On 2014 Apr 08, David Reardon commented:

The authors of this study¹ concluded that smoking explains about one-third of the variation in preterm birth rates among low income and high income groups (SES) while reproductive history accounts for only one-fourth of preterm births.

Unfortunately this analysis and conclusion is marred by the incorrect assumption that smoking behavior is independent of prior reproductive history. It is not.

Smoking behavior is driven by many emotional factors, including loss and bereavement.² Women are especially more likely to explain a desire to smoke to cope with emotional upsets.³

Most importantly to the study at hand, research has consistently shown that women with a history of abortion smoke substantially more.^4,5 In addition, a dose effect has also been observed, with the number of abortions correlating with even higher rates of smoking.⁶

Research has also shown that women with a history of abortion are more likely to persist in or increase smoking (and alcohol or illegal drug use) during subsequent wanted pregnancies.^7,8 The most common explanation for this—provided by women themselves and by therapists experienced in treating post-abortion maladjustment⁹ is that subsequent wanted pregnancies may stir up unresolved feelings of loss, grief, or guilt relative to past abortions. From this perspective, smoking, drinking, and the use of other mood altering substances are just forms self-medication employed to assist in the repression of unresolved negative emotions.

A causal connection between abortion and smoking behavior is reported in a survey of 527 women interviewed one month after their abortions in which 23% reported using smoking specifically “to help deal with [their] abortion." Drinking and drug use were also reported as being used “to help deal with” their abortions by 18% and 9% respectively.10 Yet another follow up survey of women after their abortions found that higher post-abortion anxiety scores correlated to heavier smoking patterns.¹¹

It is also known that smoking rates increase with exposue to trauma and PTSD^12. This is important because studies of abortion patients, using multiple scales and assessments before and subsequent to abortion, show a significantly higher rates of PTSD following abortion.^13,14,15

In light of this evidence, it is clear that history of abortion should not be treated as simply an aspect of a woman’s physical history. It has psychological components more profound than, for example, a history of placenta previa. These psychological reactions can contribute to behaviors such as elevated smoking, drinking, and drug use which may not only persist through subsequent wanted pregnancies^16, but may even be accentuated by the emotions surrounding the pregnancy.⁹

In light of the above observations, I would encourage the authors to undertake additional analyses to tease out any possible distinctions between the direct biological effect associated with abortion and the possible indirect effects which may be associated with the psychological effects of abortion on behaviors like smoking.

Notably, the current study observe adjusted odds ratios for extremely preterm, very preterm, and moderately preterm for abortion (1.28, 1.16, 1.07, respectively) which were in a range similar to the adjusted odds ratios for smoking (1.21, 1.23, 1.15). Additional analyses could be performed to separate the potential effects of smoking and abortion.

In my proposed analysis, the first uninterrupted pregnancy outcomes (full term live singleton birth, stillbirth, moderate preterm, very preterm, extremely preterm, miscarriage, ectopic pregnancy) would be compared for three groups of women (no smoking, quit smoking during first trimester, smoked beyond first trimester) with results segregated for a prior exposure to induced abortion.

The proposed analysis would also allow us to determine if a history of abortion does reduce the likelihood that woman will stop smoking in the first trimester. In addition, comparing the two groups of women without any history of smoking would give us a clearer picture of the effects of abortion when smoking is not a confounding factor. This comparison would not eliminate other possible indirect, emotional factors (such as eating disorders, which can also be associated with abortion^9, might still play a role, but it would at least demonstrate whether smoking behavior in combination with abortion is confounding these currently published results.

References

1) Raisanen S, Gissler M, Saari J, Kramer M, Heinonen S (2013) Contribution of Risk Factors to Extremely, Very and Moderately Preterm Births – Register- Based Analysis of 1,390,742 Singleton Births. PLoS ONE 8(4): e60660.

2) Parkes CM, Brown RJ. Health after bereavement. A controlled study of young Boston widows and widowers. Psychosom Med. 1972 Sep-Oct;34(5):449-61.

