- Email: [email protected]
The Co-Occurrence of Maternal Depressive Symptoms and Smoking in a National Survey of Mothers
The Co-Occurrence of Maternal Depressive Symptoms and Smoking in a National Survey of Mothers Megan Kavanaugh, MD; Robert C. McMillen, PhD; John M. Pascoe, MD, MPH; Linda Hill Southward, PhD; Jonathan P. Winickoff, MD, MPH; Michael Weitzman, MD Context.—Both maternal smoking and depression are common and can adversely impact child health and functioning, yet few studies have explored their co-occurrence among mothers. Objective.—To determine the prevalence and associations of depression and smoking among mothers in the United States. Design.—Random-digit-dial national telephone survey of 1530 households conducted in 2002. Respondents were asked about their sociodemographic characteristics, smoking status, and their children’s receipt of Medicaid. A validated 3-item depression screen was administered. Bivariate and multiple regression analyses for maternal smoking and a positive depression screen were performed. Setting.—National sample. Participants.—Seven hundred two mothers with children aged less than 19 years living in their homes. Results.—The response rate was 61%. Among mothers, 24.3% were smokers, 24.4% had a positive depression screen, 8.1% had both, and 40.6% were smokers and/or had a positive depression screen. All rates were greater among mothers whose children receive Medicaid (37.6%, 47.5%, 20.6%, and 64.5%) than those whose children do not receive Medicaid (21.1%, 19.0%, 4.8%, and 35.3%) (P , .001) for each. In multivariate analyses, maternal smoking was independently associated with a 70% increased risk of depressive symptoms (odds radio, 1.7; 95% confidence interval, 1.1–2.6). Conclusions.—This study highlights both the frequency and the co-occurrence of maternal smoking and maternal depressive symptoms, two negative influences on children’s health and development, as well as their increased prevalence among mothers whose children receive Medicaid, thereby highlighting the economic disparities associated with both. These findings have significant implications for our nation’s children, health care clinicians, and health care payers. KEY WORDS:
environmental tobacco smoke; maternal depression; Medicaid; smoking
Ambulatory Pediatrics 2005;5:341 348
M
ing.1–3
aternal smoking and depression are common and each have significant adverse effects on both maternal and child health and functionOver 20% of parents smoke4 and more than one
third of children are exposed to secondhand smoke at home.5 Prenatal and childhood exposure to tobacco smoke is associated with increased childhood morbidity and mortality, including lower respiratory tract infections and hospitalizations, asthma, recurrent otitis media, and Sudden Infant Death Syndrome, as well as increased rates of cognitive and behavioral problems.1,6,7 The reported prevalence of depressive symptoms among mothers with young children ranges from 17% to 42%.8–13 Depressed mothers are less likely to read to or engage in a variety of diseaseprevention practices with their children.14,15 Children who live with depressed mothers have more physical,2,16 mental health,17,18 and behavioral19 problems. While there are substantial literatures both on child health disparities and the epidemiology and effects of adult smoking and maternal depression, to date we are unaware of any recognition of maternal smoking or depression as issues of child health disparities. The adult literature clearly demonstrates that poor, near poor, and poorly educated individuals are far more likely to be tobacco smokers. Unlike many disparities in child health, however, adults from most racial and ethnic minorities smoke at lower rates than do white individuals.20 Among adults, depression is clearly more common in women and in single or divorced persons. There are no differences in rates of depression by race or ethnicity and, while the data are mixed, there may be slightly higher rates of depression among adults of lower socioeconomic status.21
From the American Academy of Pediatrics (Drs Kavanaugh and Weitzman), Center for Child Health Research, Rochester, NY; University of Rochester School of Medicine and Dentistry (Dr Kavanaugh), Rochester, NY; Social Science Research Center (Drs McMillen and Southward), Mississippi State University, Starkville, Miss; Tobacco Consortium (Drs McMillen, Winickoff and Weitzman), American Academy of Pediatrics, Center for Child Health Research, Rochester, NY; Department of Pediatrics (Dr Pascoe), Wright State University School of Medicine and The Children’s Medical Center, Dayton, Ohio; Health, Early Care and Education Consortium (Drs Pascoe, Southward, and Weitzman), American Academy of Pediatrics, Center for Child Health Research, Rochester, NY; MGH Center for Child and Adolescent Health Policy (Dr Winickoff), General Pediatrics Division, MassGeneral Hospital for Children, Boston, Mass; Tobacco Research and Treatment Center (Dr Winickoff), MassGeneral Hospital, Boston, Mass; and Strong Children’s Research Center (Dr Weitzman), Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY. These findings have been presented, in part, at the 2003 Pediatric Academic Societies’ Meeting in Seattle, Wash. Address correspondence to Michael Weitzman, MD, Center for Child Health Research, 1351 Mount Hope Avenue, Suite 130, Rochester, NY 14620 (e-mail: [email protected]). Received for publication December 1, 2004; accepted March 6, 2005. AMBULATORY PEDIATRICS Copyright q 2005 by Ambulatory Pediatric Association
341
Volume 5, Number 6 November–December 2005
342
Kavanaugh et al
A positive association between smoking and depression in the general population is well recognized,22 yet few studies have explored this association specifically in mothers. Two studies using the 1988 National Maternal Health and Infant Health Survey and its 1991 Longitudinal Follow-Up Survey found a positive association between smoking and a positive depression screen among mothers with children less than age 40 months,14,23 and in a multisite clinic-based study, mothers who smoked were more likely to have a positive depression screen than were nonsmokers.13 Among pregnant women, 2 studies found smokers more likely to report depressive symptoms than nonsmokers.24,25 Despite these findings, the literature does not provide rates of the co-occurrence of maternal smoking and depressive symptoms. Given the individual risks to children of each of these exposures, additive or multiplicative adverse effects may occur in a substantial proportion of children exposed to both. This has yet to be fully explored in the literature; however, in 1 study, the negative effect of maternal depression on the social functioning of preschoolers was amplified solely among mothers who where smokers.9 The purpose of this study was threefold: to determine the prevalence of smoking and depressive symptoms, individually and as co-occurrences, among a nationally representative sample of mothers; to investigate whether mothers who smoke cigarettes are more likely to screen positive for depression than nonsmoking mothers; and, because so few states provide Medicaid support for smoking cessation or mental health services, to determine if children covered by Medicaid are disproportionately at risk for such exposures. We hypothesized that a significant percentage of mothers both smoke and screen positive for depression, that mothers who smoke cigarettes are more likely to have positive depression screens, that rates of both maternal smoking and maternal depression are higher among children covered by Medicaid, and that maternal smoking and maternal depression are child health disparity issues. METHODS Human Subjects The internal review board at Mississippi State University approved this project on March 1, 2002. Informed consent was obtained orally as part of the introduction to the telephone interview by trained interviewers. Sample The Social Climate Survey of Early Child Health and Well-Being was administered to a representative sample of US adult females via telephone in April of 2002. The sample is representative of the civilian, noninstitutionalized adult female population over age 18 in the United States (including Alaska and Hawaii). Households were selected using random-digit-dialing procedures to include households with unlisted numbers. Within a household, the female adult to be interviewed was selected by asking to speak with the person in the household who is 18 years
AMBULATORY PEDIATRICS
of age or older, and who will have the next (or who had the last) birthday; whether to ask for the next or last birthday was randomly determined by the computer. Five attempts were made to contact each selected household. In order to examine maternal depression and cigarette smoking, analyses were restricted to adult females who had at least 1 child under age 19 years living at home with them. Measures The results presented are from data on a subset of measures included in the Social Climate Survey of Early Child Health and Well-Being. The survey is designed to assess a broad range of early childcare beliefs, knowledge, and practices. The telephone survey included a variety of questions that target the knowledge and attitudes of adult women toward health care and issues affecting the health outcomes of infants and young children. Current Smoking Two questions from the Behavior Risk Factor Surveillance System Questionnaire were used to assess the current smoking status of respondents. Respondents were asked, ‘‘Have you smoked at least 100 cigarettes in your entire life?’’ Respondents who reported that they had were then asked, ‘‘Do you now smoke cigarettes every day, some days, or not at all?’’ Respondents who reported that they have smoked at least 100 cigarettes and now smoke every day or some days were categorized as current smokers. Maternal Depression Screen Information about maternal depression was obtained using a previously validated 3-item screening tool developed by Kemper and Babonis.10 Respondents were asked: 1) ‘‘On how many days in the past week did you feel depressed?’’ 2) ‘‘In the past year, have you had 2 weeks or more during which you felt sad, blue, depressed, or when you lost all interest in things that you usually care about or enjoy?’’ 3) ‘‘Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?’’ Using the identical criteria employed by Kemper and Babonis, if a mother responded yes to 2 or 3 of these statements, the screen was scored positive; question 1 was scored a yes if the mother felt depressed on 1 or more days in the past week. The 3-item tool has a sensitivity of 100% and a specificity of 88% compared with the RAND 8-item screening instrument for depressive disorders (the RAND corporation is a nonprofit research organization). Sociodemographic Variables The survey included several items to assess demographic factors. Survey participants identified their race as white, African American, Asian or Pacific Islander, American Indian or Alaska Native, or other. The race variable was collapsed into a dichotomous variable (white and nonwhite, with nonwhite being all survey participants who did not identify their race as white) for purposes of analyses because there were few nonwhite, non-African
