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Self-reported nicotine exposure and plasma levels of cotinine in early and late pregnancy
Abstract
BACKGROUND: The accuracy of maternal self-reported smoking information, especially exposure to environmental tobacco smoke, has been questioned. This study aimed to validate self-reported smoking, smoking cessation, and environmental tobacco smoke exposure in early and late pregnancy, using the biomarker cotinine as the gold standard. METHODS: Prospective cohort study of 953 pregnant Swedish women between 1996 and 1998. In-person interviews and cotinine measurements were performed at 6-12 and 31-34 completed weeks of gestation. All women were asked about nicotine exposures throughout pregnancy, including cigarette smoking, oral snuff, nicotine replacement therapy, and environmental tobacco smoke exposure. RESULTS: The validity of self-reported daily smoking was high in early and late pregnancy. However, among women reporting smoking cessation before the first interview and between the first and second interviews, 13% and 25% misreported active smoking, respectively. According to cotinine measurements, 22% of non-smoking women were exposed to environmental tobacco smoke in early pregnancy, and 8% were exposed in late pregnancy. Self-reported information on environmental tobacco smoke exposure in early and late pregnancy misclassified most exposed women as unexposed. CONCLUSION: The results of this study indicate that self-reported smoking information among pregnant women can be trusted. However, among women reporting smoking cessation during pregnancy, the misclassification rate increased with recency of quitting. Environmental tobacco smoke exposure was common among non-smokers, and the low validity of self-reported environmental tobacco smoke exposure suggests that future studies on environmental tobacco smoke exposure and risks of pregnancy outcomes may have to rely on biomarker assessments.
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“Nevertheless, a study performed in Sweden comparing self-reported nicotine exposure and plasma levels of cotinine in early and late pregnancy concluded that self-reported information on nicotine exposure had acceptable validity [49].”
From The effect of swedish snuff (snus) on offspring birthweight: a sibling analysis (2013) · cites this paper as [49]
Citations
Cites
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Self-citationCotinine as a Biomarker of Environmental Tobacco Smoke Exposure
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“Cotinine is a nicotine-specific metabolite, and detectable levels can, besides tobacco smoke, also be caused by other nicotine products including oral snuff and nicotine replacement therapy (9).”
BackgroundSpontaneous quitting: Self-initiated smoking cessation in early pregnancy
Solomon, L., & Quinn, V. P. (2004) · Nicotine & Tobacco Research · doi:10.1080/14622200410001669132 · Cited by 179
Accuracy of self‐reported cigarette smoking among pregnant women in the 1990s
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In Utero Exposure to Smoking and Peripheral Chemoreceptor Function in Preterm Neonates
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Benedum, C. M., Yazdy, M. M., Mitchell, A. A., & Werler, M. M. (2013) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph10083263 · Cited by 21
“Studies have shown that reliability of self-reported smoking during pregnancy is generally good [49–51], but subjects may underreport the amount they smoke [52,53].”
BackgroundPlasma cotinine indicates an increased risk of preeclampsia in previous and passive smokers
Luo, Z., Julien, P., Wei, S. Q., Audibert, F., Smith, G. N., & Fraser, W. D. (2013) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2013.09.041 · Cited by 21
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Hair nicotine levels in non-smoking pregnant women whose spouses smoke outside of the home
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“However, studies on SHS exposure of pregnant women by their spouses or other household members have mainly focused on the prevalence and patterns of SHS exposure”
BackgroundMiron, P., Côté, Y. P., & Lambert, J. (2008) · Prenatal Diagnosis · doi:10.1002/pd.1930 · Cited by 19
“But an important percentage of the women who state that they do not smoke are, in fact, smokers who are not reporting it (Lindqvist et al., 2002; George et al., 2006).”
Effects of Tobacco Smoking in Pregnancy on Offspring Intelligence at the Age of 5
Eriksen, H. F., Kesmodel, U. S., Wimberley, T., Underbjerg, M., Kilburn, T. R., & Mortensen, E. L. (2012) · Journal of Pregnancy · doi:10.1155/2012/945196 · Cited by 19
“Validations of self-reported smoking in pregnancy by measures of cotinine levels suggest that self-reports may lead to misclassification, not because women report their own smoking unreliably, but because of passive smoking [51, 52].”
BackgroundYu, Y., Tsai, H.-J., Liu, X., Mestan, K. K. L., Zhang, S., Pearson, C., Ortiz, K., Xu, X., ZUCKERMAN, B. S., & Wang, X. (2008) · Human Genetics · doi:10.1007/s00439-008-0589-2 · Cited by 19
“However, previous studies have demonstrated fair agreement between self-reported smoking amounts with serum and urinary levels of cotinine, a biochemical marker of cigarette smoke (George et al. 2006; KlebanoV et al. 2001; Peacock et al. 1998).”