3) United States Public Health Service, Adult Use of Tobacco. U.S. Dept of Health, Education and Welfare, CDC, Bureau of Health Education (1975)

4) Pedersen W. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study. Addiction. 2007 Dec;102(12):1971-8.

5) Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal pregnancy survey, Br J Obstet Gynaecol 108:1036-1042, 2001.

6) Levin AA, Schoenbaum SC, Monson RR, Stubblefield PG, Ryan KJ. Association of induced abortion with subsequent pregnancy loss. JAMA. 1980 Jun 27;243(24):2495-9.

7) Coleman P, Reardon D, Rue V, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obst Gynecol 2002; 187: 1673–8.

8) Coleman P, Reardon D, Cougle J. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol 2005; 10: 255–68.

9) Burke T, Reardon DC. Forbidden Grief: The Unspoken Pain of Abortion. Acorn Books. (2002) Springfield, IL.

10) Major B, Richards C, Cooper ML, Cozzarelli C, Zubek J. Personal resilience, cognitive appraisals, and coping: an integrative model of adjustment to abortion. J Pers Soc Psychol. 1998 Mar;74(3):735-52.

11) Henshaw R, et al, "Psychological responses following medical abortion (using mifepristone and gemepost) and surgical aspiration. Acta Obstet Gynecol Scand 73:812, 1994.

12) Feldner MT, Babson KA, Zvolensky MJ. Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature.. Clin Psychol Rev. 2007 Jan;27(1):14-45. Epub 2006 Oct 10.

13) Sharain Suliman et. al., Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. BMC Psychiatry 2007, 7:24.

14) Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.

15) Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol. Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion. C. Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

16) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy.Br J Health Psychol. 2005 May;10(Pt 2):255-68.

On 2014 Apr 08, David Reardon commented:

The authors of this study¹ concluded that smoking explains about one-third of the variation in preterm birth rates among low income and high income groups (SES) while reproductive history accounts for only one-fourth of preterm births.

Unfortunately this analysis and conclusion is marred by the incorrect assumption that smoking behavior is independent of prior reproductive history. It is not.

Smoking behavior is driven by many emotional factors, including loss and bereavement.² Women are especially more likely to explain a desire to smoke to cope with emotional upsets.³

Most importantly to the study at hand, research has consistently shown that women with a history of abortion smoke substantially more.^4,5 In addition, a dose effect has also been observed, with the number of abortions correlating with even higher rates of smoking.⁶

Research has also shown that women with a history of abortion are more likely to persist in or increase smoking (and alcohol or illegal drug use) during subsequent wanted pregnancies.^7,8 The most common explanation for this—provided by women themselves and by therapists experienced in treating post-abortion maladjustment⁹ is that subsequent wanted pregnancies may stir up unresolved feelings of loss, grief, or guilt relative to past abortions. From this perspective, smoking, drinking, and the use of other mood altering substances are just forms self-medication employed to assist in the repression of unresolved negative emotions.

A causal connection between abortion and smoking behavior is reported in a survey of 527 women interviewed one month after their abortions in which 23% reported using smoking specifically “to help deal with [their] abortion." Drinking and drug use were also reported as being used “to help deal with” their abortions by 18% and 9% respectively.10 Yet another follow up survey of women after their abortions found that higher post-abortion anxiety scores correlated to heavier smoking patterns.¹¹

It is also known that smoking rates increase with exposue to trauma and PTSD^12. This is important because studies of abortion patients, using multiple scales and assessments before and subsequent to abortion, show a significantly higher rates of PTSD following abortion.^13,14,15

In light of this evidence, it is clear that history of abortion should not be treated as simply an aspect of a woman’s physical history. It has psychological components more profound than, for example, a history of placenta previa. These psychological reactions can contribute to behaviors such as elevated smoking, drinking, and drug use which may not only persist through subsequent wanted pregnancies^16, but may even be accentuated by the emotions surrounding the pregnancy.⁹

In light of the above observations, I would encourage the authors to undertake additional analyses to tease out any possible distinctions between the direct biological effect associated with abortion and the possible indirect effects which may be associated with the psychological effects of abortion on behaviors like smoking.