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
343
Table 1. Survey Mothers’ Characteristics (N 5 702) Total Total (Unweighted (Weighted Count) Percent)* Race White Nonwhite African American Asian/Pacific Islander American Indian/Alaska Native Other
529 168 103 17 13 35
75.7 23.6 15.7 1.8 1.1 5.0
Age 18–24 25–44 451
88 435 179
12.8 61.2 26.0
Education ,12 years High school grad Some college College grad
63 180 249 209
8.4 25.9 35.7 29.9
Marital status Married Not married
488 214
69.2 30.8
Children on Medicaid No Yes
561 127
81.8 18.2
Region Northeast Midwest South West
125 187 274 116
19.2 24.1 35.9 20.7
Rural/urban residence Rural Urban
188 514
26.2 73.8
Smoking status Nonsmoker Smoker
531 171
75.7 24.3
Depression screen Negative Positive
520 166
75.6 24.4
Figure 1. Rates of smoking and a positive depression screen (PDS) in a national sample of mothers.
tions were considered significant at the P , .05 level. Multivariate logistic regression procedures were performed to examine these relationships while controlling for sociodemographic factors. These analyses included the variables found to be associated (P , .05) with maternal depressive symptoms or maternal smoking in bivariate analyses (race, education, marital status, receipt of Medicaid, smoking status, and/or result of the depression screen) as well as age, rural/urban residence, and US Census region. RESULTS
*Percentages may not add to 100 due to rounding.
American respondents. Maternal age was collapsed into a 3-level categorical variable (18–24, 25–44, and 451), and education was collapsed into a 4-level categorical variable (,12 years, high-school graduate, some college, college graduate). Region was coded based on the four US Census geographic regions (northeast, midwest, south, and west). Marital status (married and not married), receipt of Medicaid for 1 or more children, and rural/urban residence were determined by self-report. Based on US Census definitions,26 respondents who reported living in a community with fewer than 2500 people were categorized as rural and those living in larger communities were classified as urban. Analyses All analyses were conducted by SPSS analytic software. We examined factors related to smoking and maternal depression with Pearson x2 procedures. Associa-
Of 2480 eligible female respondents contacted, 1513 (61.0%) completed the interview and 967 refused to participate. Within this sample, there were 702 female respondents with children younger than 19 living in their homes (Table 1). The sample was weighted by race within each Census region, based on 1999 US Census estimates, to ensure that it was representative of the US population of females. Among mothers in this sample, 24.3% were smokers, 24.4% had a positive depression screen, 40.6% were smokers and/or had a positive depression screen, and 8.1% were smokers with a positive depression screen (Figure 1). One third of smokers had a positive depression screen and vice versa. Mothers with children on Medicaid were nearly twice as likely to smoke and/or have a positive depression screen (P , .001) and were 5 times more likely to both smoke and have a positive depression screen (P , .001) than were mothers of children not receiving Medicaid (Figure 2). In bivariate analyses (Table 2), a positive depression screen was associated with nonwhite race, lower educational achievement, being single, having a child receiving Medicaid, and maternal smoking (P , .05 for each). Maternal smoking was associated with white race, lower educational achievement, being single, having a child receiving Medicaid, and a positive depression screen (P , .05 for each). Co-occurrence of smoking and a positive depression screen was associated with younger maternal
344
Kavanaugh et al
Figure 2. Rates of maternal smoking and positive depression screens (PDS) by child receipt of Medicaid.
age, lower educational achievement, being single, and having a child receiving Medicaid (P , .05 for each). In a model that includes maternal race, age, education, marital status, rural/urban residence, US Census region, child Medicaid coverage, and smoking status/depressive symptoms (Table 3), maternal smoking was independently associated with white race, lower educational achievement, and a positive depression screen. A positive maternal screen for depression was independently associated with nonwhite race, age greater than 45 years, having a child covered by Medicaid, and smoking status. The cooccurrence of a positive maternal depression screen and being a smoker was independently associated with lower educational achievement and having a child covered by Medicaid. DISCUSSION The findings from this study highlight several key issues for our nation’s children: high rates of smoking and of positive depression screens among mothers; greater than 40% of mothers and nearly two thirds of mothers whose children receive Medicaid have positive depression screens and/or smoke cigarettes; and maternal smoking and positive depression screens are independently asso-
AMBULATORY PEDIATRICS
ciated. They reveal significant variation in rates of maternal smoking, of positive depression screens, and of the combination of maternal smoking and a positive depression screen between mothers whose children are and are not covered by Medicaid. Almost one half of mothers whose children receive Medicaid have positive depression screens, one third are smokers, and one fifth both smoke and have positive depression screens, rates that are approximately 2–3 times higher than those found in mothers whose children are not covered by Medicaid. These findings have troubling implications for the well-being of children, and highlight opportunities for child health care systems to address two highly prevalent and harmful child exposures that are in fact child health disparities. The prevalence of each, and both together, is much higher among mothers with children on Medicaid, therefore likely to be poor or near-poor, and among those with less education. The individual rates of maternal smoking and positive depression screens in this study are generally consistent with previously published rates, and the factors associated with each are consistent with findings among women in general.20 Consistent with the general adult literature and of studies of mothers of infants and toddlers,13,14,22–25,27 the study found an association between smoking and a positive depression screen. After controlling for potentially confounding sociodemographic variables, smoking mothers remain 70% more likely than nonsmoking mothers to screen positive for depression, supporting the addition of cigarette smoking as a risk factor for depression advocated by the Institute of Medicine (family history of mood disorder, experiencing a severely stressful event, low selfesteem, living in poverty, and being female).28 The crosssectional design of this survey prevents conclusions about the causal direction and etiology of the association between smoking and depression, but mounting evidence from other studies points to involvement of both genetic and environmental factors.22,29 Despite declines in the overall rate of smoking among US adults,20 high rates persist in certain populations. In this sample, almost 1 in 2 mothers with less than a high school education is a smoker, compared with fewer than 1 in 10 mothers with a college degree. Women whose children receive Medicaid are nearly twice as likely to be current smokers as other mothers, which is consistent with findings that Medicaid recipients overall are twice as likely to smoke as nonrecipients.30 The rates of screening positive for depression, and of being both a smoker and having a positive depression screen, are also significantly higher in this study among mothers with lower educational achievements and those with children on Medicaid. Lower levels of maternal education have been associated with poorer child outcomes, including increased rates of injury mortality, school failure, and behavior problems.31–33 The majority of children covered by Medicaid are lowincome children, and poverty adversely affects child outcomes, including development, academic achievement, and behavior.31,32,34 Children already at increased risk of adverse health outcomes, therefore, are the most likely to
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
345
Table 2. Rates of Maternal Smoking and Positive Depression Screen by Maternal Characteristics Current Smoker (%)
P
Positive Depression Screen (%)
P
Smoker and Positive Depression Screen (%)
P
Race White Nonwhite
26.6 16.8
.010
21.7 33.5
.002
8.2 7.8
(.85)
Age 18–24 (reference) 25–44 451
27.5 26.9 16.9
.025
28.1 21.1 30.6
.034
12.1 8.8 4.9
(.095)
Education Not a high school grad High school grad Some college College grad (reference)
48.3 36.3 22.2 9.5
,.001
47.5 30.7 18.9 19.3
,.001
25.0 12.1 5.6 2.6
,.001
Martial status Married Not married
19.3 35.8
,.001
20.5 33.2
,.001
5.3 14.7
,.001
Children on Medicaid No Yes
21.1 37.6
,.001
19.0 47.5
,.001
4.8 20.6
,.001
Smoking status Nonsmoker Smoker
... ...
