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Maternal Smoking Before and During Pregnancy and the Risk of Sudden Unexpected Infant Death
Open accessAbstract
OBJECTIVES: Maternal smoking during pregnancy is an established risk factor for sudden unexpected infant death (SUID). Here, we aim to investigate the effects of maternal prepregnancy smoking, reduction during pregnancy, and smoking during pregnancy on SUID rates. METHODS: We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2007–2011: 20 685 463 births and 19 127 SUIDs). SUID was defined as deaths at <1 year of age with International Classification of Diseases, 10th Revision codes R95 (sudden infant death syndrome), R99 (ill-defined or unknown cause), or W75 (accidental suffocation or strangulation in bed). RESULTS: SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31–2.57) with any maternal smoking during pregnancy and increased twofold between no smoking and smoking 1 cigarette daily throughout pregnancy. For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 from 1 to 20 cigarettes; beyond 20 cigarettes, the relationship plateaued. Mothers who quit or reduced their smoking decreased their odds compared with those who continued smoking (reduced: aOR = 0.88, 95% CI 0.79–0.98; quit: aOR = 0.77, 95% CI 0.67–0.87). If we assume causality, 22% of SUIDs in the United States can be directly attributed to maternal smoking during pregnancy. CONCLUSIONS: These data support the need for smoking cessation before pregnancy. If no women smoked in pregnancy, SUID rates in the United States could be reduced substantially.
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Written from the paper’s full text.
TL;DR
Maternal smoking during pregnancy more than doubled the risk of sudden unexpected infant death (SUID) in 2007–2011 US linked birth/infant death data, with a dose-response relationship up to 20 cigarettes per day. Quitting or reducing smoking lowered risk, and assuming causality, about 22% of US SUID cases were attributable to prenatal smoking.
Key findings
- Any maternal smoking during pregnancy was associated with more than doubled SUID risk (adjusted odds ratio [aOR] = 2.44; 95% CI 2.31–2.57); the aOR was similar in the subset with cigarette-count data (aOR = 2.40; 95% CI 2.23–2.59).
- Risk increased with daily cigarette use: smoking 1 cigarette/day throughout pregnancy was associated with aOR = 1.98 (95% CI 1.73–2.28), and from 1 to 20 cigarettes/day each additional cigarette increased odds by 0.07 (aOR = 0.07 × daily cigarettes + 1.91), with a plateau beyond 20 cigarettes/day.
- Compared with continued smokers, reducing smoking was associated with aOR = 0.88 (95% CI 0.79–0.98) and quitting with aOR = 0.77 (95% CI 0.67–0.87). Compared with never smoking, prepregnancy smoking only was aOR = 1.47 (95% CI 1.16–1.87), smoking only during pregnancy was aOR = 2.22 (95% CI 1.15–4.29), and smoking before and during pregnancy was aOR = 2.52 (95% CI 2.25–2.83).
- Assuming causality, an estimated ~800 infants per year, or 22% of all US SUID cases, were attributed to maternal smoking during pregnancy; dose-effect relationships were found for R95, R99, and W75, but not for non-SUID causes P07.2, P07.3, and P01.1.
Methods
- Retrospective cross-sectional cohort study using the CDC Birth Cohort Linked Birth/Infant Death Data Set for 2007–2011: 20,685,463 births and 19,127 SUIDs; SUID was defined as death at <1 year with ICD-10 codes R95, R99, or W75. Prepregnancy smoking analyses used 2011 data only (3,134,781 births, 2,585 SUIDs).
- Logistic regression and generalized additive models were adjusted for maternal and paternal race/ethnicity, age, marital status, education, live birth order, prenatal visits, gestational length, delivery method, infant sex, and birth weight; smoking was modeled dichotomously, by trimester, by daily cigarette count, and as quit/reduce/continue categories.
- Population-attributable risk was estimated by using the logistic regression model with all mothers artificially set as nonsmokers and assuming causation.
Limitations
- Stated by the authors: smoking estimates are likely conservative because the data set lacks environmental smoke exposure during pregnancy or postpartum, including paternal smoking; smoking is self-reported and may be underestimated or denied; only 60% of births had data on number of cigarettes smoked, though missingness was related to the 2003 birth certificate revision rather than maternal characteristics.
- Stated by the authors: there may be selection bias in the reduction/quit groups because those who reduced started at a higher average number of cigarettes in the first trimester, whereas those who quit smoked fewer cigarettes in the first trimester.
- Evident from the text: the study is observational and cross-sectional, so causality is not established; the 22% attributable fraction explicitly assumes causality, and the authors note possible residual confounding, especially by socioeconomic factors.
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Claims the paper makes
25 Own result · 5 Own method · 5 Own interpretation · 2 Check pending · 2 No full text of the sources · 1 Not checked yet
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For 1 to 20 cigarettes per day, the probability of SUID increased linearly, with each additional cigarette smoked per day increasing the odds by 0.07 (aOR = 0.07 × number of daily cigarettes + 1.91) (Supplemental Fig 4).”
plainstates a cause- Asserted: passes — The authors put it forward as true.
