The Dominican Republic is a country where tobacco control activities have been nearly nonexistent, and countrywide public health surveillance on tobacco use prevalence, trends, and tobacco-related diseases are not currently part of the national public health agenda. A major strength of this study is that it provides the first look into understanding beliefs, attitudes, and exposure to tobacco use and secondhand smoke among pregnant women in the Dominican Republic. It also provides further suggestive evidence that tobacco use and SHS among pregnant women are a current or emergent public health problem in some countries of the Latin America and Caribbean region.
This study further provides a comparison between the Dominican Republic and Argentina, Uruguay, Ecuador, Brazil, and Guatemala regarding cigarette smoking prevalence among pregnant women to help characterize regional differences in tobacco use. Overall, 3% of respondents from the Dominican Republic reported being a current smoker, which is higher than Ecuador (0.8%) and Guatemala (0.8%) and lower than Argentina (10%), Uruguay (18%), and Brazil (6%). These rates are lower than the overall estimated smoking prevalence rates among adult women in Dominican Republic (11%), Argentina (24%), Uruguay (29%), Ecuador (6%), Guatemala (4%), and Brazil (12%; Shafey et al., 2009
). Differences in cigarette smoking prevalence among adult women and pregnant women may be attributed to different epidemiological stages of the tobacco epidemic each country is experiencing and the lack of comprehensive tobacco control measures that still remains in many LAC countries (Bianco et al., 2006
). It is important to note that increased attention by policy makers has been given to the tobacco epidemic via the WHO’s Framework Convention on Tobacco Control, which includes key provisions for evidence-based tobacco control (Bianco et al., 2006
). Among the comparison countries included in this study, Argentina and Ecuador have signed the treaty and Brazil, Guatemala, and Uruguay have ratified the treaty. The Dominican Republic has neither signed nor ratified this treaty and has lagged behind these countries in developing comprehensive tobacco control policies.
Although the Dominican Republic had fewer women who ever tried smoking when compared with other Latin American countries, the majority of women who reported experimenting with smoking started at a very young age. Research shows that most women who become regular smokers as adults started experimenting with tobacco at an early age (U.S. DHHS, 2001). Data from the Global Youth Tobacco Survey (GYTS) indicate that historical gender differences in smoking uptake and prevalence among girls (aged 13–15 years) are changing, with girls smoking just as much and sometimes more than boys in many parts of the world (GYTS Collaborating Group, 2003
). Postpartum smoking relapse, although not a specific aim of this study, is an important area of concern since review of existing research has shown postpartum smoking relapse rates to range from 70% to 85% among women who smoke but quit sometime during pregnancy (Fang et al., 2004
). Approximately 7% of respondents in this study reported intent to begin or resume smoking after pregnancy, representing an area for further research.
Data from this study also suggest that SHS is a public health concern in the Dominican Republic, with 76% of households allowing smoking and both women and children experiencing considerable levels of SHS. Compared with other Latin American countries in the study of Bloch et al. (2008)
, participants from the Dominican Republic had the highest rates of smoking allowed in households. This is in marked contrast to the low percentage of Dominican respondents who reported SHS for themselves (16%) and their young children (14%), which could indicate underreporting or lack of awareness by respondents. Ossip-Klein et al. (2008)
found that 76% of households allowed smoking in their home across six underprivileged Dominican Republic communities. Wipfli et al. (2008)
examined SHS among women and children in 31 countries and found that hair nicotine concentration was nearly twice as high in children younger than 5 years living with smokers compared with those older than 5 years living with smokers. Households that allowed smoking had a 12.9 increase in air nicotine concentration compared with smoke-free homes (Wipfli et al., 2008
). Research has also found that women and children are most often exposed to tobacco in the home, given its key location for smoking, as they carry out their daily lives (Andrews and Heath, 2003
). Consequently, many women and children cannot avoid being victims of SHS.
A difference emerged between the concepts of harm and illness in regards to tobacco use and SHS. The majority of respondents from this study believe that smoking can cause harm to both the smoker and unborn child, but only a third believe smoking can lead to illness. Similarly, the majority of respondents believe exposure to secondhand smoke is harmful to nonsmokers, but only 23% believe exposure to secondhand smoke could cause general illness. The difference between “harm” and “illness” is an important one because of the potential cultural connotations that define these concepts. According to Kleinman, Eisenberg, and Good (1978)
, harm is culturally shaped by the way it is perceived, experienced, and the way disease is coped with and is based on cultural specific explanations of sickness, which are culturally based systems of meaning (p. 141). On the other hand, illness is based on a biomedical viewpoint in which the recognition and treatment of disease is the primary influence, and the cultural and social factors that shape the concept of harm as a legitimate clinical concern in treating disease are dismissed (Kleinman et al., 1978
). These data suggest a clear need for a national effort to educate women on the actual health risks of tobacco use and SHS and the benefits of quitting as part of a comprehensive public health effort to thwart the tobacco epidemic in the Dominican Republic.
Limitations for this study include the low number of smokers in the study sample, the use of self-report data from participants (e.g., current smoking status) due to the inability to verify accuracy and reliability of such self-reports (e.g., biological verification of smoking status, which is often used in tobacco control research data, was not feasible), the overall small sample size, the use of only two urban settings, and the use of a convenience sample so that it is not known whether these results would be generalizable to other settings. In addition, this study did not allow for an in-depth examination of the sociodemographic and social–cultural factors that contribute to tobacco use and secondhand exposure during pregnancy but serves as a preliminary indication of the problem. Although the survey assessed cessation efforts among women who quit during pregnancy, no quitters were identified. Similar to the limitations in the study of Bloch et al. (2008)
, smoking during pregnancy is socially stigmatized; therefore, underreporting is expected and could have led to the underestimation of the scope of this public health issue in the Dominican Republic. The use of medical personnel as data collectors may have further increased the likelihood of underreporting. Anecdotal evidence of underreporting was provided by data collectors who stated that after interviews, some of the respondents who self-reported as nonsmokers were later observed smoking outside of the public health hospitals. Finally, there was a 4-year gap between the current study and that of Bloch et al., which may limit comparisons, though the lack of tobacco control activities in the Dominican Republic over this time period may mitigate these temporal concerns.
Results can help further the understanding of the maternal and child health aspect of this complex global tobacco epidemic and its potential effects on low- and middle-income countries such as the Dominican Republic. In addition, it provides a starting point for including tobacco use and SHS reduction as part of the Dominican Republic’s public health efforts that include improving maternal and child health.