Principal Health Policy The prevalence of smoking among pregnant and postpartum women in Israel: a national survey and...

The prevalence of smoking among pregnant and postpartum women in Israel: a national survey and review

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Health Policy 73 (2005) 1–9

The prevalence of smoking among pregnant and postpartum
women in Israel: a national survey and review
Nirah Fishera,c,∗ , Yona Amitaia,c , Miri Haringmana,c ,
Hana Meirazb,c , Nira Baramb,c , Alex Leventhalc

Department of Mother, Child and Adolescent Health, Ministry of Health, 20 King David Street, Jerusalem 91010, Israel
b Public Health Nursing, Ministry of Health, Jerusalem 91010, Israel
c The Public Health Service, Ministry of Health, Jerusalem 91010, Israel

Background: Cigarette smoking during pregnancy is a significant health risk to the developing fetus. In order to develop and
implement an appropriate preconceptional and prenatal smoking cessation program a national pregnancy risk survey was done.
Methods: The survey was conducted through the Public Health Service’s, Mother and Child Health Clinics (MCHC). The
nursing staff initiated structured interviews with pregnant women and mothers of newborn infants. Questions included in the
survey addressed folic acid utilization, smoking habits, onset of prenatal care and demographic characteristics.
Results: Overall, of the 1613 questionnaires received with smoking data, 12.8% of the women had smoked either in the 3 months
preceding their current pregnancy and/or during their pregnancy. The smoking prevalence in Jewish women, was significantly
greater then that found among Arab women (17.2 and 3.0%, P < .001, OR = 7.5, CI = 4.2−13.4). The prevalence of smoking for
the duration of the pregnancy was 8.0% among Jewish women and 1.8% among Arab women. Among Jewish women, smoking
prevalence was significantly associated with education, women who had completed 12 years of education were more likely to
be nonsmokers (P = .034, OR = 1.8, CI = 1.0–3).
Conclusion: Smoking in the preconceptional and prenatal period is a significant problem among Jewish women. Since less
years of education is a significant risk factor, smoking cessation programs should focus on this subgroup of Jewish women.
© 2004 Elsevier Ireland Ltd. All ; rights reserved.
Keywords: Smoking; Prenatal; Survey; Review; Preconceptional

1. Introduction

∗ Corresponding author. Tel.: +972 2 6228834;
fax: +972 2 6228907.
E-mail address: (N. Fisher).

One-third of the global adult population, or 1.1 billion people, use tobacco [1]. Since the release of the first
U.S. Surgeon General’s report on smoking and health
in 1964, the concept that ‘cigarette smoking is a health
hazard of sufficient importance to warrant appropriate

0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.


N. Fisher et al. / Health Policy 73 (2005) 1–9

remedial action’ has achieved worldwide recognition
The WHO ‘Tobacco Free Initiative Atlas’ concludes
that tobacco use is one of the leading preventable causes
of death, and the second major cause of death worldwide [1].
Approximately 250,000,000 women in the world are
daily smokers [1]. The first Surgeon General’s report
on women and smoking was published in 1980 [3].
Women who smoke are at risk for cancer, cardiovascular disease and chronic obstructive pulmonary disease
as are male smokers [1–4]. Female smokers in addition are at risk for many reproductive related disorders
The incidence of self reported amenorrhea tends to
be about 50% higher among smokers than among nonsmokers [5]. Cigarette smoking is associated with an increased risk of primary and secondary infertility [6,7].
The pregnancy rate of smokers over time is 60–90% of
that of nonsmokers [5–7].
Once fertilization is achieved, cigarette smoking is
associated with an increased risk of ectopic pregnancy
(RR = 1.8) [8]. When the pregnancy is in utero, women
who smoke have an increased risk of premature rupture
of membranes associated with premature delivery [9].
Preterm delivery (<37 weeks gestation) is strongly
associated with an increased risk for fetal, neonatal and
perinatal mortality [1,3,4,9]. The 1980 Surgeon General’s report on the health consequences of smoking
for women concluded that smoking during pregnancy
increases the risk of preterm delivery, and that this risk
is incremental with the quantity of cigarettes smoked
[3]. The report estimated that 11–14% of preterm births
were attributable to smoking during pregnancy. Since
then other studies have demonstrated similar findings
[1,4,9,10]. Smoking cessation during pregnancy seems
to reduce the risk for preterm delivery, but reducing the amount of cigarettes smoked does not seem
to have this effect [4,10]. Smoking in pregnancy is
associated with a reduced birth weight of approximately 250 g [1,3,4,9–14]. The weight differential increases with and is apparently a direct function of the
quantity smoked [3,4,13,14]. Maternal smoking during pregnancy is a risk factor for low birth weight
(LBW < 2500 g) (RR = 1.5–3.5) and small for gestational age infants (SGA) (RR = 1.5–10) [1,3,4,9–14].
Cigarette smoking during pregnancy has been associated with an increased risk for stillbirth (fetal death af-