ResultThe dynamics of cardiac autonomic control in sleeping preterm neonates exposed in utero to smoking
Blanchard, E. S., Chardon, K., Djeddi, D., Leke, A., Delanaud, S., Bach, V., & Telliez, F. (2016) · Clinical Neurophysiology · doi:10.1016/j.clinph.2016.05.001 · Cited by 18
“However, many studies have 341shown that self-reports are acceptably reliable (George et al., 2006; 342McDonald et al., 2005).”
BackgroundSchechter, J. C., Fuemmeler, B. F., Hoyo, C., Murphy, S. K., Zhang, J. J., & Kollins, S. H. (2018) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph15010083 · Cited by 18
“Specifically, the current study corroborates previous findings that as many as 20% of non-smoking women may be inaccurate in their assessment of their level of passive exposure during pregnancy [21,22].”
BackgroundResultInfluentialDoes fetal smoke exposure affect childhood bone mass? The Generation R Study
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Self-Reported Exposure to Second-Hand Smoke and Positive Urinary Cotinine in Pregnant Nonsmokers
Paek, Y., Kang, J. B., Myung, S., Lee, D. H., Seong, M., Seo, H. G., Cho, J. J., Song, H. J., Park, K., Kim, C. H., et al. (2009) · Yonsei Medical Journal · doi:10.3349/ymj.2009.50.3.345 · Cited by 16
Exposure to second-hand smoke and reproductive outcomes depending on maternal asthma
Sunyer, J., García‐Esteban, R., Castilla, A. M., Aurrekoetxea, J. J., Íñiguez, C., Tardón, A., Espada, M., Lertxundi, A., Chatzi, L., Rebagliato, M., et al. (2012) · European Respiratory Journal · doi:10.1183/09031936.00091411 · Cited by 16
Smoking among pregnant women in small towns in Poland
Balwicki, Ł., Zarzeczna-Baran, M., Wierucki, Ł., Jędrzejczyk, T., Strahl, M., Wrotkowska, M., Goniewicz, M. L., & Zdrojewski, T. R. (2015) · International Journal of Public Health · doi:10.1007/s00038-015-0735-2 · Cited by 15
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“Previous literature examining the relationship between self-reported ETS exposure and biochemical smoke exposure has been mixed with some studies indicating high levels of sensitivity of the self-reported measures [22,29], where others have found weak or nonexistent relationships, particularly among pregnant women whe…”
ResultVillamor, E., Susser, E., & Cnattingius, S. (2022) · European Journal of Epidemiology · doi:10.1007/s10654-022-00884-3 · Cited by 14
“Smoking was determined by self-report at either the first prenatal visit or in the third trimester; this has been validated with cotinine markers [33].”
MethodDavis, M. C., Broadwater, D. R., Amburgy, J. W., & Harrigan, M. R. (2015) · Clinical Neurology and Neurosurgery · doi:10.1016/j.clineuro.2015.06.016 · Cited by 14
Smoking during pregnancy: changes and associated risk factors in Spain, 1980-2016
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Tsinisizeli, N. P., Sotiroudis, G., Xenakis, A., & Lykeridou, A. (2014) · Chemosphere · doi:10.1016/j.chemosphere.2014.09.094 · Cited by 13
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Mitha, A., Chen, R., Johansson, S., Razaz, N., & Cnattingius, S. (2020) · International Journal of Epidemiology · doi:10.1093/ije/dyaa088 · Cited by 13
“Smoking status was collected by self-report at the first prenatal visit and has been previously validated using cotinine markers.(20) Gestational age was determined using the following hierarchy: early second-trimester ultrasound (83.”
MethodSellers, R., Warne, N., Rice, F. J., Langley, K., Maughan, B., Pickles, A. R., Thapar, A., & Collishaw, S. (2020) · International Journal of Epidemiology · doi:10.1093/ije/dyaa001 · Cited by 13
Workplace Secondhand Smoke Exposure in the U.S. Trucking Industry
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Xiao, X., Li, Y., Song, X., Xu, Q., Yang, S., Wu, J., & Seto, E. (2018) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph15071499 · Cited by 12
Wei, Y., Andersson, T., Edstorp, J., Löfvenborg, J. E., Talbäck, M., Feychting, M., & Carlsson, S. (2022) · BMC Medicine · doi:10.1186/s12916-022-02447-5 · Cited by 11
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Ein‐Mor, E., Berman, T., Barnett‐Itzhaki, Z., Göen, T., Ergaz, Z., Natsheh, J., Ben‐Chetrit, A., Haimov‐Kochman, R., & Calderon‐Margalit, R. (2019) · International Journal of Hygiene and Environmental Health · doi:10.1016/j.ijheh.2019.07.006 · Cited by 10
“Previous findings have found low validity of self-reported exposure to ETS during pregnancy (O'connor et al., 1995; George et al., 2006).”
