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Original Article

Maternal smoking, weight status and dietary behaviours during

pregnancy: Findings from first-time mothers in south-west Sydney,

Australia

Li M. WEN,1,2 Chris RISSEL,1,2 Judy M. SIMPSON,1 Eric LEE3 and Louise A. BAUR1,41

Sydney School of Public Health, University of Sydney,2

Health Promotion Service, Sydney South West Area Health Service,3

University of NSW,4

Discipline of Paediatrics & Child Health, Sydney Medical School, University of Sydney, Sydney,

New South Wales, Australia

Background: Few studies have been conducted examining the relationship between maternal smoking, weight status and

dietary behaviours during pregnancy.

Aim: The objective of the study was to examine the relationship between maternal smoking, weight status and dietary

behaviours during pregnancy.

Methods: An analysis of cross-sectional baseline survey data was conducted with 406 first-time mothers participating in

the Healthy Beginnings Trial (HBT) conducted in south-west Sydney, Australia. Mothers reports of their smokingstatus, dietary behaviours and pre-pregnancy weight and height were collected through face-to-face interviews. The

relationships were examined using log-binomial regression modelling.

Results: Maternal smoking status was not associated with weight status. However, smoking was positively associated with

soft drink consumption and negatively associated with daily fruit intake. After adjusting for age, marital status and

education level, mothers who reported consuming >1 cup of soft drink per day were more likely to smoke than those

consuming less soft drink (adjusted risk ratio, ARR 1.48, 95% CI 1.022.22, P = 0.05). Mothers who reported having 2

serves of fruit daily were significantly less likely to smoke than those having less fruit (ARR 0.54, 95% CI 0.290.95,

P = 0.04).

Conclusions: The study found no evidence linking maternal smoking and weight status and did not support the notion

that smoking could lead to a lower weight status. However, maternal smoking was associated with fruit and soft drink

consumption and needs to be considered while examining dietary behaviours and weight status.

Key words: dietary behaviours, maternal smoking, overweight and obesity, survey.

Introduction

Maternal smoking and overweight and obesity during

pregnancy are major risk factors adversely affecting the

health of the mother and the infant.14

In Australia, about

17% of mothers report smoking during pregnancy5

and

around 40% of women of child-bearing age are overweight

or obese.6 Overweight and obese mothers are more likely to

have overweight and obese children,4

and maternal smoking

during pregnancy is also an independent risk factor for

overweight and obese children.7,8

Research into the relationship between smoking and

weight status in the general population has led to mixed

results. There is some evidence that smokers tend to weigh

the same or less than nonsmokers,911 despite smokers

consuming similar or more calories than nonsmokers,9,12,13

and engaging in the same or less physical activity than

nonsmokers.13,14 The reasons for these results are notentirely clear. It is possible that nicotines physiological effect

results in appetite suppression, increased resting metabolic

rates and reduced calorie storage,1517 which could

potentially lead to a lower body weight among smokers.

Some young women believe that smoking could help them

maintain lower weight.1821

However, smoking is also associated with various

unhealthy dietary behaviours that could lead to overweight

Correspondence: Dr Li M. Wen, Health Promotion Service,

Sydney South West Area Health Service, Level 9, King George

V Building, Missenden Road, Camperdown, Sydney,

NSW 2050, Australia. Email: lmwen@email.cs.nsw.gov.au

The authors declare that they have no competing interests in

this study.

This is part of the Healthy Beginnings Trial funded by the

Australian National Health and Medical Research Council (ID

number: 393112). HBT is registered with the Australian

Clinical Trial Registry (ACTRNO12607000168459).

Received 10 May 2010; accepted 27 September 2010.

2011 The Authors 31

Australian and New Zealand Journal of Obstetrics and Gynaecology 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Australian and New Zealand Journal of Obstetrics and Gynaecology 2011; 51: 3137 DOI: 10.1111/j.1479-828X.2010.01259.x

Te Australian and

New Zealand Journalof Obstetrics andGynaecology

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and obesity. Smokers tend to eat less fruit and vegetables

than nonsmokers,11,12,2227 there being a doseresponse

relationship, where the higher the level of smoking, the lower

the level of fruit and vegetable consumption.23,2527

Accordingly, smokers may also have a poorer nutrient intake

than nonsmokers, with a lower intake of vitamins C and E,

beta-carotene, polyunsaturated fat and fibre, and a greater

intake of saturated fat and processed foods.12,2428

Such

differences in nutrition between smokers and nonsmokersare of significant concern, as smoking and poor nutrition

may synergistically increase the risks of cancer and

cardiovascular disease.28

However, there are no data on whether the associations

between maternal smoking, weight status and dietary

behaviours are seen among pregnant women, which is a

group in which smoking, weight status and dietary

behaviours may have profound health impacts. Other studies

on the topic have tended to focus on general population

samples,2224,27

middle-aged populations11,12,23

or adolescent

populations.25,26,29

In this study, we analysed the baseline data from the

Healthy Beginnings Trial (HBT), which was conducted to

test the effectiveness of an early childhood obesityintervention in the first two years of life.