ter 28 weeks gestation) and neonatal death (within 28
days of birth) [1,3,4,15,16]. Of the 136,390 live births
in Israel in 2001, over 9500 or 7.3% were LBW infants
[17]. Israeli infant mortality data for the birth cohort
of 2001 reveal an overwhelming overrepresentation of
LBW infants, and 62% of the mortality incidence is
among infants who were LBW [17].
A number of large studies have noted an increased
risk for cleft lip with increasing amounts of maternal
smoking [1,4,18,19]. Czeizel reported an increased risk
for limb reductions for infants born to mothers who
smoked during the pregnancy and in other studies maternal smoking was found to be a risk factor for congenital urinary tract abnormalities (RR = 2.3) [1,4,20–22].
Abruptio placenta has been associated with maternal
cigarette smoking [4,23].
In 2003, Law et al. reported that tobacco exposed
newborns manifested a distinctive pattern of abnormal
neurobehavioral functions including excitability, hypertonicity and increased settling time. There was a
definite dose-response relationship with higher maternal salivary cotinine [24].
Smoking compromises breastfeeding, both in
amount and duration. The daily milk production of lactating smokers is approximately 250 ml less than that
of non-smokers. Reduced maternal milk supplies, negatively impact on breastfeeding duration [4,25].
In many studies maternal smoking during pregnancy
has been associated with an increased risk for sudden
infant death syndrome (SIDS) (RR = 2.3–3) [1,4,26].
Smoking while pregnant has also been indicated as
a risk factor for the development of ADHD [4,27,28].
In addition to all of the obstetric and gynecological issues it is important to mention that the leading
cause of death for women in Israel in the 25–44 year
age bracket is cancer [29]. The WHO has concluded
that 30% of all cancer mortality is smoking related [1].
Among Israeli women aged 45–64, cardiovascular and
heart disease is the predominant cause of mortality and
was responsible for over 40% of all deaths [29,30].
Smoking triples the risk of dying from ischemic heart
disease, arteriosclerosis and aortic aneurisms among
middle-aged women and increases more than four-fold
the risk of a CVA [1,29,31].
Given the vast array of insults to the woman, the
fetus and the infant as a result of maternal smoking,
this study was undertaken as part of a national survey
of pregnancy risk. Within the context of preconcep-

N. Fisher et al. / Health Policy 73 (2005) 1–9

tional folic acid utilization we assessed health habits of
pregnant women and mothers of newborn infants and
addressed smoking prevalence in pregnant and postpartum women.


asked if they were currently smoking, and if so how
many cigarettes daily.
Religion was classified as Jewish, Moslem Arab,
Christian Arab, Druze and other and/or unknown. Statistical analysis was performed using SPSS 11.