21.1 21.134.8
,.001
... ...
Depression screen Negative Positive
20.5 33.9
,.001
be exposed to maternal depression and/or secondhand smoke. Increased rates of depressive symptoms among mothers who smoke and increased rates of depressive symptoms and/or smoking among mothers whose children receive Medicaid may also have practice and policy implications. As summarized by the American Academy of Pediatrics Task Force on the Family, ‘‘The health and well-being of children are inextricably linked to their parents’ physical, emotional, and social health, social circumstances, and child rearing practices.’’35 The important role of pediatricians in addressing parental smoking, for example, has been detailed by several organizations.36–38 Studies reflect that identification by children’s primary care clinicians of parental smoking or child secondhand smoke exposure occurs more than half of the time, but far fewer clinicians offer parents specific cessation assistance.4,39,40 Unfortunately, the care of maternal depression is no better; pediatric clinicians correctly identify less than one third of depressed mothers. 41 Ideally, all parents would be screened for smoking and depression and identified parents would be triaged appropriately. Both experience and the literature suggest this is not happening; therefore, Medicaid status may be a helpful prompt to screen for both maternal depression and maternal smoking, and the detection of maternal smoking may serve as a reminder to screen for maternal depression. Despite the importance of the family on child health, only 14 state Medicaid programs covered some form of pharmacotherapy for tobacco cessation treatment for par-
... ...
... ...
ents under Early and Periodic Screening, Detection, and Treatment services as of 2000. Fewer than 7 state programs covered nicotine-replacement therapy for parents under such programs, and only 4 covered tobacco-cessation counseling.42 Also, as of 2000, only 20 state Medicaid programs covered parents with incomes at the federal poverty line and low-income parents are more likely to be uninsured than low-income children.43 Increased coverage of treatment for maternal tobacco use and of maternal depression by child Medicaid programs would be consistent with a step toward helping these at-risk mothers and children. Given that parental smoking has been shown to be responsible for significant child health care costs44 and parental depression has been linked to increased child health and mental-health service utilization and expenditures,17 increased coverage of smoking cessation and mental-health treatment for parents may not result in too much of an overall cost increase for state Medicaid programs. There are several limitations of this study. As with all telephone surveys, households without telephone service—most likely very low-income households—are not included in the survey. The characteristics of these mothers and of mothers who refused to participate in the survey are not known. The 61% response rate in this study is not ideal, but is not uncommon among other published random-digit-dial surveys.45,46 The survey did not ask a complete smoking history with age of smoking onset, quantity of cigarettes smoked per day, and length of smoking duration, nor was smoking status confirmed with
346
Kavanaugh et al
AMBULATORY PEDIATRICS
Table 3. Maternal Characteristics Independently Associated with Maternal Smoking and Positive Maternal Depression Screen* Characteristic
OR Maternal Smoking (95% CI)
OR Positive Maternal Depression Screen (95% CI)
OR Maternal Smoking and PMDS (95% CI)
Race White Nonwhite
3.5† (2.0–6.1) 1.0
0.6 (0.4–0.9) 1.0
1.9 (0.9–4.1) 1.0
Age 18–24 25–44 451
1.0 1.8 (1.0–3.2) 0.8 (0.4–1.6)
1.0 1.1 (0.6–2.0) 2.2† (1.1–4.3)
1.0 1.3 (0.6–3.0) 0.6 (0.2–4.1)
Education College grad Some college High school grad Not a high school grad
1.0 2.5† (1.4–4.5) 5.2† (2.8–9.6) 7.5† (1.4–4.5)
1.0 0.9 (0.5–1.5) 1.3 (0.8–2.2) 1.7 (0.8–3.6)
1.0 1.7 (0.6–4.8) 3.4† (1.2–9.4) 5.1† (1.6–16.4)
Marital status Married Not married
1.0 2.1† (1.3–3.2)
1.0 1.2 (0.8–1.9)
1.0 1.8 (1.0–3.5)
Residence Urban Rural
1.0 0.8 (0.5–1.2)
1.0 1.4 (0.9–2.2)
1.0 1.1 (0.6–2.1)
Children on Medicaid No Yes
1.0 1.4 (0.8–2.3)
1.0 2.8† (1.8–4.5)
1.0 3.2† (1.7–6.2)
Smoker No Yes
... ...
1.0 1.7† (1.1–2.6)
... ...
Depression screen Negative Positive
1.0 1.7† (1.1–2.6)
... ...
... ...
