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Secondhand smoke exposure during pregnancy: a cross-sectional analysis of data from Demographic and Health Survey from 30 low-income and middle-income countries
  1. Sian Reece1,
  2. Camille Morgan2,
  3. Mark Parascandola2,
  4. Kamran Siddiqi1
  1. 1 Department of Health Science, University of York, York, UK
  2. 2 Tobacco Control Research Branch, National Cancer Institute, Rockville, Maryland, USA
  1. Correspondence to Dr Sian Reece, Department of Health Science, University of York, York YO10 5DD, UK; sianreece{at}


Background Secondhand smoke (SHS) exposure during pregnancy increases the risk of infant stillbirth, congenital malformations, low birth weight and respiratory illnesses. However, little is known about the extent of SHS exposure during pregnancy. We assessed the prevalence of SHS exposure in pregnant women in low-income and middle-income countries (LMICs).

Methods We used Demographic and Health Survey data collected between 2008 and 2013 from 30 LMICs. We estimated weighted country-specific prevalence of SHS exposure among 37 427 pregnant women. We accounted for sampling weights, clustering and stratification in the sampling methods. We also explored associations between sociodemographic variables and SHS exposure in pregnant women using pairwise multinomial regression model.

Findings The prevalence of daily SHS exposure during pregnancy ranged from 6% (95% CI 5% to 7%) (Nigeria) to 73% (95% CI 62% to 81%) (Armenia) and was greater than active tobacco use in pregnancy across all countries studied. Being wealthier, maternal employment, higher education and urban households were associated with lower SHS exposure in full regression models. SHS exposure in pregnant women closely mirrors WHO Global Adult Tobacco Survey male active smoking patterns. Daily SHS exposure accounted for a greater population attributable fraction of stillbirths than active smoking, ranging from 1% of stillbirths (Nigeria) to 14% (Indonesia).

Interpretation We have demonstrated that SHS exposure during pregnancy is far more common than active smoking in LMICs, accounting for more stillbirths than active smoking. Protecting pregnant women from SHS exposure should be a key strategy to improve maternal and child health.

  • secondhand smoke
  • surveillance and monitoring
  • global health
  • low/middle income country

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  • Contributors SR and KS conceptualised the study. SR developed the analytical strategy, contributed to the statistical analysis, interpretation of the results and cowrote the first draft of the report. CM contributed to obtaining data, statistical analysis, interpretation of the results and cowrote the first draft of the report. KS and MP contributed to the analytical strategy, interpretation of results and revision of the report.

  • Funding This study was partially funded by the UK Medical Research Council.

  • Disclaimer Data collected by the Demographic Health Surveys is anonymised at the point of collection and interviews are only conducted if the participant provides informed consent. This study did not apply for ethics review given its utilisation of secondary anonymous data.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Approval has been granted for the use of this data from Demographic Health Surveys for the purposes of this study. Additional unpublished data from this study are available upon request from Demographic Health Surveys.