ResultMaternal smoking in pregnancy and blood pressure during childhood and adolescence: a meta-analysis
Mourino, N., Varela‐Lema, L., Ahluwalia, J. S., Rey‐Brandariz, J., Candal‐Pedreira, C., Ruano‐Raviña, A., Vila-Fariñas, A., Torres, A., & Pérez‐Ríos, M. (2023) · European Journal of Pediatrics · doi:10.1007/s00431-023-04836-1 · Cited by 10
Wallin, H. P., Gissler, M., Korhonen, P. E., & Ekblad, M. O. (2022) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14473 · Cited by 9
Association between maternal body mass index in early pregnancy and anorexia nervosa in daughters
Razaz, N., & Cnattingius, S. (2018) · International Journal of Eating Disorders · doi:10.1002/eat.22921 · Cited by 10
Preterm Birth and Later Retinal Detachment
Bonamy, A. E., Holmström, G. E., Stephansson, O., Ludvigsson, J. F., & Cnattingius, S. (2013) · Ophthalmology · doi:10.1016/j.ophtha.2013.03.035 · Cited by 10
David, A. T., Sharma, V., Bittencourt, L., Gurka, K. K., Pérez, J. G., & Lopez‐Quintero, C. (2023) · Preventive Medicine · doi:10.1016/j.ypmed.2023.107770 · Cited by 10
Maternal Smoking and Hospital Treatment During Pregnancy
Wallin, H. P., Gissler, M., Korhonen, P. E., & Ekblad, M. O. (2019) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntz137 · Cited by 9
Snus in pregnancy and infant birth size: a mother–child birth cohort study
Kreyberg, I., Hilde, K., Bains, K. E. S., Carlsen, K., Granum, B. B., Haugen, G. N., Hedlin, G., Jonassen, C. M., Nordhagen, L. S., Nordlund, B., et al. (2019) · ERJ Open Research · doi:10.1183/23120541.00255-2019 · Cited by 7
Influence of CYP2A6*4 Genotypes on Maternal Serum Cotinine Among Chinese Nonsmoking Pregnant Women
Xie, C., Wen, X., Ding, P., Liu, T., He, Y., Niu, Z., Lin, J., Yuan, S., Guo, X., Jia, D., et al. (2013) · Nicotine & Tobacco Research · doi:10.1093/ntr/ntt164 · Cited by 7
Ratsch, A., Steadman, K. J., Ryu, B., & Bogossian, F. E. (2019) · Methods and Protocols · doi:10.3390/mps2020047 · Cited by 7
“Maternal venous blood Indicates recency of maternal nicotine exposure [94].”
BackgroundVillamor, E., Susser, E., & Cnattingius, S. (2022) · American Journal of Epidemiology · doi:10.1093/aje/kwac068 · Cited by 6
Liu, W., Zhang, Y., Wang, Y., Klinger, F. G., Tan, S., Farini, D., Felici, M. D., Shen, W., & Cheng, S. (2021) · Frontiers in Cell and Developmental Biology · doi:10.3389/fcell.2021.723388 · Cited by 6
“Importantly, this cotinine concentration was within the range reported by human pregnant smokers (21.5–228.1 ng/ml; George et al., 2006).”
InfluentialNicotine Intake in Pregnant Smokers and a General Population of Smokers
Berlin, I., Jacob, N., & Heishman, S. J. (2017) · Journal of Studies on Alcohol and Drugs · doi:10.15288/jsad.2017.79.126 · Cited by 5
Ratsch, A., Bogossian, F. E., Burmeister, E. A., Ryu, B., & Steadman, K. J. (2022) · BMC Public Health · doi:10.1186/s12889-022-14609-4 · Cited by 5
“Maternal venous blood - indicates recency of maternal nicotine exposure [62]”
BackgroundBeer, R. J., Cnattingius, S., Susser, E., & Villamor, E. (2023) · Bipolar Disorders · doi:10.1111/bdi.13327 · Cited by 5
Massey, S. H., Mroczek, D. K., Burns, J. L., Clark, C. A. C., Espy, K. A., & Wakschlag, L. S. (2018) · Neurotoxicology and Teratology · doi:10.1016/j.ntt.2018.02.003 · Cited by 5
“…are typically used to distinguish true smoking from environmental smoke exposure by pregnant women (Dempsey et al., 2002; Kim, 2016), cutoffs do not distinguish between smoking that occurred one or more days prior to specimen collection from environmental tobacco exposure (George et al., 2006).”