*Odds ratios are adjusted for all variables in the table as well as 2002 U.S. Census region. OR indicates odds ratios; CI, confidence interval. †95% CI does not include 1.
biologic markers such as cotinine. Self-reported smoking status, however, is the method used by clinicians and has been shown to be a reliable method of determining smoking status.47 A more detailed survey may have highlighted additional subpopulations of smokers who are especially likely to be depressed, subgroups of depressed mothers more likely to smoke, or the presence of a dose-effect relationship. Further, the 3-item tool for depression used in the survey provides a depression screen rather than diagnosis; thus, the actual prevalence of DSM-IV diagnosed depression among these mothers is unknown and is probably lower.10 However, rates of positive depression screens in this study are comparable with national estimates of maternal depressive symptoms,8–13 and this tool has been used as a measure of maternal depressive symptoms in other published studies.8,48 Last, this study lacked information to calculate a measure of poverty, a sociodemographic characteristic associated with increased rates of both smoking and depression. Children’s receipt of Medicaid includes largely low-income children but misses up to one fifth of low-income children.43 Child Medicaid enrollment, however, does identify a group of mothers whose children’s health care is covered by federal- and
state-funded programs and may therefore be of particular policy interest. Further studies are warranted that include more comprehensive poverty measures and that allow for examination of other maternal factors as well as studies that examine the health and development outcomes of children exposed to both maternal depression and secondhand smoke. Intervention strategies for parents with a dual diagnosis also are needed. In addition, the impact of potential policy changes on the well-being of children and their parents is an area of critically important research. This study highlights both the high frequencies and the co-occurrence of maternal smoking and maternal depressive symptoms, two negative influences on children’s health and development, as well as their increased prevalence among mothers whose children receive Medicaid. These findings have significant implications for our nation’s children, health care clinicians, and health care payers. Clearly, universal insurance would ensure substantially improved access. Short of this, better Medicaid reimbursement for mental-health services and smoking-cessation therapy would be in the best interests of our children, as would enhanced involvement of children’s
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
primary health care clinicians in what are two of the most common threats to children’s health and well-being. REFERENCES 1. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph 10. NIH Publication 99-4645. Bethesda, Md: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 1999. 2. Weissman MM, John K, Merikangas KR, et al. Depressed parents and their children. General health, social, and psychiatric problems. Am J Dis Child. 1986;140:801–805. 3. Women and Smoking: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General, ed. Rockville, Md: US Dept of Health and Human Services; 2001. 4. Winickoff JP, McMillen RC, Carroll BC, et al. Addressing parental smoking in pediatrics and family practice: a national survey of parents. Pediatrics. 2003;112:1146–1151. 5. Pirkle JL, Flegal KM, Bernert JT, et al. Exposure of the US population to environmental tobacco smoke—The Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA. 1996;275:1233–1240. 6. Weitzman M, Byrd RS, Aligne CA, Moss M. The effects of tobacco exposure on children’s behavioral and cognitive functioning: implications for clinical and public health policy and future research. Neurotoxicol Teratol. 2002;24:397–406. 7. Cook DG, Strachan DP. Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax. 1999;54:357–365. 8. Lanzi RG, Pascoe JM, Keltner B, Ramey SL. Correlates of maternal depressive symptoms in a National Head Start program sample. Arch Ped Adol Med. 1999;153:801–807. 9. Burdette HL, Whitaker RC, Harvey-Berino J, Kahn RS. Depressive symptoms in low-income mothers and emotional and social functioning in their preschool children. Ambul Pediatr. 2003;3:288–294. 10. Kemper KJ, Babonis TR. Screening for maternal depression in pediatric clinics. Am J Dis Child. 1992;146:876–878. 11. McLennan JD, Kotelchuck M, Cho H. Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers. J Am Acad Child Adolesc Psychiatry. 2001; 40:1316–1323. 12. Olson AL, Dibrigida LA. Depressive symptoms and work role satisfaction in mothers of toddlers. Pediatrics. 1994;94:363– 367. 13. Kahn RS, Wise PH, Finkelstein JA, et al. The scope of unmet maternal health needs in pediatric settings. Pediatrics. 1999; 103:576–581. 14. Leiferman J. The effect of maternal depressive symptomatology on maternal behaviors associated with child health. Health Educ Behav. 2002;29:596–607. 15. McLennan JD, Kotelchuck M. Parental prevention practices for young children in the context of maternal depression. Pediatrics. 2000;105:1090–1095. 16. Kramer RA, Warner V, Olfson M, et al. General medical problems among the offspring of depressed parents: a 10-year follow-up. J Am Acad Child Adolesc Psychiatry. 1998;37:602– 611. 17. Olfson M, Marcus SC, Druss B, et al. Parental depression, child mental health problems, and health care utilization. Med Care. 2003;41:716–721. 18. Hammen C, Brennan PA. Severity, chronicity, and timing of maternal depression and risk for adolescent offspring diagnoses in a community sample. Arch Gen Psychiat. 2003;60:253–258. 19. Leadbeater BJ, Bishop SJ. Predictors of behavior problems in preschool-children of inner-city Afro-American and Puerto-Rican adolescent others. Child Dev. 1994;65:638–648.
347
20. Cigarette smoking among adults—United States, 2001. MMWR. 2003;52:953–980. 21. Akiskal HS. Mood disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 7th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2000. 22. Fergusson DM, Goodwin RD, Horwood LJ. Major depression and cigarette smoking: results of a 21-year longitudinal study. Psychol Med. 2003;33:1357–1367. 23. Kahn RS, Certain L, Whitaker RC. A reexamination of smoking before, during, and after pregnancy. Am J Publ Health. 2002; 92:1801–1808. 24. Pritchard CW. Depression and smoking in pregnancy in Scotland. J Epidemiol Commun Health. 1994;48:377–382. 25. Zhu SH, Valbo A. Depression and smoking during pregnancy. Addict Behav. 2002;27:649–658. 26. US Census Bureau. Urban and Rural Definitions. 6-7-0004. Washington, DC: US Census Bureau; 1995. 27. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness—a population-based prevalence study. JAMA. 2000;284: 2606–2610. 28. Institute of Medicine. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Mrazek PJ and Haggerty RJ, eds. Washington, DC: National Academy Press; 1994:163–171. 29. McCaffery JM, Niaura R, Swan GE, Carmelli D. A study of depressive symptoms and smoking behavior in adult male twins from the NHLBI twin study. Nicotine Tob Res. 2003;5:77–83. 30. State Medicaid coverage for tobacco-dependence treatments— United States, 1998 and 2000. MMWR. 2001;50:979–982. 31. Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic conditions, socioeconomic risks, and behavioral-problems in children and adolescents. Pediatrics. 1990;85:267–276. 32. Byrd RS, Weitzman ML. Predictors of early grade retention among children in the United States. Pediatrics. 1994;93:481– 487. 33. Scholer SJ, Hickson GB, Ray WA. Sociodemographic factors identify US infants at high risk of injury mortality. Pediatrics. 1999;103:1183–1188. 34. Duncan GJ, Brooks-Gunn J, Klebanov PK. Economic deprivation and early-childhood development. Child Dev. 1994;65: 296–318. 35. Schor EL, Billingsley MM, Golden AL, et al. Report of the task force on the family. Pediatrics. 2003;111:1541–1571. 36. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1998. 37. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service; 2000. 38. Jacobs EA, Joffe A, Knight JR, et al. Tobacco’s toll: implications for the pediatrician. Pediatrics. 2001;107:794–798. 39. Tanski SE, Klein JD, Winickoff JP, et al. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics. 2003;111:e162–e167. 40. Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, et al. Counseling smoking parents of young children—comparison of pediatricians and family physicians. Arch Ped Adol Med. 2001;155:25–31. 41. Heneghan AM, Silver EJ, Bauman LJ, Stein RE. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000;106:1367–1373. 42. Ibrahim JK, Schauffler HH, Barker DC, Orleans CT. Coverage of tobacco dependence treatments for pregnant women and for children and their parents. Am J Publ Health. 2002;92:1940– 1942. 43. Ross DC, Cox L. Enrolling Children and Families in Health Coverage: The Promise of Doing More. Kaiser Commission on Medicaid and the Uninsured, ed. Washington, DC: Henry J. Kaiser Family Foundation; 2002. 44. Aligne CA, Stoddard JJ. Tobacco and children—an economic
348
Kavanaugh et al
evaluation of the medical effects of parental smoking. Arch Ped Adol Med. 1997;151:648–653. 45. Hersey JC, Niederdeppe J, Evans WD, et al. The effects of state counterindustry media campaigns on beliefs, attitudes, and smoking status among teens and young adults. Prev Med. 2003; 37:544–552. 46. Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by
AMBULATORY PEDIATRICS means of a random digit dial telephone survey: a 5-year followup study. J Allergy Clin Immunol. 2003;112:1203–1207. 47. Patrick DL, Cheadle A, Thompson DC, et al. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health. 1994;84:1086–1093. 48. Casey P, Goolsby S, Berkowitz C, et al. Maternal depression, changing public assistance, food security, and child health status. Pediatrics. 2004;113:298–304.