2. Methods
3. Results
The target population consisted of all pregnant
women and recently pregnant, mothers of infants under
age 2 months, who presented at the MCHC for either
prenatal or newborn care.
The survey was conducted both on women in the
prenatal service and women who entered the service for
newborn care within 2 months of having given birth.
We surveyed the pregnant population in order to minimize bias recall. Approximately 60% of Israeli women
are followed by the public health services clinics at
some point in their prenatal care. Prenatal care is offered at the MCHC and also through the ‘kupot cholim’
(sick funds – HMOs). In regards to the newborn and
toddler population, the government sponsored MCHC
provide care to approximately 84% of all children from
birth to school age. Both groups of women were therefore included in order to insure a representative population.
In August 2002, a total of 2334 questionnaires were
distributed via district health offices to 521 MCHC,
throughout the country. Three to five questionnaires
were distributed to each MCHC, in proportion to the
population served. The public health nursing staff at
the individual clinics conducted a structured interview.
During the study period sampling was done on the first
women who presented at the individual child health
Women were asked if they had smoked in the 3
months preceding their pregnancy, and if so how many
cigarettes daily. Having smoked in the 3 months preceding the pregnancy and or during the pregnancy was
defined as ‘smoking prevalence’.
In order to assess the prevalence of smoking, while
pregnant; mothers of newborns were asked if they had
smoked in the final 3 months of their pregnancy, and
pregnant women were asked if they had smoked in the
3 months preceding the administration of the questionnaire. Smokers were designated as ‘smoked throughout
the pregnancy’ if they had responded affirmatively to
either question. In addition, mothers of newborns were

A total of 1661 (71%) questionnaires were returned
from 395 MCHC (76%). The 395 MCHC that responded had received a total of 1757 questionnaires.
The compliance rate from the individual MCHC that
took part in the study was 95%.
Smoking status data was available for 1613 (97.0%)
of survey respondents. The respondent population was
comprised of 1064 (66.0%) Jews, 350 (21.7%) Arab
Moslems, 67 (4.2%) Arab Christians, 76 (4.2%) Druze
and 56 (3.5%) ‘other/or religion unknown’ women.
Due to the small numbers involved, the non-Jewish minorities were combined (N = 493, 31%), and treated as
one bloc for statistical analysis. The data was examined
as it related to Jewish and Arab blocs. Jewish women
surveyed were significantly older (P < .001), had significantly fewer pregnancies (P = .003), and significantly
more years of education (P < .001) than Arab women
(Table 1).
3.1. Smoking prevalence
The overall smoking prevalence in the study population was 12.8% (N = 207) (Table 1). The smoking
prevalence in Jewish women (17.2%) was significantly
greater than that of Arab women (3.0%). The difference in prevalence between Jewish and Arab women
remained significant after adjusting for age, education and parity differentials between the two groups
(OR = 7.5, CI = 4.2–13.4).
Women interviewed postnataly (N = 781), had a
smoking prevalence of 15.2% (N = 119). Women interviewed while pregnant (N = 783) reported a significantly lower smoking prevalence of 10.7% (N = 84).
This difference remained significant even after adjusting for education, parity and age (P = .003, OR = 0.615,
CI = 0.446–0.847).
When examining Jewish women as a subgroup, the
smoking prevalence was 18.3% for women interviewed
as mothers of newborns and 16.0% for women inter-


N. Fisher et al. / Health Policy 73 (2005) 1–9

Table 1
Survey demographics and self reported smoking prevalence
Total (N = 1613)


Age Mean (S.D.)

Number of children

Years of education

Jewish women
Arab women
Jewish smokers
Jewish non-smokers
Arab smokers
Arab non-smokers


28.8 (5.3) 28a
27 (5.1) 26
29 (5.3) 28
28.7 (5.3) 28
29 (6.5) 29
27.0 (5.0) 26

2.3 (1.8) 2.0b
2.5 (1.5) 2.0
1.8 (1.4) 1.0
2.4 (1.9) 2.0d
2.5 (1.9) 2.0
2.5 (1.5) 2.0

13.7 (2.6) 13.0c
11.6 (2.8) 12
13.0 (2.0) 12
13.8 (2.7) 13e
10.9 (2.6) 10.5
11.6 (2.9) 12

Smoking prevalence
Smoked throughout

Total (N = 1613)

(N = 1064) (%)

Arab Moslem, Christian
and Druze (N = 493) (%)

Unknown and
other (N = 56) (%)

