Despite the well-known dangers of smoking cigarettes during pregnancy, the percentage of expectant women who smoked in Spokane County is almost twice the rate of pregnant smokers in Washington state as a whole, say Spokane Regional Health District (SRHD) officials. 

In 2011, the most recent year for which data is available, 15.9 percent of births—or one in six—in Spokane County were to mothers who smoked at some point during their pregnancy, says Adrian Dominguez, SRHD epidemiologist, but that number is down from a high of 18.2 percent in 2008. Statewide, the rate of maternal smoking in 2011 was 9 percent, or not quite one in 10.

Smoking during pregnancy can cause premature birth, certain birth defects like cleft palate, low newborn birth weights, and probability of miscarriage, among other problems, according to the national Centers for Disease Control and Prevention. 

Elaine Conley, SRHD director of community and family services, says the impact of smoking while pregnant is profound.

“Cigarette smoke is in the mother’s blood stream and crosses the placenta barrier and thus affects the fetus. Cigarette smoke contains more than 4,000 chemicals, but especially harmful is nicotine and carbon monoxide,” Conley says. 

She says the two chemicals account for almost every smoking-related complication in pregnancy.

“Nicotine and carbon monoxide decrease the baby’s supply of oxygen by narrowing blood vessels throughout the mother’s body, including the ones in the umbilical cord,” Conley says. 

On average, she says, smoking during pregnancy doubles the chances a baby will be born early or weigh less than 5 1/2 pounds at birth, which is considered a low birth weight. On average, a pack-a-day pregnant smoker will shave about one-half pound from a baby’s birth weight. Undersized babies may have underdeveloped bodies, including their lungs, which might not be ready to work on their own at birth. 

In Spokane County in 2011, 9 percent of births were born preterm, meaning the babies born alive before 37 weeks of pregnancy are completed, and 6 percent of newborns had a low birth weight, about the same as the rates for Washington State as a whole.

 Children of smoking mothers are more vulnerable to asthma and have increased risk of Sudden Infant Death Syndrome, Conley says. Smoking also doubles the risk of stillbirth, she adds. 

“The CDC published a study in 2011 that found babies of mothers who smoked in the first trimester of pregnancy were at 20 to 70 percent higher risk of having certain types of congenital heart defects than babies whose moms did not smoke during pregnancy,” she says.

The problem is one of the biggest challenges the health district faces, says Conley, adding that there are several factors at play including lower rates of both education and income.

“Younger women with less education and lower income are more likely to smoke during pregnancy than women over 25 who have some college education,” she says. 

But the problem of maternal smoking is much more complex than simply education and income. 

Conley says there are a myriad of causes behind the numbers, including age, stress levels, safety issues, crime rates, domestic violence, and to a considerable degree, neighborhood. The health district has identified 10 neighborhoods in the county that had significantly higher maternal smoking rates between 2005 and 2009.

 The West Central neighborhood had the highest maternal smoking rate out of 30 neighborhoods, at 41 percent. Its rate was more than 10 times higher than the South Hill’s Manito neighborhood, which had the lowest maternal smoking rate, at 4 percent. That report was part of data released by the health district which shows where local health is improving and where it’s lagging behind. 

The report shows that in Spokane County overall, about 20 percent of adults reported tobacco use in 2011, which is down from 2006, when it was more than 24 percent. 

The higher smoking rates are indicative of the stressors people are under in the county, Conley says, adding that many of the women in the those neighborhoods are teens, single parents, younger, living in areas with the highest crime rates, with low incomes.

Conley says stressors show up in behaviors reflected not only in rates of smoking but also drinking and violence.   

Domestic violence rates involving pregnant women, defined as a pregnancy where the mother reported being physically hurt in any way by her husband or partner in the 12 months before getting pregnant, show that mothers experienced domestic violence in 2.2 percent of births in Spokane County during 2006-2010, the most recent data available. The statewide rate was 2.9 percent.  

SHRD numbers also show that more than 27 percent of women on Medicaid in Spokane County from 2007-2011 smoked while pregnant.

Added to the stress factors, cultural norms contribute to why it is so difficult for some women to quit smoking while pregnant, she says. 

“It can be extremely difficult to stop smoking if you started very early,” Conley says. 

Plus, she says, growing up in a family of smokers normalizes the behavior.

 “Smoking may be the only viable method they see to manage stress, and no amount of education will stop them,” she says. “Personal education will only work with a minority of folks.”

“If they see that nothing bad happened to those women they’ve seen smoking, they think there are no risk factors,” Conley says.

The solutions to the problem are to be found “upstream,” she says. 

“Community-wide initiatives impacting the root causes need to be initiated and/or expanded, which needs to include policy and system-level change while at the same time focusing on social, organizational, and individual behavior changes,” Conley asserts. 

And most importantly, she says, county residents must have a shared vision for the future of children and families in the community because issues such as maternal smoking ultimately affect the entire community—from the most marginalized to the most affluent. 

The average hospital cost for newborns born healthy is about $10,000, Conley says. If a baby is born prematurely, under 37 weeks of gestation, those hospital costs can rise to more than $55,000, and if a baby is unhealthy at birth, the average hospital costs can be more than $72,000, she says. 

She contends those costs are borne by the entire community. 

Dominguez agrees that the problem affects everyone in the county. 

“It’s a significant economic and social issue, and (our) leaders need to grasp this and figure out how to deal with the larger issues. It will not happen overnight,” he says. “Funders and policymakers must understand that it may take five years or more before we see any results, and we have to continue to fund this issue to address Spokane County-specific solutions.” 

In addressing the problem, one of the programs the county uses is the Nurse Family Partnership.

Conley says the program screens pregnant women for evidence of depression or other mental health issues, and nurses monitor the growth and development of children, identifying whether an intervention is needed and following up to assure treatment plans are followed. Families are matched with a nurse who goes to their home and works around trauma issues and Child Protective Services involvement or attachment issues, as well as identifying triggers and developing safe strategies for caring for their children.    

She says the nursing program is for low-income, early-pregnancy women.

“Twenty-two percent of them are smoking when they enter the program,” she says. “That number drops to 10 percent by 36 weeks of pregnancy, but immediately after the birth, they are back to smoking.”