Cited by 27Smoking Behavior and CessationPrenatal Substance Exposure EffectsNeuroscience of respiration and sleep

The DOI matches its Crossref record; 36 of the 36 references it cites were found in a registry or an index; none of the 53 sources its claims cite is checked for support yet.

Association of maternal snuff use and smoking with Sudden Infant Death Syndrome: a national register study

Open access

Abstract

Background: The aim was to study whether non-combustible nicotine (Swedish snuff) use in pregnancy is associated with elevated risk of post neonatal mortality, Sudden Infant Death Syndrome (SIDS), and Sudden Unexpected Infant Death (SUID) and to study how cessation before the antenatal booking influenced these risks. Methods: This was a population-based register study of all infants with information on tobacco exposure in early pregnancy born in Sweden 1999–2019, n = 2,061,514. Self-reported tobacco use in early pregnancy was categorized as nonuse, snuff use, and moderate and heavy smoking. Multiple logistic regression models were used to estimate crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results: Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. The risks of snuff use and moderate smoking were of similar magnitude. Heavy smoking was associated with the highest risks. Cessation of smoking and snuff use before the antenatal booking was associated with lower risks of SIDS and SUID compared to that of continuous usage. Conclusions: Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. Nicotine is the common substance in cigarette smoke and snuff. These findings support the hypothesis that nicotine contributes to an elevated risk of SIDS. Impact: Maternal snuff use and smoking in early pregnancy were associated with increased risks of post neonatal mortality, SIDS, and SUID. Cessation of smoking and snuff use before the first antenatal visit was associated with reduced risks of SIDS and SUID. The common substance in cigarette smoke and snuff is nicotine. Our findings suggest that nicotine contributes to an elevated risk of SIDS and SUID. The implication of our findings is that all forms of nicotine should be avoided in pregnancy.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

In a Swedish national register study of 2,061,514 births, maternal snuff use in early pregnancy was associated with increased risks of postneonatal mortality, SIDS, and SUID, with risks similar to moderate smoking and lower than heavy smoking. Cessation of snuff or smoking before the antenatal booking was associated with lower risks of SIDS and SUID, supporting the hypothesis that nicotine contributes to elevated SIDS risk.

Key findings

  • Maternal snuff use vs nonuse was associated with postneonatal mortality aOR 1.71 (95% CI 1.16–2.52), SIDS aOR 3.70 (95% CI 2.06–6.65), and SUID aOR 2.90 (95% CI 1.75–4.80) in adjusted model 1.
  • Heavy smoking carried the highest risks: postneonatal mortality aOR 2.72 (95% CI 2.17–3.41), SIDS aOR 7.03 (95% CI 5.04–9.79), and SUID aOR 5.44 (95% CI 4.10–7.22); moderate smoking risks were similar in magnitude to snuff use for SIDS (aOR 4.31, 95% CI 3.26–5.70) and SUID (aOR 3.20, 95% CI 2.53–4.05).
  • Among mothers who stopped before the antenatal booking, SIDS risk remained elevated for former snuff users (aOR 2.13, 95% CI 1.04–4.34) but not significantly for former smokers (aOR 1.35, 95% CI 0.89–2.05); SUID risks were aOR 1.37 (95% CI 0.73–2.58) for stopped snuff and aOR 1.29 (95% CI 0.95–1.74) for stopped smoking.
  • Of 611 SUID cases, 60% were SIDS (n = 381), 11 were accidental strangulation in bed, and 219 were unspecified cause; postneonatal mortality rate was 0.8 per 1000 live-born infants.

Methods

  • Population-based register study of all live-born infants in Sweden born 1999–2019 with information on tobacco exposure in early pregnancy; main analyses included n = 2,061,514 births, and cessation analyses included n = 1,996,980 live births.
  • Self-reported tobacco use at the antenatal booking was categorized as nonuse, snuff use, moderate smoking (1–9 cigarettes/day), or heavy smoking (≥10 cigarettes/day); cessation categories combined use 3 months before pregnancy with use in early pregnancy.
  • Multiple logistic regression estimated crude and adjusted odds ratios with 95% CIs; adjusted model 1 included maternal age, parity, cohabitant with father-to-be, maternal education, and mother’s country of birth; model 2 additionally adjusted for gestational age and birth weight for gestational age. Outcomes were postneonatal mortality (28–364 days), SIDS (ICD-10 R95), and SUID (SIDS, unspecified cause R99, or strangulation/suffocation in bed W75).