N = 1406
N = 207
N = 98

N = 881
N = 183
N = 85

N = 478
N = 15

N = 47





P < .001, OR = 1.1, CI = 1.05–1.11.
P < .003, OR = 0.883, CI = 0.81–0.96.
P < .001, OR = 1.3, CI = 1.3–1.4.
P < .001, OR = 1.24, CI = 1.11–1.39.
P = .001, OR = 1.12, CI = 1.05–1.19.
P < .001, OR = 7.5, CI = 4.2–13.4. Jewish women vs. Arab women after adjusting for age, education, and parity.

viewed while pregnant. This difference was not significant (P = .076). Among Arab women the overall smoking prevalence among women interviewed as mothers
of newborns was 5.0%, and for women interviewed
while pregnant, the overall smoking prevalence was
2.0%. This difference in prevalence was significant after adjusting for education, parity and age (P = .022,
OR = 0.26, CI = 0.082–0.822). Due to the small number of actual smokers among Arab women interviewed
(15/493), only a partial further analysis was done for
Arab women smokers.
3.2. Smoking intensity
An analysis of Jewish smokers revealed that 27.9%
(N = 51) were light smokers (smoking 1–5 cigarettes
daily), 27.3% (N = 50) were average smokers (smoking 6–10 cigarettes daily), 37.2% (N = 68) were heavy
smokers (smoking 11–20 cigarettes per day) and 7.7%
(N = 14) were very heavy smokers (smoking more than
20 cigarettes daily) (Table 2C).
3.3. Demographics and smoking indicators
Jewish women, 30 years of age and older had
the highest rate of smoking. Smoking intensity also

increased with age. Not only did older women
tend to smoke, they also smoked more cigarettes
than their younger smoking counterparts, though
not significantly (P = .251) (Table 2A). Jewish
women smokers had significantly fewer children and
less years of education than Jewish non-smokers
(Table 1).
The prevalence of smoking decreased with increasing education in the Jewish population (Table 2B).
While the trend was significant in the Jewish population (P < .001), in the Arab population smoking
prevalence actually increased with increasing education (3.0–4.5%) though not significantly. Smoking intensity also decreased with increasing education in the
Jewish population (Table 2C).
More than half (53.6%) of the Jewish women smokers (98/183), reported that they had stopped smoking
for at least 3 months while pregnant as opposed to less
than half (40.0%) of the Arab women smokers (6/15).
The prevalence of smoking throughout the pregnancy
was 8.0% for Jewish women and 1.8% for Arab women
(Fig. 1).
Approximately one third (19/62) of the Jewish
‘mothers of newborns’, who reported a smoking cessation in the final 3 months of pregnancy, had re-

N. Fisher et al. / Health Policy 73 (2005) 1–9


Table 2
Smoking prevalence and smoking intensity: correlates of age and education
Age group




(A) Smoking prevalence and age groupings
Jewish survey respondents (N = 1059)
Smoking prevalence (N = 181, total Jewish smokers) (%)
Heavy and very heavy smokers (N = 82) (%)

N = 236
N = 36 (15.3)
N = 16 (6.8)

N = 399
N = 68 (17.0)
N = 28 (7.0)

N = 424
N = 77 (18.2)
N = 38 (9.0)

Years of education

Total Jewish women

(B) Educational groupings smoking prevalence
≤12 years
N = 506
13–15 years
N = 297
≥16 years
N = 257

Jewish smokers* N (%)

Total Arab women

Arab smokers N (%)

114 (22.5)
42 (14.1)a
26 (10.1)

N = 363
N = 67
N = 54

11 (3.0)
3 (4.5)
0 (0.0)

Years of education** 1–5 Light smokers N (%) 6–10 Average smokers N (%) 11–20 Heavy smokers N (%) >20 Very heavy smokers N (%)
(C) Smoking intensity (Number of daily cigarettes): distribution among Jewish women as correlates of educational group
29 (5.8)
31 (6.3)
43 (8.7)
11 (2.2)
12 (4.7)
14 (4.9)
17 (5.9)
2 (0.7)
9 (3.1)
5 (2.0)
8 (3.1)
1 (0.4)

50 (27.5)

50 (27.5)

68 (37.4)

14 (7.7)

