Copyright C 1999 by The Johns Hopkins University School of Hygiene and Public Hearth
All rights reserved
Pnnted in U.SA.
Gayle C. Windham,1 Julie Von Behren,1 Kirsten Waller,1'2 and Laura Fenster1
The authors examined the risk of spontaneous abortion from environmental tobacco smoke (ETS) exposure
in a prospective study of over 5,000 women conducted in California during 1990-1991. Among nonsmokers,
there was little association by hours of ETS exposure at home or work (adjusted odds ratio (OR) for any
exposure = 1.01, 95% confidence interval (Cl) 0.80-1.27), or by paternal smoking. However, the risks
associated with ETS exposure were increased among nonsmokers who had moderate alcohol or heavy caffeine
consumption. A moderate association with maternal smoking was observed (adjusted OR for >5 cigarettes per
day = 1.3, 95% Cl 0.91-1.9). Am J Epidemiol 1999; 149:243-7.
Details of data collection have been published elsewhere (7, 8) and are summarized briefly here. Pregnant
women were recruited during 1990-1991 from a large
Received for publication November 18, 1997, and accepted for
publication June 15, 1998.
Abbreviations: Cl, confidence interval; ETS, environmental tobacco smoke; OR, odds ratio; SAB, spontaneous abortion.
1
Environmental Health Investigations Branch, Department of
Health Services, Oakland, CA.
2
Currentty with Public Health Institute, Berkeley, CA.
Reprint requests to Dr. Gayle Windham, Department of Health
Services, 1515 Clay Street, Suite 1700, Oakland, CA 94612.
243
244
Windham et al.
variable
Maternal age (years)
<35
Pregnancy history
No prior pregnancy
No SAB, but pregnancy
1 prior SAB
2 SABs
Maternal race
White
Hispanic
Black
Asian or Filipino
Education
<High school
High school graduate
Some college or graduate
Employed at interview
Yes
No
Gestational age (weeks) at
interview
^8
>8
Smoke before or during
pregnancy
Yes
No
ETS exposure (hours/day)
in nonsmokers
0
0.5
1.0-1.5
2.0-5.5
56
No. of
pregnancies
SABs(%)
4,583
561
8.8
17.5
1,320
2,754
815
247
8.4
9.5
9.8
18.6
3,390
945
330
475
9.4
8.3
13.0
12.0
338
1,789
3,012
7.7
9.2
10.2
3,861
1,281
10.3
7.8
3,287
1,847
11.1
7.3
933
4,209
10.4
9.6
3,016
313
311
344
210
9.6
11.2
8.4
9.0
9.5
245
Exposed
Total
FIGURE 1. Proportion of nonsmokers who reported exposure to environmental tobacco smoke (ETS) at home, work, and combined, by hours
exposed, in a prospective study of pregnancy outcome, California, 1990-1991.
No.
SAB
(%)
Adjusted
OR
95%Clt
571
743
1,178
10.9
9.0
9.6
1.15
0.88
1.01
0.86-1.55
0.66-1.17
0.80-1.27
Work
ETS Exposure
Home
246
Windham et al.
TABLE 3. Additive models for effect modification of caffeine and alcohol on association of
environmental tobacco smoke (ETS) and spontaneous abortion (SAB), in nonsmokere, California,
1990-1991
Caffeine consumption
ETS
Caffeine
(mg/day)
None
Any
None
Any
300
300
>300
>300
No.
2,955
1,138
61
40
SABs
9.6
8.9
9.8
27.5
Alcohol consumption
Adjusted'
' 95% Clf
ORt
0.93
0.84
3.4
0.73-1.2
0.35-2.0
1.7-7.0
Alcohol
(drinks/wtc)
NO.
3,002
1,168
14
10
S3
S3
>3
>3
SABs
(%)
9.6
9.3
14.3
30.0
Adjusted
OR
0.98
1.0
2.9
95% Cl
0.78-1.2
0.22^1.8
0.72-11.6
Paternal smoking
(cigarettes/day)
No.
SABs(%)
0
1-10
11-20
>20
3,550
405
186
55
9.6
Adjusted*
0 R +
95% CI*
9.4
0.98
0.73-1.3
9.1
10.9
1-4
5-9
0.97
0.41-2.3
10
were details about the intensity of exposure. The proportion of nonsmokers who reported ETS exposure is
lower than in some studies, but is similar to our study
conducted 4 years earlier and to other studies in
California of nonpregnant women (5, 17). California
has lower smoking rates than other states and more
severe smoking restrictions (17, 18), so that exposure
to ETS may not only be less frequent but also of a
lower magnitude or intensity. To date, the literature on
the possible association of ETS exposure and fetal
loss is somewhat limited. Additional studies should
include highly exposed women to provide power for
detecting a possible association and more detailed
exposure assessment.
REFERENCES
1. US Department of Health and Human Services. The health
consequences of smoking for women: a report of the Surgeon
General. Atlanta, GA: USDHHS, Public Health Service,
Office of the Assistant Secretary for Health, Office of
Smoking and Health, 1980.
No
SABs
(%)
Adjusted
OR
4,607
209
119
208
9.4
9.6
13.5
13.5
+
0.91
} 13
95% Clt
0.56-1.5
0.91-1.9
* Adjusted for maternal age, prior fetal loss, alcohol and caffeine
consumption during pregnancy, and gestational age at interview,
t Cl, confidence interval.
X Reference group.
2. Stillman RJ, Rosenberg MJ, Sachs BP. Smoking and reproduction. Fertil Steril 1986;46:545-66.
3. Windham GC. Effects of tobacco smoke on risk of spontaneous abortion. In: Current issues in smoking and reproductive
health. ARHP Clinical Proceedings 1996:13-15.
4. DiFranza JR, Lew RA. Effect of maternal cigarette smoking on
pregnancy complications and sudden infant death syndrome. J
Fam Pract 1995;40:385-94.
5. Windham GC, Swan SH, Fenster L. Parental cigarette smoking
and the risk of spontaneous abortion. Am J Epidemiol 1992;
135:1394-1403.
6. Ahlborg G Jr, Bodin L. Tobacco smoke exposure and pregnancy outcome among working women. A prospective study at
prenatal care centers in Orebro County, Sweden. Am J
Epidemiol 1991;133:338-47.
7. Fenster L, Schaefer C, Mathur A, et al. Psychologic stress in
the workplace and spontaneous abortion. Am J Epidemiol
1995;142:1176-83.
8. Windham GC, Von Behren J, Fenster L, et al. Moderate maternal alcohol consumption and risk of spontaneous abortion.
Epidemiology 1997;8:509-14.
9. Rothman KJ. Modern epidemiology. Boston, MA: Little,
Brown, 1986.
10. Hosmer DW, Lemeshow S. Confidence interval estimation of
interaction. Epidemiology 1992;3:452-6.
11. Kline J, Stein Z. Spontaneous abortion. In: Bracken MB, ed.
Perinatal epidemiology. New York: Oxford University Press,
1984:23-51.
12. Anokute CC. Epidemiology of spontaneous abortions: the
effects of alcohol consumption and cigarette smoking. J Nat!
MedAssoc 1986;78:771-5.
13. Harlap S, Shiono PH. Alcohol, smoking, and incidence of
Am J Epidemiol Vol. 149, No. 3, 1999
247
Am J Epidemiol