Limitations

  • Stated: diagnoses came from the Cause of Death Register without medical-record validation, and crime scene investigations are not routinely performed in Sweden, so some accidental strangulation/suffocation could have been misclassified as SIDS.
  • Stated: self-reported tobacco use was not validated by cotinine levels, number of snuff pouches per day was unavailable, and exact quit timing between 3 months before pregnancy and the antenatal booking was unknown.
  • Stated: causal conclusions are limited by lack of information on alcohol/substance use and prenatal/postnatal environmental tobacco smoke, residual confounding, and inability to conduct sibling/family designs due to limited power; the paper also notes possible collider stratification bias from stratifying on gestational age and birth weight.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1038/s41390-022-02463-4

Cites

36 of 36 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Fig. 1 Schematic presentation of the study population. Flow chart of the source population, exclusions, the final study population as well as categorization of exposures.
Fig. 1 Schematic presentation of the study population. Flow chart of the source population, exclusions, the final study population as well as categorization of exposures.CC BY · PubMed Central
Fig. 2 Distribution of cases of SUID, SIDS, accidental strangulation/ suffocation and unspecified death. Presentation of number of deaths/year in 1999–2019 of Sudden Unexpected Infant Death (SUID) as well as presentation of deaths of Sudden Infant Death Syndrome (SIDS), accidental strangulation/suffocation and unspecified death of the newborn.
Fig. 2 Distribution of cases of SUID, SIDS, accidental strangulation/ suffocation and unspecified death. Presentation of number of deaths/year in 1999–2019 of Sudden Unexpected Infant Death (SUID) as well as presentation of deaths of Sudden Infant Death Syndrome (SIDS), accidental strangulation/suffocation and unspecified death of the newborn.CC BY · PubMed Central

Verification

Claims the paper makes

39 Own result · 16 No full text of the sources · 16 Not checked yet · 11 Own method · 11 Own interpretation · 2 Sources not found · 2 Check pending · 1 No basis given

Verify all 19 references — free account

Show all 55 claims

  • It may state two separate claims as one. 25
  • The quote only partly states this claim. 2
  • Probably not a substantial claim. 26
43 of 43
  • The paper relies on this without support.

    Nicotine is the common substance in cigarette smoke and snuff.

    “Nicotine is the common substance in cigarette smoke and snuff.”
    “The common substance in cigarette smoke and snuff is nicotine.”
  • The paper relies on this without support.

    Whether nicotine, in the form of Swedish snuff, increases the risk of post neonatal mortality and SIDS has not previously been studied.

    “Whether nicotine, in the form of Swedish snuff, increases the risk of post neonatal mortality and SIDS has to our knowledge not previously been studied.”
  • The paper relies on this without support.

    Preterm or SGA birth is highly associated with tobacco use, post neonatal mortality, and SIDS and potentially on the causal pathway between the exposure and the outcome.

    “Preterm or small for gestational age (SGA) birth is highly associated with both tobacco use, post neonatal mortality, and SIDS and potentially on the causal pathway between the exposure and the outcome.”
  • The paper relies on this without support.

    The MBR contains information on demography, maternal reproductive history, pregnancy, delivery, and neonatal period for 98% of all births in Sweden.

    “The MBR is a national register containing information on the demography, maternal reproductive history, pregnancy, delivery, and neonatal period for 98% of all births in Sweden.”
  • The paper relies on this without support.

    The common substance in cigarette smoke and snuff is nicotine.

    “The common substance in cigarette smoke and snuff is nicotine.”
  • The paper relies on this without support.

    No safe level of prenatal nicotine has been established.

    “No safe level of prenatal nicotine has been established.”
  • The paper relies on this without support.

    A proportion of women who used snuff or smoked pre-pregnancy and quit before pregnancy restarted later in pregnancy or in the postpartum period.

    “It is also likely that a proportion of women who used snuff or smoked pre-pregnancy and quit before pregnancy restarted later in pregnancy or in the postpartum period.”
7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

4 of 4

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Metadata

Authors
Gunnerbeck, A., Lundholm, C., Rhedin, S., Mitha, A., Chen, R., D’Onofrio, B. M., & Almqvist, C.
Affiliations
  • Karolinska Institutet (SE)
  • Inserm (FR)
  • Sun Yat-sen University (CN)
  • Karolinska University Hospital (SE)
Corresponding author
Gunnerbeck, Anna
Venue
Pediatric Research
Published
2023-02-09
Volume
94
Issue
2
Pages
811-819
ISSN
  • 0031-3998 (ISSN-L)
  • 1530-0447
OpenAlex
W4319454736
Cited by
27
References
36
Citations by year
2026: 11 · 2025: 6 · 2024: 6 · 2023: 4
FWCI
5.97
Type
journal article
Language
en
Open access
Locations
  • Pediatric Research (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Hjärt-Lungfonden (2021-0416)
  • Karolinska Institutet
  • Stockholms Läns Landsting
  • Vetenskapsrådet (2018-02640, 2018-)
  • Stiftelsen Frimurare Barnhuset i Stockholm
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Substance Exposure Effects
  • Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Neuroscience of respiration and sleep
Keywords
sudden infant death syndrome, sudden unexpected infant death, nicotine, postneonatal mortality, infant mortality risk
MeSH terms
Female, Humans, Infant, Infant Mortality, Infant, Newborn, Nicotine, Pregnancy, Risk Factors, Smoking, Sudden Infant Death, Tobacco, Smokeless

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