Women’s Perspectives on Smoking and Pregnancy and Graphic Warning Labels

Smoking during pregnancy causes adverse health outcomes that can affect women and infants during and after pregnancy. It increases the likelihood of pregnancy complications such as placenta previa, placental abruption, miscarriage, preterm birth, and premature membrane rupture.1,2 Infants born to women who smoke are at higher risk for low birthweight (LBW), stillbirth, infant death (sudden infant death syndrome, or SIDS)1,2 and may be at risk of orofacial clefts (ie, cleft lip with or without cleft palate and cleft palate alone).2–4 Women of childbearing age who smoke are also at higher risk of conception delay and infertility.1,2 Despite these risks, according to US Pregnancy Risk Assessment Monitoring System data from 27 sites in 2010, 23% of US women smoked in the 3 months before pregnancy and almost 11% smoked during the last trimester of pregnancy.5 US women are increasingly aware that smoking during pregnancy is risky.6 Two studies published more than 10 years ago showed that US women were familiar with the risk of LBW.7,8 Since then, as previously mentioned, a preponderance of scientific evidence has shown causal associations between smoking before and during pregnancy and adverse health outcomes. Therefore, additional research is needed on women’s knowledge, attitudes, and beliefs about the health outcomes currently known to be associated with smoking before and during pregnancy. Furthermore, to our knowledge, no studies have ever assessed US women’s knowledge about specific birth defects associated with smoking during pregnancy or which health outcomes might motivate women to quit. Findings could stimulate new or improve existing cessation programs, educational campaigns, and policies that target women of childbearing age. One initiative that may have widespread reach and influence among US women who smoke is the placement of graphic warning labels on cigarette packages. Studies have found that graphic warning labels attract the attention of smokers,9 increase awareness of health hazards of smoking,10 increase smokers’ thoughts about these health risks,10,11 and promote interest in smoking cessation.9,12 A detailed timeline of the US Food and Drug Administration’s (FDA) graphic warning label regulations and court decisions has been previously published.13 The Family Smoking Prevention and Tobacco Control Act of 2009 gave the FDA regulatory authority to establish rules for larger and more prominent warning labels, including graphics, on cigarette packaging and advertising. In June 2011, FDA published a final rule requiring graphic warning on cigarette packages and proposed that 9 new warning labels would be in place at the beginning of September 2012. One of 9 proposed graphic warning labels was a cartoon-style graphic of a baby in an incubator with the text warning: “Smoking during pregnancy can harm your baby.” Court challenges have delayed implementation of graphic warnings. A federal appeals court blocked the proposed warnings, citing a violation of corporate speech rights and requesting additional evidence that FDA’s proposed warnings would discourage smoking.14 The FDA currently plans to undertake research to support new rule-making consistent with the Tobacco Control Act. We conducted focus groups with women ages 18–30 who were smokers and planning a pregnancy or who were recently pregnant. We explored women’s knowledge, attitudes, and beliefs about adverse health outcomes associated with smoking and pregnancy and which outcomes might motivate them to quit before and during pregnancy. We also examined women’s reactions to graphic warning labels that depicted 2 adverse outcomes associated with tobacco use: an infant with cleft lip with or without cleft palate and an infant in an incubator.