environmental tobacco smoke; maternal depression; Medicaid; smoking
Ambulatory Pediatrics 2005;5:341 348
M
ing.1–3
aternal smoking and depression are common and each have significant adverse effects on both maternal and child health and functionOver 20% of parents smoke4 and more than one
third of children are exposed to secondhand smoke at home.5 Prenatal and childhood exposure to tobacco smoke is associated with increased childhood morbidity and mortality, including lower respiratory tract infections and hospitalizations, asthma, recurrent otitis media, and Sudden Infant Death Syndrome, as well as increased rates of cognitive and behavioral problems.1,6,7 The reported prevalence of depressive symptoms among mothers with young children ranges from 17% to 42%.8–13 Depressed mothers are less likely to read to or engage in a variety of diseaseprevention practices with their children.14,15 Children who live with depressed mothers have more physical,2,16 mental health,17,18 and behavioral19 problems. While there are substantial literatures both on child health disparities and the epidemiology and effects of adult smoking and maternal depression, to date we are unaware of any recognition of maternal smoking or depression as issues of child health disparities. The adult literature clearly demonstrates that poor, near poor, and poorly educated individuals are far more likely to be tobacco smokers. Unlike many disparities in child health, however, adults from most racial and ethnic minorities smoke at lower rates than do white individuals.20 Among adults, depression is clearly more common in women and in single or divorced persons. There are no differences in rates of depression by race or ethnicity and, while the data are mixed, there may be slightly higher rates of depression among adults of lower socioeconomic status.21
From the American Academy of Pediatrics (Drs Kavanaugh and Weitzman), Center for Child Health Research, Rochester, NY; University of Rochester School of Medicine and Dentistry (Dr Kavanaugh), Rochester, NY; Social Science Research Center (Drs McMillen and Southward), Mississippi State University, Starkville, Miss; Tobacco Consortium (Drs McMillen, Winickoff and Weitzman), American Academy of Pediatrics, Center for Child Health Research, Rochester, NY; Department of Pediatrics (Dr Pascoe), Wright State University School of Medicine and The Children’s Medical Center, Dayton, Ohio; Health, Early Care and Education Consortium (Drs Pascoe, Southward, and Weitzman), American Academy of Pediatrics, Center for Child Health Research, Rochester, NY; MGH Center for Child and Adolescent Health Policy (Dr Winickoff), General Pediatrics Division, MassGeneral Hospital for Children, Boston, Mass; Tobacco Research and Treatment Center (Dr Winickoff), MassGeneral Hospital, Boston, Mass; and Strong Children’s Research Center (Dr Weitzman), Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY. These findings have been presented, in part, at the 2003 Pediatric Academic Societies’ Meeting in Seattle, Wash. Address correspondence to Michael Weitzman, MD, Center for Child Health Research, 1351 Mount Hope Avenue, Suite 130, Rochester, NY 14620 (e-mail: [email protected]). Received for publication December 1, 2004; accepted March 6, 2005. AMBULATORY PEDIATRICS Copyright q 2005 by Ambulatory Pediatric Association
341
Volume 5, Number 6 November–December 2005
342
Kavanaugh et al
A positive association between smoking and depression in the general population is well recognized,22 yet few studies have explored this association specifically in mothers. Two studies using the 1988 National Maternal Health and Infant Health Survey and its 1991 Longitudinal Follow-Up Survey found a positive association between smoking and a positive depression screen among mothers with children less than age 40 months,14,23 and in a multisite clinic-based study, mothers who smoked were more likely to have a positive depression screen than were nonsmokers.13 Among pregnant women, 2 studies found smokers more likely to report depressive symptoms than nonsmokers.24,25 Despite these findings, the literature does not provide rates of the co-occurrence of maternal smoking and depressive symptoms. Given the individual risks to children of each of these exposures, additive or multiplicative adverse effects may occur in a substantial proportion of children exposed to both. This has yet to be fully explored in the literature; however, in 1 study, the negative effect of maternal depression on the social functioning of preschoolers was amplified solely among mothers who where smokers.9 The purpose of this study was threefold: to determine the prevalence of smoking and depressive symptoms, individually and as co-occurrences, among a nationally representative sample of mothers; to investigate whether mothers who smoke cigarettes are more likely to screen positive for depression than nonsmoking mothers; and, because so few states provide Medicaid support for smoking cessation or mental health services, to determine if children covered by Medicaid are disproportionately at risk for such exposures. We hypothesized that a significant percentage of mothers both smoke and screen positive for depression, that mothers who smoke cigarettes are more likely to have positive depression screens, that rates of both maternal smoking and maternal depression are higher among children covered by Medicaid, and that maternal smoking and maternal depression are child health disparity issues. METHODS Human Subjects The internal review board at Mississippi State University approved this project on March 1, 2002. Informed consent was obtained orally as part of the introduction to the telephone interview by trained interviewers. Sample The Social Climate Survey of Early Child Health and Well-Being was administered to a representative sample of US adult females via telephone in April of 2002. The sample is representative of the civilian, noninstitutionalized adult female population over age 18 in the United States (including Alaska and Hawaii). Households were selected using random-digit-dialing procedures to include households with unlisted numbers. Within a household, the female adult to be interviewed was selected by asking to speak with the person in the household who is 18 years
AMBULATORY PEDIATRICS
of age or older, and who will have the next (or who had the last) birthday; whether to ask for the next or last birthday was randomly determined by the computer. Five attempts were made to contact each selected household. In order to examine maternal depression and cigarette smoking, analyses were restricted to adult females who had at least 1 child under age 19 years living at home with them. Measures The results presented are from data on a subset of measures included in the Social Climate Survey of Early Child Health and Well-Being. The survey is designed to assess a broad range of early childcare beliefs, knowledge, and practices. The telephone survey included a variety of questions that target the knowledge and attitudes of adult women toward health care and issues affecting the health outcomes of infants and young children. Current Smoking Two questions from the Behavior Risk Factor Surveillance System Questionnaire were used to assess the current smoking status of respondents. Respondents were asked, ‘‘Have you smoked at least 100 cigarettes in your entire life?’’ Respondents who reported that they had were then asked, ‘‘Do you now smoke cigarettes every day, some days, or not at all?’’ Respondents who reported that they have smoked at least 100 cigarettes and now smoke every day or some days were categorized as current smokers. Maternal Depression Screen Information about maternal depression was obtained using a previously validated 3-item screening tool developed by Kemper and Babonis.10 Respondents were asked: 1) ‘‘On how many days in the past week did you feel depressed?’’ 2) ‘‘In the past year, have you had 2 weeks or more during which you felt sad, blue, depressed, or when you lost all interest in things that you usually care about or enjoy?’’ 3) ‘‘Have you had 2 years or more in your life when you felt depressed or sad most days, even if you felt okay sometimes?’’ Using the identical criteria employed by Kemper and Babonis, if a mother responded yes to 2 or 3 of these statements, the screen was scored positive; question 1 was scored a yes if the mother felt depressed on 1 or more days in the past week. The 3-item tool has a sensitivity of 100% and a specificity of 88% compared with the RAND 8-item screening instrument for depressive disorders (the RAND corporation is a nonprofit research organization). Sociodemographic Variables The survey included several items to assess demographic factors. Survey participants identified their race as white, African American, Asian or Pacific Islander, American Indian or Alaska Native, or other. The race variable was collapsed into a dichotomous variable (white and nonwhite, with nonwhite being all survey participants who did not identify their race as white) for purposes of analyses because there were few nonwhite, non-African
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
343
Table 1. Survey Mothers’ Characteristics (N 5 702) Total Total (Unweighted (Weighted Count) Percent)* Race White Nonwhite African American Asian/Pacific Islander American Indian/Alaska Native Other
529 168 103 17 13 35
75.7 23.6 15.7 1.8 1.1 5.0
Age 18–24 25–44 451
88 435 179
12.8 61.2 26.0
Education ,12 years High school grad Some college College grad
63 180 249 209
8.4 25.9 35.7 29.9
Marital status Married Not married
488 214
69.2 30.8
Children on Medicaid No Yes
561 127
81.8 18.2
Region Northeast Midwest South West
125 187 274 116
19.2 24.1 35.9 20.7
Rural/urban residence Rural Urban
188 514
26.2 73.8
Smoking status Nonsmoker Smoker
531 171
75.7 24.3
Depression screen Negative Positive
520 166
75.6 24.4
Figure 1. Rates of smoking and a positive depression screen (PDS) in a national sample of mothers.