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In the paper
“Of mothers who smoked during pregnancy, 55% did not reduce smoking during pregnancy, 20% quit smoking by the beginning of the third trimester, and 24% reduced their smoking.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Compared with mothers who did not smoke in the 3 months before or during pregnancy, SUID risk progressively increased for those who smoked before pregnancy and quit before pregnancy (aOR = 1.47; 95% CI 1.16–1.87), those who did not smoke before but smoked during pregnancy (aOR = 2.22; 95% CI 1.15–4.29), and those who smoked before and during pregnancy (aOR = 2.52; 95% CI 2.25–2.83).”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Compared with mothers who did not smoke in the 3 months before or during pregnancy, SUID risk progressively increased for those who smoked before pregnancy and quit before pregnancy (aOR = 1.47; 95% CI 1.16–1.87), those who did not smoke before but smoked during pregnancy (aOR = 2.22; 95% CI 1.15–4.29), and those who smoked before and during pregnancy (aOR = 2.52; 95% CI 2.25–2.83).”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“SUID risk more than doubled (adjusted odds ratio [aOR] = 2.44; 95% confidence interval [CI] 2.31–2.57) with any maternal smoking during pregnancy”
- Also stated in: § Results · plain
“By using a dichotomous variable of smoking (yes or no), SUID risk more than doubled (aOR = 2.44; 95% CI 2.31–2.57) with any maternal smoking during pregnancy.”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Results · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Conversely, non-SUID causes of death, including P07.2 (extreme immaturity of the newborn), P07.3 (prematurity), and P01.1 (newborn affected by premature rupture of membranes) did not exhibit this positive dose-response relationship (Fig 3).”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The logistic regression models plotting the correlation between maternal smoking and specific ICD-10 codes for SUID revealed a statistically significant dose-effect relationship between maternal smoking and odds of R95, R99, and W75 (Fig 3).”
- Also stated in: § Discussion · plain
“The relationship between smoking and rates for R95, R99, and W75 diagnoses individually revealed similar linear trends.”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Discussion · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Compared with continued smokers, SUID risk in the reduced group was slightly decreased (aOR = 0.88; 95% CI 0.79–0.98), whereas those who quit exhibited the largest reduction in risk (aOR = 0.77; 95% CI 0.67–0.87).”
plainstates an association- Asserted: passes — The authors put it forward as true.
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- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There was a positive correlation between average number of daily cigarettes during pregnancy and the risk of SUID (Table 1).”
- Also stated in: § Discussion · plain
“There was a linear correlation between average number of daily cigarettes smoked and increased risk for SUID.”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Discussion · plain
A result the paper states — it cites no source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The largest predictor of SUID risk with maternal prenatal smoking was the average number of cigarettes smoked daily over the 3 trimesters.”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- It may state two separate claims as one. 7
- Probably not a substantial claim. 3
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“a flattening of the curve after 20+ daily cigarettes with much wider CIs because of fewer cases (Fig 2).”
plainstates an association- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“In addition, smoking rates are self-reported. Because it is widely known that smoking is an unhealthy behavior, it is likely that some women underestimated or denied their true smoking habits.”
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“This was unexpected because smoking increases the risk of preterm birth, which is associated with higher mortality and morbidity.37”
What the sources say
- Not checked — no full text of the sourcecites [37] Abel, 1980, Smoking during pregnancy: a review of effects on growth and development of offspring, Hum Biol
plainstates a cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Although the study adjusted for many potential confounders, residual confounding, especially with socioeconomic factors, might explain this finding.”
hedgedstates a possible cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These findings support the idea that, despite differing labels on the death certificate, there may be commonalities in intrinsic and/or extrinsic factors, and these deaths should consistently be considered together as SUID.”
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“However, the missing data were not related to maternal characteristics but instead to the adoption of the 2003 revision of the US Standard Certificate of Live Birth, and therefore had minimal effect on the estimates.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Assuming causality, an estimated ∼800 infants per year, or 22% of all SUID cases in the United States, were attributed to maternal smoking during pregnancy.”
- Also stated in: § Discussion · hedged
“If causality is assumed in our model, we estimate that ∼22% of all US SUID cases are directly attributable to smoking (ie, if every mother did not smoke during pregnancy, there would have been an estimated 800 fewer SUIDs in the United States in 2011 alone).”
hedgedstates a cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- The authors state this as an assumption: Maternal smoking during pregnancy causally affects SUID risk.
- Also stated in: § Discussion · hedged
None of the sources cited for this claim have been checked yet.