Due to small number of smokers in the Arab population intensity and age-group analysis was done only on Jewish women.
a Jewish women with 13–15 years of education were more likely to be non-smokers (P < 0.001, OR = 2.5, CI = 1.6–4.0) than Jewish women
with ≤12 years of education, age NS.
∗ P < 0.001 in Jewish women between educational group and smoking: even after controlling for age.
∗∗ P = <0.001 between educational group and smoking intensity group.

sumed smoking by the time of the postpartum interview
(Table 3).
A Jewish light smoker was more than twice as likely
to have stopped smoking while pregnant than a Jewish heavy and very heavy smoker (P = .024). Among
Jewish women who reported smoking cessation while

pregnant, average smokers were less likely to have resumed smoking postpartum (P = .012) than heavy and
very heavy smokers (Table 3).
Preconceptional folic acid utilization among Jewish
smokers was significantly lower (25.1%) than among
Jewish non-smokers (36.5%), even after adjusting for

Table 3
Smoking habits of Jewish smokers as defined by smoking group and postnatal smoking behavior
Smoking group and daily
cigarette consumption

Light smokers 1–5
Average smokers 6–10
Heavy and very heavy
smokers ≥11 cigarettes


Smoked throughout
the pregnancy N (% of
smokers in that group)

Smoking cessation of 3
months while pregnant
N (% of smokers in that

Mothers of newborns
in smoking cessation

Mothers of newborns
in smoking cessation
group who resumed
smoking postpartum N


15 (29.0)

36 (71.0)a

N = 25

7 (28.0)


24 (48.0)

25 (50.0)

N = 17

5 (29.0)b


45 (55.0)

37 (45.0)

N = 20

7 (35.0)


84 (46.0)

98 (54.0)

N = 62

19 (31.0)

a Light smokers were more likely to have stopped smoking while pregnant versus heavy and very heavy smokers, controlling for age and
education (P = 0.024, OR = 2.6, CI = 1.14–6.11).
b Average smokers were less likely to have resumed smoking postpartum than heavy and very heavy smokers, controlling for age and education
(P = 0.012, OR = 0.278, CI = 0.103–0.752).


N. Fisher et al. / Health Policy 73 (2005) 1–9

Fig. 1. Smoking patterns in currently pregnant and recently pregnant israeli women.

age and education (P = .038, OR = 0.67, CI = 0.46–98).
Arab women smokers also had decreased folic acid
utilization (13.3%) versus their non-smoking Arab
counterparts (20.9%) though the differential was not

4. Discussion
In a survey of women aged 21–54 conducted by
the Israel Center for Disease Control (ICDC), the
prevalence of smoking in women varied by age group
(18.8–25.7%) and older women tended to be the heaviest smokers [32].
Our study focused only on currently and recently
pregnant women. Smoking prevalence overall in our

study was 12.8% with a worrisome prevalence of
17.2% reported by Jewish women, preconceptionaly.
Jewish women gave birth to 94,327 babies in 2002
[30]. We can now postulate that over 16,000 of those
pregnancies began while the woman was smoking.
Arab women gave birth to 40,931 babies in 2002 [30].
With a smoking prevalence of 3.0% approximately
1200 births were affected. It is important to note that
the proportion of the Arabs in the general population in
Israel is approximately 19%. Their representative participation in the survey however, was 32%, which is
similar to their proportion of births in 2001 [30].
In our survey the prevalence of smoking among
women increases with age; older women have a higher
prevalence of smoking and tend to be heavier smokers.
In 2002, the number of births for Jewish women aged

