How The Anti-Smokers Lie About Neonatal Costs And Smoking

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A relatively recent study of how fetal cocaine exposure affects the length and cost of neonatal hospital stays also had unpublicized findings on maternal smoking  (The Neonatal Costs of Maternal Cocaine Use. CS Phibbs et al. JAMA 1991;266: 1521-1526). 82.8% of the mothers of cocaine-exposed infants smoked, compared to 17.1% in the nonexposed.

 Cocaine and other drugs increased medical costs by an average of $5200, which they estimated to cost $500 million nationally. Any prenatal care reduced costs between $4300 and $5000, and length of stay by 2.9 to 3.6 days.

 Alcohol-exposed infants had nonsignificantly higher costs and longer stays, and black infants had nonsignificantly lower costs and shorter stays. And, in the authors' words, "The coefficients for maternal smoking and mother's age were consistently not significant and were close to zero."

 Costs until medical discharge averaged $4 less for babies whose mothers smoked. However, the costs until actual discharge, those added by social work rather than medical need, averaged $528 more. But no medical costs would be avoided, and the social problems of poverty, young mothers, and out of wedlock births would not be solved, by a crusade against maternal smoking.

 Yet anti-smokers attribute $652 million in additional US neonatal costs to maternal smoking. The source for that figure is a letter from Manning et al answering a question about their RAND Corp. study (JAMA 1989;262:901).

 Maternity costs were specifically excluded from this study, and they used no data from it in their letter. They based their claim of a 2 cent per pack cost on the speculation that "If up to one third of pregnant women persist in smoking and are twice as likely to have low birthweight babies, then smoking may be responsible for up to one fourth of all neonatal intensive care unit costs for low-birth-weight babies."

 But this is just a guesstimate based on unfounded assumptions. There haven't been any direct measurements of alleged costs. And serious illness is concentrated in preterm infants, not those who are merely a few grams below average weight.

 A study of 45,000 placentas in the Collaborative Perinatal Study  (Acute chorioamnionitis and the disorders that produce placental insufficiency. RL Naeye. In: Monographs in Pathology No.33, Pathology of Reproductive Failure. FT Kraus et al, eds. Williams and Wilkins 1991. Ch 10, pp 286-307) found that "Acute chorioamnionitis is the largest contributor to the poor pregnancy out-comes of black women and women who have low socioeconomic status," and that it is "the most common cause of preterm labor wherever it has been studied."

 It is also the most commonly missed perinatal diagnosis. Only 1/10 of affected mothers show symptoms, and only 1/4 of fatal cases could be diagnosed without histopathological analysis.  (RL Naeye. The investigation of perinatal deaths (edit). NEJM 1983;309(10):611-612).

 Chorioamnionitis causes villous edema, which results in hypoxia. Low Apgar scores and respiratory distress correlate with the amount of edema. Preterm infants without edema do almost as well as healthy term infants  (The clinical significance of placental villous edema. RL Naeye et al. Pediatrics 1983;71(4):588-594). Poor placental circulation alone, such as that caused by maternal hypertension, does not cause edema, and, "in twin placentas with two completely separate placental circulations the edema was much more severe on the side with the chorioamnionitis" than the unaffected side, proving that the edema originated with the infected fetus, not in the mother's circulation.

 Claims that smoking causes preterm birth are false associations tied to the rates of infection. "Because the frequency of preterm births has hardly changed in the United States during the past three decades, it is unlikely that anything currently being done in the health care system is preventing these infections." This explains why controlling for number of prenatal visits doesn't fully compensate for different infection rates in different subpopulations. This deficiency in medical care is being blamed on the victims themselves.

 But Phibbs found that prenatal care made some difference. Due to socio-economic factors, smokers get the short end here as well.  In the National Longitudinal Survey of Youth 1979-1988, Abma and Mott (Substance use and prenatal care during pregnancy among young women. Fam Planning Perspect 1991; 23(3):117-122,128) found that "Forty-five percent of women who did not receive early prenatal care smoked cigarettes, compared with 35 percent of those who did." Among Hispanics, there was little difference in prenatal care by smoking status. Among blacks, a slightly higher percentage of those who received early prenatal care smoked.

 But among whites, 54.1% of those not receiving early prenatal care smoked, versus 37.8% of those who did receive it. The difference was small among women with less than 12 years of schooling, but large among those with 13 or more years: 37.8% of non-recipients of early prenatal care smoked, versus 19.5% of those who did receive it.

 This accords with the results of studies of race, class, smoking, and birth outcomes. The differences are greatest among low-risk white women. In an examination of National Center for Health Statistics data,  Virji and Cottington (Letter. NEJM Mar 24 1988;318(12):785) noted that the risk of very low birth weight was less for black smokers than non-smokers.

NCHS (Advance report of final natality statistics, 1987. Monthly vital statistics report;38(3 suppl) Hyattsville MD: Public Health Service 1989) also found that "more than 9 in 10 mothers who have graduated from college began prenatal care in the first trimester, compared with just over half of those who are not high school graduates....In 1987, as in the past several years (except 1984), gains in the receipt of prenatal care were confined to the best educated women."

 Courtesy of Carol Thompson 08/23/93
Smokers' Rights Action Group
P.O. Box 259575
Madison, WI 53725-9575
Phone: 608-249-4568

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