tions were considered significant at the P , .05 level. Multivariate logistic regression procedures were performed to examine these relationships while controlling for sociodemographic factors. These analyses included the variables found to be associated (P , .05) with maternal depressive symptoms or maternal smoking in bivariate analyses (race, education, marital status, receipt of Medicaid, smoking status, and/or result of the depression screen) as well as age, rural/urban residence, and US Census region. RESULTS
*Percentages may not add to 100 due to rounding.
American respondents. Maternal age was collapsed into a 3-level categorical variable (18–24, 25–44, and 451), and education was collapsed into a 4-level categorical variable (,12 years, high-school graduate, some college, college graduate). Region was coded based on the four US Census geographic regions (northeast, midwest, south, and west). Marital status (married and not married), receipt of Medicaid for 1 or more children, and rural/urban residence were determined by self-report. Based on US Census definitions,26 respondents who reported living in a community with fewer than 2500 people were categorized as rural and those living in larger communities were classified as urban. Analyses All analyses were conducted by SPSS analytic software. We examined factors related to smoking and maternal depression with Pearson x2 procedures. Associa-
Of 2480 eligible female respondents contacted, 1513 (61.0%) completed the interview and 967 refused to participate. Within this sample, there were 702 female respondents with children younger than 19 living in their homes (Table 1). The sample was weighted by race within each Census region, based on 1999 US Census estimates, to ensure that it was representative of the US population of females. Among mothers in this sample, 24.3% were smokers, 24.4% had a positive depression screen, 40.6% were smokers and/or had a positive depression screen, and 8.1% were smokers with a positive depression screen (Figure 1). One third of smokers had a positive depression screen and vice versa. Mothers with children on Medicaid were nearly twice as likely to smoke and/or have a positive depression screen (P , .001) and were 5 times more likely to both smoke and have a positive depression screen (P , .001) than were mothers of children not receiving Medicaid (Figure 2). In bivariate analyses (Table 2), a positive depression screen was associated with nonwhite race, lower educational achievement, being single, having a child receiving Medicaid, and maternal smoking (P , .05 for each). Maternal smoking was associated with white race, lower educational achievement, being single, having a child receiving Medicaid, and a positive depression screen (P , .05 for each). Co-occurrence of smoking and a positive depression screen was associated with younger maternal
344
Kavanaugh et al
Figure 2. Rates of maternal smoking and positive depression screens (PDS) by child receipt of Medicaid.
age, lower educational achievement, being single, and having a child receiving Medicaid (P , .05 for each). In a model that includes maternal race, age, education, marital status, rural/urban residence, US Census region, child Medicaid coverage, and smoking status/depressive symptoms (Table 3), maternal smoking was independently associated with white race, lower educational achievement, and a positive depression screen. A positive maternal screen for depression was independently associated with nonwhite race, age greater than 45 years, having a child covered by Medicaid, and smoking status. The cooccurrence of a positive maternal depression screen and being a smoker was independently associated with lower educational achievement and having a child covered by Medicaid. DISCUSSION The findings from this study highlight several key issues for our nation’s children: high rates of smoking and of positive depression screens among mothers; greater than 40% of mothers and nearly two thirds of mothers whose children receive Medicaid have positive depression screens and/or smoke cigarettes; and maternal smoking and positive depression screens are independently asso-
AMBULATORY PEDIATRICS
ciated. They reveal significant variation in rates of maternal smoking, of positive depression screens, and of the combination of maternal smoking and a positive depression screen between mothers whose children are and are not covered by Medicaid. Almost one half of mothers whose children receive Medicaid have positive depression screens, one third are smokers, and one fifth both smoke and have positive depression screens, rates that are approximately 2–3 times higher than those found in mothers whose children are not covered by Medicaid. These findings have troubling implications for the well-being of children, and highlight opportunities for child health care systems to address two highly prevalent and harmful child exposures that are in fact child health disparities. The prevalence of each, and both together, is much higher among mothers with children on Medicaid, therefore likely to be poor or near-poor, and among those with less education. The individual rates of maternal smoking and positive depression screens in this study are generally consistent with previously published rates, and the factors associated with each are consistent with findings among women in general.20 Consistent with the general adult literature and of studies of mothers of infants and toddlers,13,14,22–25,27 the study found an association between smoking and a positive depression screen. After controlling for potentially confounding sociodemographic variables, smoking mothers remain 70% more likely than nonsmoking mothers to screen positive for depression, supporting the addition of cigarette smoking as a risk factor for depression advocated by the Institute of Medicine (family history of mood disorder, experiencing a severely stressful event, low selfesteem, living in poverty, and being female).28 The crosssectional design of this survey prevents conclusions about the causal direction and etiology of the association between smoking and depression, but mounting evidence from other studies points to involvement of both genetic and environmental factors.22,29 Despite declines in the overall rate of smoking among US adults,20 high rates persist in certain populations. In this sample, almost 1 in 2 mothers with less than a high school education is a smoker, compared with fewer than 1 in 10 mothers with a college degree. Women whose children receive Medicaid are nearly twice as likely to be current smokers as other mothers, which is consistent with findings that Medicaid recipients overall are twice as likely to smoke as nonrecipients.30 The rates of screening positive for depression, and of being both a smoker and having a positive depression screen, are also significantly higher in this study among mothers with lower educational achievements and those with children on Medicaid. Lower levels of maternal education have been associated with poorer child outcomes, including increased rates of injury mortality, school failure, and behavior problems.31–33 The majority of children covered by Medicaid are lowincome children, and poverty adversely affects child outcomes, including development, academic achievement, and behavior.31,32,34 Children already at increased risk of adverse health outcomes, therefore, are the most likely to
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
345
Table 2. Rates of Maternal Smoking and Positive Depression Screen by Maternal Characteristics Current Smoker (%)
P
Positive Depression Screen (%)
P
Smoker and Positive Depression Screen (%)
P
Race White Nonwhite
26.6 16.8
.010
21.7 33.5
.002
8.2 7.8
(.85)
Age 18–24 (reference) 25–44 451
27.5 26.9 16.9
.025
28.1 21.1 30.6
.034
12.1 8.8 4.9
(.095)
Education Not a high school grad High school grad Some college College grad (reference)
48.3 36.3 22.2 9.5
,.001
47.5 30.7 18.9 19.3
,.001
25.0 12.1 5.6 2.6
,.001
Martial status Married Not married
19.3 35.8
,.001
20.5 33.2
,.001
5.3 14.7
,.001
Children on Medicaid No Yes
21.1 37.6
,.001
19.0 47.5
,.001
4.8 20.6
,.001
Smoking status Nonsmoker Smoker
... ...