N. Fisher et al. / Health Policy 73 (2005) 1–9

30 and above was 44,075 an increase of 31.0% for that
age bracket from 1992, while the overall Jewish birth
rate rose by only 21.0% [30,33]. The age of women
having babies is increasing and older women have a
higher smoking prevalence. If we extrapolate from our
survey at a smoking prevalence of 9.1% for heavy and
very heavy smokers in the Jewish population, over 4000
babies are being born a year to women who are over
age 30 and are heavy and very heavy smokers.
Close to half of our smoking, survey respondents
reported that they had a smoking cessation hiatus of at
least 3 months while pregnant. In a study reported by
Moore et al. in 2002, the self-reported smoking cessation rate by English pregnant women was 27.4% while
the documented rate by urine assay of cotinine was in
fact 19.8% [34]. Though self-report is an easy and accessible survey methodology the question of accuracy,
reliability and predictive value remains. In our study,
mothers of newborns reported significantly higher rates
of smoking. It is possible that once no longer pregnant, women feel freer to relate their smoking histories,
which they might very well feel obligated to deny while
pregnant. Whether our numbers are real or whether
they are severely underestimated, we have a significant
health problem.
One of the major indicators or correlates with smoking status in our survey was the woman’s years of education. Women who have less years of education are
at a greater risk for being not only smokers, but also
heavy smokers.
Most tobacco use starts during childhood and adolescence [1,4,35–37]. A survey conducted by the Israeli
Defense Forces Army in 2002, reported that between
the years 1990–2000, there was an 86% increase in the
prevalence of women who smoked before their conscription. Women conscripted in 2002, reportedly began smoking on average by age 15.7 years [36]. We
must consequently focus not only on the older women
who are having babies but on the teenagers as well
since they represent the pool of future mothers and the
teenage years is when the groundwork is being laid or
corrupted in regards to future health habits.
The United Nations Tobacco Free Initiative recommends using schools as the ideal venue for imparting
not only ‘knowledge about the harmful effects of
smoking but also knowledge of the manipulations of
the tobacco industry and techniques for refusal’ [1].
Implementing a high school and elementary school


smoking cessation program would appear to be in order
as the average age of smokers is getting younger. Preventing initiation of tobacco use among young adults
and youth is more effective than providing smoking
cessation counseling once smoking has begun [1,4,37].
Nearly 10,000 babies born in Israel in 2001 were
designated LBW [17,33]. The smoking attributable
cost of neonatal health care per LBW birth in the US
is estimated to be US$ 1388 in 1999 [31]. It has been
estimated that elimination of maternal smoking could
lead to at least a 10% reduction in all infant deaths
and 12% reduction in death from perinatal conditions
[1,4,31,37]. Economics alone would seem to dictate
the necessity for a cogent and effective smoking prevention program and in this review we have not even
addressed the ramifications of passive smoke exposure
on the newborn and infant in terms of SIDS and infectious disease.
In 1988, the US Surgeon General’s report concluded
that cigarettes and other forms of tobacco are addictive,
that nicotine is the drug in tobacco that causes addiction and finally that the pharmacological and behavioral
processes that determine addiction are similar to those
that determine addiction to such drugs as heroin and
cocaine [38]. No one would think of addressing drug
addiction as solely an obstetric issue, similarly smoking cessation programs targeting women in order to
be effective must span the entire life cycle and not be
limited to the prenatal period.
The Maternal Child Health staff at the MCHC
provides ongoing comprehensive preventive care to
women and children. As such the nurse establishes an
ongoing relationship with the woman, as her caretaker
during the pregnancy and family planning clinics, and
as a health provider to the infant and toddler. There
are multiple opportunities to reinforce and follow up
on health education messages. Women are more motivated to stop smoking while pregnant and are in regular contact with health services [34]. When providing
prenatal care the nurse routinely addresses the issue
of smoking cessation. It would appear that a preconceptional and a postnatal smoking cessation program
are also needed in order to reinforce the message and
insure that pregnancies are begun smoke free, remain
smoke free throughout and that women, infants and toddlers remain smoke free postnatally. Any contact with
a woman in the childbearing years must be viewed as
an opportunity for health promotion, health education,


N. Fisher et al. / Health Policy 73 (2005) 1–9

positive behavior reinforcement, and an opportunity to
reiterate and follow up on and reinforce a smoke free
As Israel adapts a consumer-oriented lifestyle, hopefully we will forego the number one selling consumer
product in the world – cigarettes, by adapting a multidisciplinary approach that includes mass media, legislation and educational programs. The Minister of
Health in Israel in his 2003 report on smoking has
recommended this approach [32]. According to the
WHO bans on advertising of tobacco products and
tobacco tax increases are among the most cost effective population based strategies available for tobacco
control. This approach does not require a behavior
change on the part of the consumer/user, but in effect alters the environment in order to promote better health
habits [1]. Concurrent with the necessary legislation
we must develop a strategy that can appropriately target the different educational groups and ages, and effectively communicate the correct health message that
will properly impact on long-term behavior as well as