Notably, the current study observe adjusted odds ratios for extremely preterm, very preterm, and moderately preterm for abortion (1.28, 1.16, 1.07, respectively) which were in a range similar to the adjusted odds ratios for smoking (1.21, 1.23, 1.15). Additional analyses could be performed to separate the potential effects of smoking and abortion.

In my proposed analysis, the first uninterrupted pregnancy outcomes (full term live singleton birth, stillbirth, moderate preterm, very preterm, extremely preterm, miscarriage, ectopic pregnancy) would be compared for three groups of women (no smoking, quit smoking during first trimester, smoked beyond first trimester) with results segregated for a prior exposure to induced abortion.

The proposed analysis would also allow us to determine if a history of abortion does reduce the likelihood that woman will stop smoking in the first trimester. In addition, comparing the two groups of women without any history of smoking would give us a clearer picture of the effects of abortion when smoking is not a confounding factor. This comparison would not eliminate other possible indirect, emotional factors (such as eating disorders, which can also be associated with abortion^9, might still play a role, but it would at least demonstrate whether smoking behavior in combination with abortion is confounding these currently published results.

References

1) Raisanen S, Gissler M, Saari J, Kramer M, Heinonen S (2013) Contribution of Risk Factors to Extremely, Very and Moderately Preterm Births – Register- Based Analysis of 1,390,742 Singleton Births. PLoS ONE 8(4): e60660.

2) Parkes CM, Brown RJ. Health after bereavement. A controlled study of young Boston widows and widowers. Psychosom Med. 1972 Sep-Oct;34(5):449-61.

3) United States Public Health Service, Adult Use of Tobacco. U.S. Dept of Health, Education and Welfare, CDC, Bureau of Health Education (1975)

4) Pedersen W. Childbirth, abortion and subsequent substance use in young women: a population-based longitudinal study. Addiction. 2007 Dec;102(12):1971-8.

5) Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal pregnancy survey, Br J Obstet Gynaecol 108:1036-1042, 2001.

6) Levin AA, Schoenbaum SC, Monson RR, Stubblefield PG, Ryan KJ. Association of induced abortion with subsequent pregnancy loss. JAMA. 1980 Jun 27;243(24):2495-9.

7) Coleman P, Reardon D, Rue V, Cougle J. A history of induced abortion in relation to substance use during subsequent pregnancies carried to term. Am J Obst Gynecol 2002; 187: 1673–8.

8) Coleman P, Reardon D, Cougle J. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. Br J Health Psychol 2005; 10: 255–68.

9) Burke T, Reardon DC. Forbidden Grief: The Unspoken Pain of Abortion. Acorn Books. (2002) Springfield, IL.

10) Major B, Richards C, Cooper ML, Cozzarelli C, Zubek J. Personal resilience, cognitive appraisals, and coping: an integrative model of adjustment to abortion. J Pers Soc Psychol. 1998 Mar;74(3):735-52.

11) Henshaw R, et al, "Psychological responses following medical abortion (using mifepristone and gemepost) and surgical aspiration. Acta Obstet Gynecol Scand 73:812, 1994.

12) Feldner MT, Babson KA, Zvolensky MJ. Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature.. Clin Psychol Rev. 2007 Jan;27(1):14-45. Epub 2006 Oct 10.

13) Sharain Suliman et. al., Comparison of pain, cortisol levels, and psychological distress in women undergoing surgical termination of pregnancy under local anaesthesia versus intravenous sedation. BMC Psychiatry 2007, 7:24.

14) Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit, 2004 10(10): SR5-16.

15) Rousset, C. Brulfert, N. Séjourné, N. Goutaudier & H. Chabrol. Posttraumatic Stress Disorder and psychological distress following medical and surgical abortion. C. Journal of Reproductive and Infant Psychology, (2011) Volume 29(5), 506-517.

16) Coleman PK, Reardon DC, Cougle JR. Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy.Br J Health Psychol. 2005 May;10(Pt 2):255-68.