BackgroundBaheiraei, A., Banihosseini, S. Z., Heshmat, R., & Mohsenifar, A. (2012) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 4
Sundet, B. K., Kreyberg, I., Staff, A. C., Carlsen, K. L., Bains, K. E. S., Berg, J. P., Granum, B. B., Haugen, G. N., Hedlin, G., Jonassen, C. M., et al. (2022) · Biology of Sex Differences · doi:10.1186/s13293-022-00443-1 · Cited by 5
“However, studies comparable to ours have found a high association between self-reported data and nicotine exposure by blood cotinine in pregnant women, indicating that self-reporting data are valid [26, 27].”
ResultAssessment of Pregnancy Cigarette Smoking and Factors That Predict Denial
Bailey, B. A. (2010) · American Journal of Health Behavior · doi:10.5993/ajhb.34.2.4 · Cited by 4
Tabagisme et facteurs associés chez les collégiens de Dixinn en Guinée
Camara, A., Balde, D., Sidibé, S., Barry, S. M., Camara, B., Barry, A. M., & Barry, M. M. (2015) · Santé Publique · doi:10.3917/spub.154.0585 · Cited by 4
Villamor, E., Miglin, A. K., & Cnattingius, S. (2025) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2025.11.033 · Cited by 1
“25 Outcome information is also of very high quality.”
Villamor, E., & Cnattingius, S. (2024) · American Journal of Clinical Nutrition · doi:10.1016/j.ajcnut.2024.07.003 · Cited by 3
Maternal Overweight and Obesity and Risk of Perinatal Ischemic Stroke
Walås, A., Simatou, E., Andersson, M., Persson, M., Stephansson, O., Razaz, N., Sundelin, H. E. K., & Bolk, J. (2025) · Neurology · doi:10.1212/wnl.0000000000213333 · Cited by 3
Postnatal growth in children born small for gestational age with and without smoking mother
Lindström, L., Wikström, A., Bergman, E., Mulic‐Lutvica, A., Högberg, U., Ahlsson, F., & Lundgren, M. (2019) · Pediatric Research · doi:10.1038/s41390-019-0352-5 · Cited by 3
Narvestad‐Bøttger, H., Vestergaard, C. H., Rytter, D., & Bech, B. H. (2019) · Paediatric and Perinatal Epidemiology · doi:10.1111/ppe.12577 · Cited by 3
Grøtvedt, L., Egeland, G. M., Kvalvik, L. G., & Madsen, C. (2020) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-020-03384-y · Cited by 3
Wallin, H. P., Gissler, M., Korhonen, P. E., & Ekblad, M. O. (2025) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.15114 · Cited by 2
Machine learning prediction models for mode of delivery in prolonged pregnancies in Sweden
Schmauder, S., Sandström, A., Boman, M., Martin, C., & Stephansson, O. (2025) · Scientific Reports · doi:10.1038/s41598-025-19198-x · Cited by 2
“Although the validity of the information on smoking is high, there is evidence on relevant underreporting of active smoking in early and late pregnancy by self-reported quitters 31 .”
Cruvinel, É., Richter, K. P., Pollak, K. I., Ellerbeck, E. F., Nollen, N. L., Gajewski, B. J., Sullivan-Blum, Z., Zhang, C., Shergina, E., & Scheuermann, T. S. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph191610170 · Cited by 2
“However, other research has shown a high correlation between self-reported smoking and biochemical markers within pregnant populations [50,51].”
ResultMaternal early pregnancy body mass index and bipolar disorder in the offspring
Beer, R. J., Cnattingius, S., Susser, E., Wang, L., & Villamor, E. (2023) · Bipolar Disorders · doi:10.1111/bdi.13399 · Cited by 2
Villamor, E., & Cnattingius, S. (2023) · American Journal of Epidemiology · doi:10.1093/aje/kwad235 · Cited by 2
Liu, X., Zhang, Z., Wang, H., Faisal, S., He, M., Tai, S., & Lin, Y. (2024) · Frontiers in Nutrition · doi:10.3389/fnut.2024.1438170 · Cited by 2
“Studies have demonstrated that serum cotinine concentrations offer a more reliable indicator of tobacco exposure compared to self-reported smoking numbers (14, 15).”