We are indebted to the nurses of the Tipot Halav
(MCHC) throughout the country who were instrumental in interviewing the study women. Particular thanks
to the following nurse supervisors for their role in organizing the distribution of the survey questionnaire: Yael
Arbelli, Bracha Avraham, Chana Ben-Ari, Yardena
Ben-Chamu, Gila Benztik, Zahava Dror, Naomi Eidelstein, Sara Hadar, Hannah Levensohn, Rachel Maoz,
Ron Maybar, Yehudit Pasternak, Mirriam Payis, Mira
Ron, Leora Shachar, Gila Stern, Liora Vasterman and
Ilana Yaacobi. In addition we would like to thank Professor Joel Zlotogora for his inspiration.

[1] WHO Mackay J, Eriksen M. The tobacco atlas. Tobacco Free
Initiative; June 2003.
[2] U.S. Department of Health, Education and Welfare. Smoking
and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. U.S. Department of
Health, Education and Welfare, Public Health Service. Communicable Disease Center, 1964 (DHEW Publication No. 1103).

[3] U.S. Department of Health and Human Services. The Health
Consequences of Smoking for Women. A report of the Surgeon General. Washington: U.S. Department of Health and
Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health,
[4] U.S. Department of Health and Human Services. Health Consequences of Tobacco Use Among Women. A report of the Surgeon General. Washington: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,
[5] Hornsby PP, Wilcox AJ, Weinberg CR. Cigarette smoking and disturbance of menstrual function. Epidemiology
[6] Joesoef MR, Beral V, Aral SO, Rolfs RT, Cramer DW. Fertility
and use of cigarettes, alcohol, marijuana and cocaine. Annals
of Epidemiology 1993;3(6):592–4.
[7] Curtis KM, Savitz DA, Arbuckle TE. Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability.
American Journal of Epidemiology 1997;146(1):32–41.
[8] Saraiya M, Berg CJ, Kendrick JS, Strauss LT, Atrash HK,
Ahn YW. Cigarette smoking as a risk factor for ectopic
pregnancy. American Journal of Obstetrics and Gynecology
[9] Castles A, Adams EK, Melvin CL, Kelsch C, Boulton ML.
Effects of smoking during pregnancy: five meta-analyses.
American Journal of Preventive Medicine 1999;16(3):208–
[10] Mainous AG, Hueston WJ. The effect of smoking cessation during pregnancy on preterm delivery and low birthweight. Journal
of Family Practice 1994;38(3):262–6.
[11] Conter V, Cortinovis I, Rogari P, Riva L. Weight growth in
infants born to mothers who smoked during pregnancy. British
Medical Journal 1995;310(6982):768–71.
[12] Murphy NJ, Butler SW, Petersen KM, Heart V, Murphy CM.
Tobacco erases 30 years of progress: preliminary analysis of
the effect of tobacco smoking on Alaska native birth weight.
Alaska Medicine 1996;38(1):31–3.
[13] Centers for Disease Control. Effects of maternal cigarette
smoking on birth weight and preterm birth—Ohio, 1989.
Morbidity and Mortality Weekly Report 1990;39(38):662–
[14] Castro LC, Azen C, Hobel CJ, Platt LD. Maternal tobacco use
and substance abuse: reported prevalence rates and associations
with the delivery of small for gestational age neonates. Obstetrics and Gynecology 1993;81(3):208–15.
[15] Cnattingius S, Haglund B, Meirik O. Cigarette smoking as
risk factor for late fetal and early neonatal death. BMJ
[16] Schramm WF. Smoking during pregnancy: missouri longitudinal study. Paediatric and Perinatal Epidemiology
1997;11(Suppl. 1):73–83.
[17] National report on Infant Mortality for 2001. Ministry of Health.
Public Health Service. Bureau of Maternal, Child and Adolescent Health. Jerusalem, Israel, December 2002.