30We aimed to

investigate here whether maternal smoking is associated with

pre-pregnancy weight status and dietary behaviours during

pregnancy among first-time mothers living in socio-

economically disadvantaged areas of south-west Sydney,

Australia.

Methods

Design

This is a cross-sectional analysis of data from the HBT

baseline survey. The HBT is registered with the Australian

Clinical Trial Registry (ACTRNO12607000168459). The

study was conducted in south-west Sydney and approved by

the Ethics Committee of Sydney South West Area Health

Service. The details of the HBT research protocol have been

reported elsewhere.30

Study participants

A total of 667 first-time mothers at 2434 weeks of

pregnancy, who attended antenatal clinics at Liverpool or

Campbelltown Hospitals, located in south-western Sydney,

were recruited for the HBT. They were approached by

research nurses with a letter of invitation and information

about the study. First-time mothers who were able tocommunicate in English were eligible for the trial. Once

eligibility was established and consent obtained, mothers were

asked to fill in a registration form with their contact

information to allow the nurses to make further arrangements

for the baseline data collection. Four hundred and nine

mothers were interviewed at their home before giving birth

and are included in this particular study. Another 258

mothers who also participated in the HBT were excluded, as

we were not able to conduct the survey before they gave

birth. Three mothers were excluded because of missing data

on smoking, leaving 406 mothers for this analysis.

Data collection and key measures

A face-to-face interview with each participating mother was

conducted by one of the four research nurses. The interview

was of 20- to 30-min duration and included a range ofquestions about general health, smoking, dietary behaviours

and food insecurity. The majority of these questions have

been validated in an adult population and are widely used in

NSW population health surveys.31

Smoking status

To assess the mothers smoking status, she was asked

whether she was daily smoker, occasionally smoker, quit

smoking during pregnancy, quit smoking sometime ago or

have never smoked. Those mothers who were daily or

occasional smokers were categorised as smokers and the rest

as nonsmokers for this analysis.

Weight status

Mothers reported their pre-pregnancy weight and height. We

calculated maternal body mass index (BMI: weight in

kgheight in square metres) and categorised it as underweight

(

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the final model using log-binomial regression with the Stata

binreg command.

Results

The mothers ages ranged from 16 to 47 with a mean of 26

(SD = 5.5). Most of the mothers (87%) were either married

or living with their de facto partner. Twenty-three per cent

had completed tertiary education and 11% spoke a languageother than English at home. In addition, 22% were

unemployed and 55% were employed (Table 1).

Smoking and weight status

Of all 406 first-time mothers, 17% were smokers (14% daily

and 3% occasionally) and 4% reported quitting smoking

during pregnancy. Sixty-two per cent of the mothers had

never smoked. Thirty-eight cent of first-time mothers were

overweight (25%) or obese (13%).

Mothers smoking status was not associated with their

weight status. Thirty-six per cent of nonsmokers were

overweight (24%) or obese (12%) and 43% of smokers were

overweight (28%) or obese (15%) (Table 1), a nonsignificantdifference (P = 0.5). Further, the mean BMI was similar for

smokers (24.9, SD 5.3) and nonsmokers (24.5, SD 5.4),

both groups having a median BMI of 24 kgm2.

Smoking and dietary behaviours

The mean and median of soft drink consumption were 1.5

cups (SD 2.1) and one cup, respectively, and 37% reported

consuming more than one cup of soft drink per day

(Table 1). A higher proportion of smokers reported drinking

more than one cup of soft drink per day than nonsmokers

(58% vs 33%, P < 0.001). After adjusting for age, marital

status and education level, mothers who reported consumingmore than one cup of soft drink per day were more likely to

smoke than those consuming less soft drink (ARR 1.48,

95% CI 1.022.22, P = 0.05).