BackgroundVillamor, E., & Cnattingius, S. (2025) · International Journal of Obesity · doi:10.1038/s41366-025-01731-7 · Cited by 2
“Smoking during pregnancy was self-reported at either the fi rst prenatal visit or in the third trimester; this was validated against cotinine biomarkers in pregnancies occurring between 1996 and 1998, fully pertaining to the F0 generation, and partly to the F1 generation [20].”
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Zhu, M. Q., Cnattingius, S., O’Brien, L. M., & Villamor, E. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11228 · Cited by 1
Maternal early pregnancy body mass index and risk of insomnia in the offspring
Zhu, M. Q., Cnattingius, S., O'Brien, L. M., & Villamor, E. (2024) · SLEEP · doi:10.1093/sleep/zsae236 · Cited by 1
Physical Activity And Maternal/Fetal Outcomes In A Pregnant Latina Population
Gollenberg, A. (2021) · Scholarworks (University of Massachusetts Amherst) · doi:10.7275/5645472 · Cited by 1
Epidemiology of choanal atresia - the National Birth Defects Prevention Study
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“…reflection of such behavior, and maternal reports of passive exposure to cigarette smoking may have been misclassified, which supports work by George et al. (2006), who validated self-reported maternal smoking both during early and late pregnancy in a prospective cohort study of 953 pregnant…”
ResultTobacco use and dependence : does it originate in utero?
Rydell, M. (2014) · Figshare · Cited by 1
Smoking during pregnancy and fetal brain development
Ekblad, M. O. (2013) · UTUPub (University of Turku) · Cited by 1
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Gilligan, C. (2008) · NOVA (University of Newcastle Australia) · Cited by 1
Ogura, S., & Nakazono, S. (2014) · RePEc: Research Papers in Economics
Heppel, C. W. (2009) · Electronic Theses of LMU Munich (Ludwig-Maximilians-Universität München) · doi:10.5282/edoc.9901
Environmental Toxins and Essential Trace Elements at Delivery and ADHD
Ode, A. (2015) · Lund University Publications (Lund University)
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GEBEL‹KTE N‹KOT‹N REPLASMAN TEDAV‹S‹
Bayar, C. (2007)
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Paprzycki, P., & Tobacco-related, P. (2012)
Fetal Exposure to Perfluorinated Compounds and Attention Deficit Hyperactivity Disorder in Childhood
Rignell‐Hydbom, A., Ode, A., Källén, K., Gustafsson, P., Rylander, L., Jönsson, B., Olofsson, P., Ivarsson, S. A., & Lindh, C. H. (2014) · ISEE Conference Abstracts · doi:10.1289/isee.2014.o-180
Tabagisme et retard de croissance intra-utérin
Grangé, G. (2012) · Elsevier eBooks · doi:10.1016/b978-2-294-71496-2.00013-9
The use of nicotine products and effects of snus in pregnancy
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Tobacco and alcohol use during pregnancy
Bailey, B. A., & Sokol, R. J. (2021) · CRC Press eBooks · doi:10.1201/9781003222590-37
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Villamor, E., Miglin, A. K., & Cnattingius, S. (2025) · Obesity · doi:10.1002/oby.70046
Psychosocial Factors Affecting Pregnant Hispanic Women
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Metadata
- Authors
- GEORGE, L., GRANATH, F., JOHANSSON, A. L. V., & CNATTINGIUS, S.
- Affiliations
- Karolinska Institutet (SE)
- Karolinska University Hospital (SE)
- Corresponding author
- GEORGE, LENA
- Venue
- Acta Obstetricia Et Gynecologica Scandinavica
- Publisher
- Wiley
- Published
- 2006-11
- Volume
- 85
- Issue
- 11
- Pages
- 1331-1337
- ISSN
- 0001-6349 (ISSN-L)
- 1600-0412
- OpenAlex
- W1968549649
- Cited by
- 192
- References
- 21
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 5 · 2023: 5 · 2022: 14 · 2021: 7 · 2020: 13 · 2019: 8 · 2018: 10 · 2017: 8 · 2016: 5 · 2015: 11 · 2014: 11 · 2013: 11 · 2012: 14
- FWCI
- 7.73
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Acta Obstetricia Et Gynecologica Scandinavica (publishedVersion)
- PubMed (publishedVersion)
- 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
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Keywords
- maternal smoking, self-reported smoking, cotinine, passive smoking, smoking cessation, misclassification, biomarker validation, oral snuff, nicotine replacement therapy, pregnancy, early pregnancy, late pregnancy
- MeSH terms
- Cotinine, Female, Humans, Nicotine, Pregnancy, Pregnancy Trimester, First, Pregnancy Trimester, Third, Prospective Studies, Self Disclosure, Smoking, Tobacco Smoke Pollution, Smoking Cessation, Maternal Exposure
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