21.1 21.134.8
,.001
... ...
Depression screen Negative Positive
20.5 33.9
,.001
be exposed to maternal depression and/or secondhand smoke. Increased rates of depressive symptoms among mothers who smoke and increased rates of depressive symptoms and/or smoking among mothers whose children receive Medicaid may also have practice and policy implications. As summarized by the American Academy of Pediatrics Task Force on the Family, ‘‘The health and well-being of children are inextricably linked to their parents’ physical, emotional, and social health, social circumstances, and child rearing practices.’’35 The important role of pediatricians in addressing parental smoking, for example, has been detailed by several organizations.36–38 Studies reflect that identification by children’s primary care clinicians of parental smoking or child secondhand smoke exposure occurs more than half of the time, but far fewer clinicians offer parents specific cessation assistance.4,39,40 Unfortunately, the care of maternal depression is no better; pediatric clinicians correctly identify less than one third of depressed mothers. 41 Ideally, all parents would be screened for smoking and depression and identified parents would be triaged appropriately. Both experience and the literature suggest this is not happening; therefore, Medicaid status may be a helpful prompt to screen for both maternal depression and maternal smoking, and the detection of maternal smoking may serve as a reminder to screen for maternal depression. Despite the importance of the family on child health, only 14 state Medicaid programs covered some form of pharmacotherapy for tobacco cessation treatment for par-
... ...
... ...
ents under Early and Periodic Screening, Detection, and Treatment services as of 2000. Fewer than 7 state programs covered nicotine-replacement therapy for parents under such programs, and only 4 covered tobacco-cessation counseling.42 Also, as of 2000, only 20 state Medicaid programs covered parents with incomes at the federal poverty line and low-income parents are more likely to be uninsured than low-income children.43 Increased coverage of treatment for maternal tobacco use and of maternal depression by child Medicaid programs would be consistent with a step toward helping these at-risk mothers and children. Given that parental smoking has been shown to be responsible for significant child health care costs44 and parental depression has been linked to increased child health and mental-health service utilization and expenditures,17 increased coverage of smoking cessation and mental-health treatment for parents may not result in too much of an overall cost increase for state Medicaid programs. There are several limitations of this study. As with all telephone surveys, households without telephone service—most likely very low-income households—are not included in the survey. The characteristics of these mothers and of mothers who refused to participate in the survey are not known. The 61% response rate in this study is not ideal, but is not uncommon among other published random-digit-dial surveys.45,46 The survey did not ask a complete smoking history with age of smoking onset, quantity of cigarettes smoked per day, and length of smoking duration, nor was smoking status confirmed with
346
Kavanaugh et al
AMBULATORY PEDIATRICS
Table 3. Maternal Characteristics Independently Associated with Maternal Smoking and Positive Maternal Depression Screen* Characteristic
OR Maternal Smoking (95% CI)
OR Positive Maternal Depression Screen (95% CI)
OR Maternal Smoking and PMDS (95% CI)
Race White Nonwhite
3.5† (2.0–6.1) 1.0
0.6 (0.4–0.9) 1.0
1.9 (0.9–4.1) 1.0
Age 18–24 25–44 451
1.0 1.8 (1.0–3.2) 0.8 (0.4–1.6)
1.0 1.1 (0.6–2.0) 2.2† (1.1–4.3)
1.0 1.3 (0.6–3.0) 0.6 (0.2–4.1)
Education College grad Some college High school grad Not a high school grad
1.0 2.5† (1.4–4.5) 5.2† (2.8–9.6) 7.5† (1.4–4.5)
1.0 0.9 (0.5–1.5) 1.3 (0.8–2.2) 1.7 (0.8–3.6)
1.0 1.7 (0.6–4.8) 3.4† (1.2–9.4) 5.1† (1.6–16.4)
Marital status Married Not married
1.0 2.1† (1.3–3.2)
1.0 1.2 (0.8–1.9)
1.0 1.8 (1.0–3.5)
Residence Urban Rural
1.0 0.8 (0.5–1.2)
1.0 1.4 (0.9–2.2)
1.0 1.1 (0.6–2.1)
Children on Medicaid No Yes
1.0 1.4 (0.8–2.3)
1.0 2.8† (1.8–4.5)
1.0 3.2† (1.7–6.2)
Smoker No Yes
... ...
1.0 1.7† (1.1–2.6)
... ...
Depression screen Negative Positive
1.0 1.7† (1.1–2.6)
... ...
... ...
*Odds ratios are adjusted for all variables in the table as well as 2002 U.S. Census region. OR indicates odds ratios; CI, confidence interval. †95% CI does not include 1.