With an average daily consumption of two serves of fruit,

there were 11% of mothers having no fruit or less than

1 serveday. Over a third (38%) of mothers reported having

less than two serves of fruit a day (Table 1). In particular,

among smokers, 54% ate less than two serves of fruit per

day compared to 35% of nonsmokers (P = 0.003). On

multivariate analysis, after adjusting for education, marital

status and age, consumption of fruit remained significantly

associated with smoking. Mothers who reported consuming

two or more serves of fruit per day were significantly less

likely to be smokers than those consuming less than twoserves of fruit (ARR 0.54, 95% CI 0.290.95, P = 0.04).

The mean and median daily vegetable consumption were

2.3 (SD 1.34) and two serves, respectively. About one-third

of mothers (32%) reported having less than two serves of

vegetables per day and only 7% consumed the recommended

number of serves of vegetables (five serves). Smokers tended

to consume fewer vegetables than nonsmokers, but this trend

was not statistically significant (trend P = 0.15).

Smokers reported eating chips, fries or wedges

significantly more often than nonsmokers (trend P = 0.007),

with 41% of smokers and 26% of nonsmokers eating them

more than twice a week. However, this association did not

remain after adjustment for differences in age, marital status

and education (Table 1). No difference was found in the

frequency of consuming fast food between smokers and

nonsmokers (P = 0.42)

Not surprisingly, mothers age, marital status, employmentstatus and education level were all associated with smoking,

but only marital status and education level remained

significant on multivariate analysis. Married and more highly

educated mothers were less likely to smoke (Table 1).

Maternal education level was the strongest predictor for

smoking, mothers with university education being

significantly less likely to smoke (ARR 0.07, 95% CI 0.02

0.29, P < 0.001) than those having an education lower than

school certificate.

Maternal education was also significantly associated with

soft drink consumption and fruit intake. As shown in

Figure 1, the proportions of mothers who smoked,

consumed less fruit (1 cup per day) reduced as level of educationincreased. These associations were all statistically significant

(trend P < 0.001, P = 0.02 and P < 0.001, respectively).

Discussion

In this cross-sectional analysis, we found that 17% of the

mothers still smoked during pregnancy and 38% mothers

were overweight or obese just prior to pregnancy. Both

figures were similar to the Australia national data,5,6 but

smoking was 3% higher than the NSW state average for

pregnant women (14%).5 The findings highlight that

smoking and overweight and obesity are lifestyle risk factors

among first-time mothers during pregnancy.In this study, we found no association between maternal

smoking and weight status, which does not support the

notion of smoking leading to a lower body weight. In fact,

the findings of a significant negative association between

smoking and fruit consumption and positive association

between smoking and soft drink consumption suggest that

smoking could potentially lead to overweight and obesity.

The study also found that the level of maternal education

plays a key role in mothers risk-taking behaviours, with less

educated mothers having significantly higher rates of

smoking, higher consumption of soft drinks and lower

consumption of fruits.

In addition, the low levels of vegetable and fruit

consumption and high levels of soft drink consumptionamong pregnant women found in this study are alarming and

require urgent nutritional interventions for first-time mothers.

Maternal smoking and weight status

Some studies suggest that smoking and body weight could

be inversely related,911 and attempts to control weight by

smoking are common among women.3436 To this end,

Maternal smoking, weight status and dietary behaviours

2011 The Authors 33

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tobacco marketing in the past has tried to associate smoking

with having a slim figure.37

It is therefore not surprising to

learn that smoking is commonly believed to help control

body weight,18,19

and its use as a weight control strategy has

been reported in adolescent girls and young adult women.18

Studies have shown that adolescents who are more

Table 1 Relationship of smoking with dietary behaviours and weight status among 406 first-time mothers on bivariate and multivariate

analysis

Smoke during pregnancy

P

Being smoker

No (N = 338) Yes (N = 68) Total

ARR 95% CI Pn (%) n (%) N (%)

Weight 0.59

Underweight 22 (7) 6 (10) 28 (7)Normal 185 (57) 27 (47) 212 (55)

Overweight 80 (24) 16 (28) 96 (25)

Obese 40 (12) 9 (15) 49 (13)

Soft drink (cup per day) 1 101 (33) 39 (58) 140 (37) 1.48 1.022.22

Fruit (serves per day) 0.003 0.04

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concerned about their weight or have a higher drive for

thinness are more likely to smoke.20,21

Our study provides no evidence linking maternal smoking

to pre-pregnancy weight status. We further found that there

was no difference in mean BMI between smokers and

nonsmokers. Our findings are consistent with those of other

studies that have not found a link between smoking andlower body weight in adolescents and young adults.