N. Fisher et al. / Health Policy 73 (2005) 1–9
[18] Shaw GM, Wasserman CR, Lammer EJ, O’Malley CD, Murray
JC, Basart AM, Tolarova MM. Orofacial clefts, parental cigarette smoking and transforming growth factor-alpha gene variants. American Journal of Human Genetics 1996;58(3):551–61.
[19] Christensen K, Olsen J, Norgaard-Pedersen B, Basso O,
Stovring H, Milhollin-Johnson L, et al. Oral clefts, transforming growth factor alpha gene variants and maternal smoking:
a population based case-control study in Denmark. American
Journal of Epidemiology 1999;149(3):248–55.
[20] Lorente C, Cordier S, Goujard J, Ayme S, Bianchi F, Calzolari E, et al. The occupational exposure and congenital malformations working group. American Journal of Public Health
[21] Czeizel AE, Kodaj I, Lenz W. Smoking during pregnancy and
congenital limb deficiency. BMJ 1994;308(6942):1473–6.
[22] Li DK, Mueller BA, Hickok DE, Daling JR, Fantel AG, Checkoway HW, et al. Maternal smoking during pregnancy and the
risk of congenital urinary tract anomalies. American Journal of
Public Health 1996;86(2):249–53.
[23] Karegard M, Gennser G. Incidence and recurrence rate of
abruptio placentae in Sweden. Obstetrics and Gynecology
[24] Law KL, Stroud LR, LaGasse LL, Niaura R, Liu J, Lester BM.
Smoking during pregnancy and newborn neurobehavior. Pediatrics 2003;111(6 Pt 1):1318–23.
[25] Hopkinson JM, Schanler RJ, Fraley JK, Garza C. Milk production by mothers of premature infants: influence of cigarette
smoking. Pediatrics 1992;90(6):934–8.
[26] Pollack HA. Sudden infant death syndrome, maternal smoking during pregnancy, and the cost-effectiveness of smoking cessation intervention. American Journal of Public Health
[27] Milberger S, Biederman J, Faraone SV, Jones J. Further evidence of an association between maternal smoking during pregnancy and attention deficit hyperactivity disorder: findings from
a high-risk sample of siblings. Journal of Clinical Child Psychology 1998;27(3):352–8.


[28] Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB,
Rodriguez A, et al. Maternal lifestyle factors in pregnancy risk
of attention deficit hyperactivity disorder and associated behaviors: review of the current evidence. American Journal of
Psychiatry 2003;160(6):1028–40.
[29] Israeli Cancer Society. FAQ Sheet on Smoking, 2003.
[30] Central Bureau of Statistics. Statistical Abstract of Israel No.
54. Jerusalem, Israel, 2003.
[31] MMWR. Annual Smoking-Attributable Mortality, Years of
Potential Life Lost, and Economic Costs – US, 1995–1999.
[32] Minister of Health’s Report on Smoking. National Survey of Israeli Youth: Health Attitudes and Behavior. Ministry of Health.
Israel Center for Disease Control. Jerusalem, Israel, 2003.
[33] Central Bureau of Statistics. Statistical Abstract of Israel No.
49. Jerusalem, Israel, 1998.
[34] Moore L, Campbell R, Whelan A, Mills N, Lupton P, Misselbrook E, et al. Self help smoking cessation in pregnancy: cluster
randomised controlled trial. BMJ 2002;325(7377):1383.
[35] Bar-Hamburger R, Rahav G, Teichman M, Gil R, Rosenblum
I. Psychoactive drug use in Israel: survey and analysis. In:
Proceedings of the IV Epidemiological Study- Reshut Lemiclchama Besamim – Drug Abuse Prevention Authority, 1998.
[36] Israel Defense Forces. Health surveillance on smoking in the
IDF 1980–2002. Chief of Staff Medical Corporation, IDF. Internal document, Israel, 2003.
[37] U.S. Department of Health and Human Services. Reducing Tobacco Use. A report of the Surgeon General. Atlanta, GA: U.S.
Department of Health and Human Services, Centers of Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and
Health, 2000.
[38] U.S. Department of Health and Human Services. Smoking and
Health. A report of the Surgeon General. Washington: U.S. Department of Health and Human Services, Public Health Service,
Office of the Assistant Secretary for Health, Office on Smoking
and Health, 1988.