9 20.3 29.7 nonsmoker 17.4 11.3 24.3 p= <.01 p= <.01 p= >.05 *Figure does not meet standards of reliabiJity or precision (more than 30-percent relative standard error). Source: NCHS, National Health Interview Survey Table 11: Restricted activity and bed disability days per child per year by age, mother' 5 smoking status, and amount smoked: United States, 1981 Restricted activity Bed disability All Under 3-5 All Under 3 to 5 Smoking status and children 3 years children 3 years amount smoked under 6 Years under 6 Years Days per child per year A11 statuses 12.2 (0. 7) 14. 7 (1.1) 9. 4 (0. .9; 6.1 (0. .5; 7.5 (0.8) 4.6 (0.6; Mother did not smoke 11.4 (0. 8) 13. 4 (1.2) 9. 2 (1.1 5.0 (0.5 5.7 (0.8) 4.2 (0.7 Mother smoked 14.4 $1. .6) 18. 6 22. 5) 9. 8 E1. .8) 9. 3 E1. .2) 12.7 (2.0) 5.6 (1 4) 15 cigarettes or less 15.5 2 1) 19.1 3 3 11. 4 2 6) 9. 9 1 7) 12.9 2.6; 6.5 (1.9 16 cigarettes or more 12.8 (2.3) 17. 9 (3. 9) 7. 6 (2. 5) 8. 4 (1. 8) 12.4 (3.2 4.3 (1.8) NOTE: Standard error in parentheses. Source: NCHS, National Health Interview Survey. Table 12: Restricted activity and bed disability days per child per year by age, mother's smoking status, and selected characteristics: United States, 1981 Restricted Activity Bed Disability All Under 3-5 All Under 3 to 5 children 3 Years years children 3 years years Selected characteristic under 6 under 6 Race Days per child per year White smoker 13.6 18.0 9.0 8.4 11.9 4.7 nonsmoker 12.1 13.9 10.0 5.1 5.8 4.3 p= >.10 p= >.10 p= >.10 p= <.05 p= <.01 p= > 10 Black smoker 19.5 22.6 15.0 14.7 17.3 11.0 nonsmoker 8.2 10.6 5.7 4.4 5.0 3.8. p= <.05 p= >.10 p= >.10 p= <.05 p= <.05 p= >.10 Mother's education Under years smo er 12.2 17.3 6.0 7.3 10.7 3.1 nonsmoker 14.8 15.7 13.8 6.3 5.2 7.5 = >.10‘ p= >.05 p= <.05 p= >.10 p= >.10 p= >.10 12+ years smoker 15.6 19.6 11.7 10.4 14.0 6.8 nonsmoker 10.7 12.9 8.1 4.7 5.8 3.4 p= <.05 p= >.05 p= >.10 p= <.01 p= <.01 p= >.05 Birth weight Low smoker 19.5 24.7 11.6 14.4 20.1 6.0 nonsmoker 8.9 7.3 10.1 3.7 3.7 3.7 p= >.05 p- >.05 p= >.10 p= <.05 p= <.05 p= >.10 Normal, high smoker 13.8 17.9 9.6 8.7 11.7 5.5 nonsmoker 11.7 13.7 9.2 5.1 5.8 4.3 p= >.10 p= >.10 p= >.10 p= <.05 p= <.01 p= >.10 Parity One smoker 16.8 17.5 15.2 9.6 10.6 7.3 nonsmoker 12.5 13.3 10.8 5.8 6.1 5.3 = >.10 = >.10 p= >.10 p= >.10 p= >.10 p= >.10 Two or more smoker 13.6 19.4 8.7 9.2 14.0 5.2 nonsmoker 11.1 13.7 8.9 4.7 5.6 4.0 = >.10 p= >.10 p= >.10 p= <.01 p= <.01 p= >.10 Mother's age (at birth) Under 20 years smoker 11.2 14.2 7.5 6.0 7.7 3.8 nonsmoker 11.3 15.1 7.2 3.8 4.4 3.2 p= >.10 = >.10 p= >.10 p= >.10 p= >.10 p= >.10 20+ years smoker 15.1 19.7 10.3 10.1 13.9 6.0 nonsmoker 11.5 13.1 9.5 5.2 5.9 4.3 p= >.05 p= <.05 p= >.10 p= <.01 p= <.01 p= >.10 Source: NCHS, National Health Interview Survey. Figure 1 in excellent health Percent Heavy smoker Nonsmoker Light smoker N SOURCE: NCHS, National Health Interview Survey 20 15 10 O Figure 2 Percent with 8 + bed days in past year \\ Nonsmoker §§§§§§§§§ Light smoker - Heavy smoker 16 Under 3 years '3 to 5 years SOURCE: NCHS, National Health Interview Survey Figure 3 Percent with 1 + chronic conditions Nonsmoker 50 40 30 20 1O 0 Under 3 years ' 3 to 5 years SOURCE: NCHS, National Health Interview Survey Figure 4 tory conditions "'8 lo resp' ith 1 '+ chron Percent w \\\\ Nonsmoker 18 1 smoker 4 ME?” Light - Heavy smoker i E 207 3 to 5 years Under3years NCHS, Nat Survey new I Health lnterv' Iona SOURCE Figure 5 Percent with 1 + hospital episodes ‘\\ \ Nonsmoker gfiiigigfi Light smoker - Heavy smoker 31 31 Under 3 years 3 to 5 years SOURCE: NCHS, National Health Interview Survey Figure 6 Number of restricted activity and bed days per year for children under 3 years 20 __ 19 Nonsmoker Light smoker - Heavy smoker 13 15— 10 Restricted activity days Bed days SOURCE: NCHS, National Health Interview Survey U. 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