38,39It

may be that the impact of smoking on weight is not found

in a younger population and only emerges in older

populations. It is also unclear whether the concern about

weight status among smokers is still present in the current

milieu because a more recent study has found that adult

smokers were less concerned about their weight than never-

smokers.40

Other studies also suggest that maternal smoking during

pregnancy may have a direct effect on obesity for future

offspring.7,8 Although the mechanism for this is not clear,

this is likely mediated through the development of

intrauterine growth restriction, which is recognised as asignificant risk factor in the subsequent development of the

metabolic syndrome, which includes obesity and its

consequences. Based on the findings of this study, we also

hypothesise that maternal unhealthy dietary behaviours

associated with smoking could impact on their childrens

dietary behaviours (eg consumption of soft drink) and

ultimately result in the development of overweight and

obesity in their children. A longitudinal study is needed to

test whether this hypothesis is true.

Smoking and fruitvegetable and soft drinkconsumptions

In general, most studies,11,12,2228 including a meta-analysis,28 have concluded that smoking is associated with

unhealthy dietary behaviours that include a higher intake of

energy dense food and lower intakes of fruit and vegetables.

However, none of the reported studies has included women

during their first pregnancy. This study confirms that the

associations between smoking and unhealthy dietary

behaviours are also found in pregnant women. Most likely

these associations are mediated through socio-economic

status (SES). Low SES is strongly linked to smoking, poor

diet and overweightobesity, regardless of whether women

are pregnant. In contrast to other studies,1113

our data

provide no evidence linking smoking to vegetable

consumption. The reason for this is not clear and needs

further explore.

It should be noted that smoking, dietary behaviours andtheir associations are very complex health issues, which are

not entirely understood. This study confirms the role of

maternal education level in influencing smoking and

unhealthy dietary behaviours. It also highlights the

importance of investigating the clustering of risk behaviours,

or multiple risk factors, when examining a specific health-

related behaviour and its association with various risk

behaviours. Tailored health promotion is needed to target

multiple health risk factors, in particular among less

educated mothers.

Strengths and limitations

Our study population of first-time mothers at 2434 weeks

pregnancy is unique because no studies of this kind have

been conducted in such a population, in which maternal

smoking was likely to be low and dietary behaviours varied

as a result of pregnancy. We have used validated

measurement tools in assessing key study variables, including

smoking, weight status and dietary behaviours.31,32 The

findings of this study are extremely important for informing

the development of health promotion intervention strategies

for smoking and unhealthy dietary behaviours of first-time

mothers during pregnancy.

However, our study is limited because of its cross-

sectional nature, and the generalisabilty is also limited

because of the locality of the study area, which is one of themost socially and economically disadvantaged areas of

metropolitan Sydney.31

No causal relationships should be

concluded from this study. Owing to the small number of

current smokers (n = 68), we did not have enough statistical

power to detect differences in further subgroup analysis

(such as dose or length of smoking). In addition, we did not

examine the effect of the ex-smokers on weight and dietary

behaviours because of the small number (n = 16).

56%

48%

47%

39%

38%

12%

13%

27%

2%

Soft drink >1 cup/day

Fruit

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Conclusion

Substantial proportions of first-time mothers were smokers,

were overweight or obese or had low levels of vegetable and

fruit consumption or high levels of soft consumption during

pregnancy. These findings were more evident among less

educated mothers.

The study found no evidence linking maternal smoking

and weight status and did not support the notion that

smoking could lead to a lower weight status. However,

maternal smoking was associated with fruit and soft drink

consumptions and needs to be considered while examining

dietary behaviours and weight status.

Acknowledgements

This is part of the Healthy Beginnings Trial funded by the

Australian National Health and Medical Research Council

(ID number: 393112). We sincerely thank the Associate

Investigators, Prof. Anita Bundy, Dr Lynn Kemp and Dr

Vicki Flood and the members of the steering committee and

working group for their advice and support. We thank all

families for their participation in this study. We also thankmembers of the project team, including Karen Wardle, Carol

Davidson; Cynthia Holbeck; Dean Murphy; Lynne Ireland;

Kim Caines; and Angela Balafas. In addition, we thank

James Kite and Therese Carroll for their support in setting

up the database and Hui Lan Xu for assisting with data

entry and analysis.

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