biologic markers such as cotinine. Self-reported smoking status, however, is the method used by clinicians and has been shown to be a reliable method of determining smoking status.47 A more detailed survey may have highlighted additional subpopulations of smokers who are especially likely to be depressed, subgroups of depressed mothers more likely to smoke, or the presence of a dose-effect relationship. Further, the 3-item tool for depression used in the survey provides a depression screen rather than diagnosis; thus, the actual prevalence of DSM-IV diagnosed depression among these mothers is unknown and is probably lower.10 However, rates of positive depression screens in this study are comparable with national estimates of maternal depressive symptoms,8–13 and this tool has been used as a measure of maternal depressive symptoms in other published studies.8,48 Last, this study lacked information to calculate a measure of poverty, a sociodemographic characteristic associated with increased rates of both smoking and depression. Children’s receipt of Medicaid includes largely low-income children but misses up to one fifth of low-income children.43 Child Medicaid enrollment, however, does identify a group of mothers whose children’s health care is covered by federal- and
state-funded programs and may therefore be of particular policy interest. Further studies are warranted that include more comprehensive poverty measures and that allow for examination of other maternal factors as well as studies that examine the health and development outcomes of children exposed to both maternal depression and secondhand smoke. Intervention strategies for parents with a dual diagnosis also are needed. In addition, the impact of potential policy changes on the well-being of children and their parents is an area of critically important research. This study highlights both the high frequencies and the co-occurrence of maternal smoking and maternal depressive symptoms, two negative influences on children’s health and development, as well as their increased prevalence among mothers whose children receive Medicaid. These findings have significant implications for our nation’s children, health care clinicians, and health care payers. Clearly, universal insurance would ensure substantially improved access. Short of this, better Medicaid reimbursement for mental-health services and smoking-cessation therapy would be in the best interests of our children, as would enhanced involvement of children’s
AMBULATORY PEDIATRICS
The Co-Occurrence of Maternal Depressive Symptoms and Smoking
primary health care clinicians in what are two of the most common threats to children’s health and well-being. REFERENCES 1. National Cancer Institute. Health Effects of Exposure to Environmental Tobacco Smoke: The Report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph 10. NIH Publication 99-4645. Bethesda, Md: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 1999. 2. Weissman MM, John K, Merikangas KR, et al. Depressed parents and their children. General health, social, and psychiatric problems. Am J Dis Child. 1986;140:801–805. 3. Women and Smoking: A Report of the Surgeon General. US Department of Health and Human Services, Office of the Surgeon General, ed. Rockville, Md: US Dept of Health and Human Services; 2001. 4. Winickoff JP, McMillen RC, Carroll BC, et al. Addressing parental smoking in pediatrics and family practice: a national survey of parents. Pediatrics. 2003;112:1146–1151. 5. Pirkle JL, Flegal KM, Bernert JT, et al. Exposure of the US population to environmental tobacco smoke—The Third National Health and Nutrition Examination Survey, 1988 to 1991. JAMA. 1996;275:1233–1240. 6. Weitzman M, Byrd RS, Aligne CA, Moss M. The effects of tobacco exposure on children’s behavioral and cognitive functioning: implications for clinical and public health policy and future research. Neurotoxicol Teratol. 2002;24:397–406. 7. Cook DG, Strachan DP. Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax. 1999;54:357–365. 8. Lanzi RG, Pascoe JM, Keltner B, Ramey SL. Correlates of maternal depressive symptoms in a National Head Start program sample. Arch Ped Adol Med. 1999;153:801–807. 9. Burdette HL, Whitaker RC, Harvey-Berino J, Kahn RS. Depressive symptoms in low-income mothers and emotional and social functioning in their preschool children. Ambul Pediatr. 2003;3:288–294. 10. Kemper KJ, Babonis TR. Screening for maternal depression in pediatric clinics. Am J Dis Child. 1992;146:876–878. 11. McLennan JD, Kotelchuck M, Cho H. Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers. J Am Acad Child Adolesc Psychiatry. 2001; 40:1316–1323. 12. Olson AL, Dibrigida LA. Depressive symptoms and work role satisfaction in mothers of toddlers. Pediatrics. 1994;94:363– 367. 13. Kahn RS, Wise PH, Finkelstein JA, et al. The scope of unmet maternal health needs in pediatric settings. Pediatrics. 1999; 103:576–581. 14. Leiferman J. The effect of maternal depressive symptomatology on maternal behaviors associated with child health. Health Educ Behav. 2002;29:596–607. 15. McLennan JD, Kotelchuck M. Parental prevention practices for young children in the context of maternal depression. Pediatrics. 2000;105:1090–1095. 16. Kramer RA, Warner V, Olfson M, et al. General medical problems among the offspring of depressed parents: a 10-year follow-up. J Am Acad Child Adolesc Psychiatry. 1998;37:602– 611. 17. Olfson M, Marcus SC, Druss B, et al. Parental depression, child mental health problems, and health care utilization. Med Care. 2003;41:716–721. 18. Hammen C, Brennan PA. Severity, chronicity, and timing of maternal depression and risk for adolescent offspring diagnoses in a community sample. Arch Gen Psychiat. 2003;60:253–258. 19. Leadbeater BJ, Bishop SJ. Predictors of behavior problems in preschool-children of inner-city Afro-American and Puerto-Rican adolescent others. Child Dev. 1994;65:638–648.
347
20. Cigarette smoking among adults—United States, 2001. MMWR. 2003;52:953–980. 21. Akiskal HS. Mood disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 7th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2000. 22. Fergusson DM, Goodwin RD, Horwood LJ. Major depression and cigarette smoking: results of a 21-year longitudinal study. Psychol Med. 2003;33:1357–1367. 23. Kahn RS, Certain L, Whitaker RC. A reexamination of smoking before, during, and after pregnancy. Am J Publ Health. 2002; 92:1801–1808. 24. Pritchard CW. Depression and smoking in pregnancy in Scotland. J Epidemiol Commun Health. 1994;48:377–382. 25. Zhu SH, Valbo A. Depression and smoking during pregnancy. Addict Behav. 2002;27:649–658. 26. US Census Bureau. Urban and Rural Definitions. 6-7-0004. Washington, DC: US Census Bureau; 1995. 27. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness—a population-based prevalence study. JAMA. 2000;284: 2606–2610. 28. Institute of Medicine. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Mrazek PJ and Haggerty RJ, eds. Washington, DC: National Academy Press; 1994:163–171. 29. McCaffery JM, Niaura R, Swan GE, Carmelli D. A study of depressive symptoms and smoking behavior in adult male twins from the NHLBI twin study. Nicotine Tob Res. 2003;5:77–83. 30. State Medicaid coverage for tobacco-dependence treatments— United States, 1998 and 2000. MMWR. 2001;50:979–982. 31. Gortmaker SL, Walker DK, Weitzman M, Sobol AM. Chronic conditions, socioeconomic risks, and behavioral-problems in children and adolescents. Pediatrics. 1990;85:267–276. 32. Byrd RS, Weitzman ML. Predictors of early grade retention among children in the United States. Pediatrics. 1994;93:481– 487. 33. Scholer SJ, Hickson GB, Ray WA. Sociodemographic factors identify US infants at high risk of injury mortality. Pediatrics. 1999;103:1183–1188. 34. Duncan GJ, Brooks-Gunn J, Klebanov PK. Economic deprivation and early-childhood development. Child Dev. 1994;65: 296–318. 35. Schor EL, Billingsley MM, Golden AL, et al. Report of the task force on the family. Pediatrics. 2003;111:1541–1571. 36. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1998. 37. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service; 2000. 38. Jacobs EA, Joffe A, Knight JR, et al. Tobacco’s toll: implications for the pediatrician. Pediatrics. 2001;107:794–798. 39. Tanski SE, Klein JD, Winickoff JP, et al. Tobacco counseling at well-child and tobacco-influenced illness visits: opportunities for improvement. Pediatrics. 2003;111:e162–e167. 40. Perez-Stable EJ, Juarez-Reyes M, Kaplan CP, et al. Counseling smoking parents of young children—comparison of pediatricians and family physicians. Arch Ped Adol Med. 2001;155:25–31. 41. Heneghan AM, Silver EJ, Bauman LJ, Stein RE. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000;106:1367–1373. 42. Ibrahim JK, Schauffler HH, Barker DC, Orleans CT. Coverage of tobacco dependence treatments for pregnant women and for children and their parents. Am J Publ Health. 2002;92:1940– 1942. 43. Ross DC, Cox L. Enrolling Children and Families in Health Coverage: The Promise of Doing More. Kaiser Commission on Medicaid and the Uninsured, ed. Washington, DC: Henry J. Kaiser Family Foundation; 2002. 44. Aligne CA, Stoddard JJ. Tobacco and children—an economic
348
Kavanaugh et al
evaluation of the medical effects of parental smoking. Arch Ped Adol Med. 1997;151:648–653. 45. Hersey JC, Niederdeppe J, Evans WD, et al. The effects of state counterindustry media campaigns on beliefs, attitudes, and smoking status among teens and young adults. Prev Med. 2003; 37:544–552. 46. Sicherer SH, Munoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by
AMBULATORY PEDIATRICS means of a random digit dial telephone survey: a 5-year followup study. J Allergy Clin Immunol. 2003;112:1203–1207. 47. Patrick DL, Cheadle A, Thompson DC, et al. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health. 1994;84:1086–1093. 48. Casey P, Goolsby S, Berkowitz C, et al. Maternal depression, changing public assistance, food security, and child health status. Pediatrics. 2004;113:298–304.