By Judith Vandewater
Of the Post-Dispatch

March 5, 2000

Edited by Virginia Baldwin Gilbert

Katresa Lucas started smoking as a teen-ager and has smoked her way through eight pregnancies.

She smoked about 15 cigarettes a day during her recent pregnancy, switching to Salem because the product seemed lighter than Newport, her regular brand. Lucas delivered a healthy 7-pound, 2-ounce girl Feb. 16.

She and baby Diamond are fortunate; the delivery was problem-free for mother and child. Dr. F. Sessions Cole sees the babies who aren't as lucky.

An energetic teacher with a signature bow tie and wit, Cole, 50, heads the neonatal intensive care unit at St. Louis Children's Hospital. He directs the division of newborn medicine at Washington University's School of Medicine and is medical director of pediatrics for BJC Health System. He chairs the St. Louis chapter of the March of Dimes.

In the debate over how Missouri will spend its multibillion dollar share of the tobacco litigation settlement, Cole speaks for the babies.

He supports the consensus in the medical community that the money should be used for health care, clinical and basic research and for smoking prevention and cessation programs.

Smoking can and does injure babies, Cole said. And women who smoke when pregnant are playing Russian roulette with their baby as the target.

Although public-health campaigns have made significant headway in the war against smoking in Missouri, much remains to be done. The Missouri Department of Health's Bureau of Health Data reports that in 1998 2 of 10 white women and about 1 of 10 black women who delivered live babies said they smoked cigarettes while pregnant. The bureau said 14.1 percent of all Missouri women who gave birth in the St. Louis area in 1998 said they smoked during pregnancy compared with 23.7 percent of all mothers who delivered in Missouri's Bootheel. Smoking cuts across all economic classes.

"My boss is the baby"

Researchers don't yet know why some women seem to be able to smoke during pregnancy without injuring their baby's health, any more than they know why some individuals succeed at quitting smoking while others fail repeatedly. Some women are genetically able to detoxify poisons in tobacco smoke better than other women. Doctors now have no way to know which women have better internal filters.

"My boss is the baby," Cole likes to say. And given the potential for dire tobacco-related health consequences when babies are exposed to smoke -- or the hardships when babies' parents are incapacitated by smoking-related disease -- Cole thinks it is not in the best interest of Missouri babies for the state Legislature to use the tobacco settlement funds to build roads or give rebates to taxpayers, or promote economic development.

Spent with forethought, the tobacco money could help researchers learn better ways to promote healthy behavior, keep children from smoking and help their parents quit. Gene research funded with tobacco settlement money may one day identify a cell-level predisposition to smoking-related disease. This and other discoveries could lead to more effective ways to treat or prevent cancer and emphysema, he said.

Cole said that the basic epidemiological facts regarding babies and smoking are these:

* The more you smoke, the more likely you are to have a premature baby.

* The more you smoke, the more likely you are to have an underweight baby, even if the baby is carried to term. "Everyone knows that the lower the weight of a baby at birth, the greater the health risks to the baby."

Researchers know that carbon monoxide and other substances in tobacco smoke reduce blood flow to the womb and thereby diminish the amount of nutrition and oxygen going to the baby. When the womb and placenta are unable to sustain the needs of the fetus, the womb pushes the fetus out. This mechanism is thought to account for premature birth. A smoker who carries to term, is still more likely to deliver an underweight baby.

Babies whose mothers smoked while pregnant are at greater risk throughout childhood of developing asthma, attention deficit disorder or of failing to thrive. A baby exposed in the uterus to smoke-borne toxins can suffer lifelong effects of stunted lung growth or neurological impairment.

If the baby comes home to a house where one or both parents smoke, and the baby is constantly breathing smoke, the damage is compounded, Cole said. Exposure to secondhand smoke can disrupt normal lung growth and reduce the number of air sacks that grow and multiply in a child's lungs through about age 8 to 10.

"If one takes a person whose lungs have been disrupted during development and induces that person to smoke when he or she is 12, one is taking a pre-existing tobacco-related lung problem and superimposing a second tobacco-related lung problem," Cole said. "There is a sequentially increasing risk for each tobacco exposure."

It is generally thought that tobacco use during pregnancy is either the main or contributing reason for about one-fourth of the admissions to neonatal intensive care units, Cole said.

No studies crisply isolate smoking as the only variable contributing to a high risk birth. Poor nutrition, alcohol and drug use are also common compounding risk factors. And a woman can be extremely careful during pregnancy, abstain from alcohol and tobacco and still have health problems that result in a premature delivery.

In the 50-incubator unit at Children's Hospital, nurses in pastel smocks with cartoon prints hover over Plexiglas Isolettes crowned with stuffed animals and flagged with Mylar balloons. Behind the sweet sentiments, and deeper into the busy unit, lie newborns with the most fragile grip on life.

One baby, born three months and one week premature, weighed 1 1/3 pounds at birth. His 18-year-old mother had no prenatal care. She smoked and engaged in other high risk behaviors during her pregnancy.

The baby is the size of a man's palm. His disproportionately large hands and feet protrude from stick thin arms and legs. He lies partially sedated as a ventilator breathes for him.

A glucose drip delivers a few thimbles worth of nourishment over 24 hours. An intravenous line thin as pencil lead feeds antibiotics and sedatives into his blood stream. Two penny-sized sticky pads on his belly hold sensors that transmit impulses measured as heart beat, respiration rate, blood pressure and temperature.

A faint red beam glows from the tip of the oximeter on the baby's wrist.

All this high-tech intervention is meant to buy time for the baby's organs to develop and grow. "We are as good as anybody in the world at doing this, but we are not as good as the placenta in the womb," Cole said. "If we did as good a job as the placenta, everything would be fine."