In the paper
“including paternal smoking, which has an independent influence on SIDS risk.3,41”
What the sources say
- Not checked — no full text of the sourcecites [3] Mitchell, 1993, Smoking and the sudden infant death syndrome., Pediatrics source
- Not checked yetcites [41] Mitchell, 1993, Dummies and the sudden infant death syndrome, Arch Dis Child source
Checked before — its earlier verdict is held back until a new check runs.
plainstates a cause- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
The authors state this as an assumption.
Maternal smoking during pregnancy causally affects SUID risk.
“Assuming causality, an estimated ∼800 infants per year, or 22% of all SUID cases in the United States, were attributed to maternal smoking during pregnancy.”
“If causality is assumed in our model, we estimate that ∼22% of all US SUID cases are directly attributable to smoking”
“By assuming causation, the difference between the result of this model and actual SUID rates is the proportion of deaths that can be attributed to smoking.”
The paper relies on this without support.
The set of covariates used in adjusted analyses adequately controls for confounding of the maternal smoking–SUID association.
“We used regression adjustment of potential confounding variables to decrease bias and to improve the precision of estimates in the smoking-SUID association.”
“On the basis of these calculations, we used the following covariates in all adjusted analyses: mother’s and father’s race and/or ethnicity/Hispanic origin, mother’s and father’s age, mother’s marital status, mother’s education, live birth order, number of prenatal visits, gestational length (weeks), delivery method (vaginal or cesarean), infant sex, and birth weight.”
The paper relies on this without support.
The CDC Birth Cohort Linked Birth/Infant Death Data Set accurately records SUID deaths and maternal smoking.
“We conducted a retrospective, cross-sectional study to assess the relationship between SUID and self-reported maternal smoking before and during pregnancy, using data from the Centers for Disease Control and Prevention (CDC) Birth Cohort Linked Birth/Infant Death Data Set for births between 2007 and 2011.”
“We defined a SUID case as an infant (<365 days old) death with the following ICD-10 codes: R95 (SIDS), R99 (ill-defined and unknown cause), or W75 (accidental suffocation or strangulation in bed).”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“Our results are in agreement with Anderson et al. who showed that infants of mothers who had stopped smoking in early pregnancy ran a reduced risk of SUID compared to those whose mothers continued to smoke.20”
From Association of maternal snuff use and smoking with Sudden Infant Death Syndrome: a national register study (2023) · cites this paper as [20]
In the citing paper
“However, despite small numbers, the estimates and confidence intervals are in agreement with international studies on smoking, post neonatal mortality, SIDS and SUID.19–22”
From Association of maternal snuff use and smoking with Sudden Infant Death Syndrome: a national register study (2023) · cites this paper as [20]
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.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Results
“those who smoked before pregnancy and quit before pregnancy (aOR = 1.47; 95% CI 1.16–1.87)”
§ Discussion
“The adjusted odds for SUID were slightly but significantly increased (aOR = 1.47; 95% CI 1.16–1.87) in cases wherein the mother smoked prepregnancy but quit during the pregnancy compared with those who never smoked.”
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Metadata
- Authors
- Anderson, T. M., Lavista Ferres, J. M., Ren, S. Y., Moon, R. Y., Goldstein, R. D., Ramirez, J.-M., & Mitchell, E. A.
- Affiliations
- Seattle Children's Research Institute (US)
- Microsoft, Redmond, Washington;
- Microsoft (United States) (US)
- University of Virginia (US)
- Boston Children's Hospital (US)
- University of Washington (US)
- University of Auckland (NZ)
- Venue
- Pediatrics
- Publisher
- American Academy of Pediatrics (AAP)
- Published
- 2019-04-01
- Volume
- 143
- Issue
- 4
- ISSN
- 0031-4005 (ISSN-L)
- 1098-4275
- PMC
- PMC6564075
- OpenAlex
- W2921964186
- Semantic Scholar
- fac285fc55c6d1b29881ec384af953de8646b03b
- Cited by
- 201
- References
- 48
- Citations by year
- 2026: 14 · 2025: 24 · 2024: 33 · 2023: 32 · 2022: 31 · 2021: 26 · 2020: 31 · 2019: 10
- FWCI
- 25.30
- Type
- journal article
- Language
- en
- Open access
- green
- pmc.ncbi.nlm.nih.gov
- Locations
- PEDIATRICS (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R01HL126523)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Substance Exposure Effects
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Smoking Behavior and Cessation
- Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Neuroscience of respiration and sleep
- Keywords
- sudden unexpected infant death, maternal smoking, smoking during pregnancy, smoking cessation, sudden infant death syndrome, infant mortality risk, attributable fraction
- MeSH terms
- Centers for Disease Control and Prevention, U.S., Female, Humans, Infant, Infant, Newborn, Maternal Behavior, Pregnancy, Pregnancy Outcome, Retrospective Studies, Smoking, Sudden Infant Death, United States, Incidence, Confidence Intervals, Odds Ratio, Databases, Factual, Smoking Cessation, Risk Assessment, Needs Assessment, Self Report
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