Until now, no one knew exactly how many pregnant women in low- and middle-income countries used tobacco products. A report in The Lancet Global Health looks at 54 countries and finds some cause for relief. The rate of tobacco use among pregnant women in those countries averages about 3 to 6 percent, though some outliers, like Turkey, have smoking rates of up to 15 percent.

The report provides the most comprehensive look at tobacco use among pregnant women in low- and middle-income countries to date. In 21 countries, the use of smokeless tobacco, such as chewing tobacco, was higher than the use of cigarettes among pregnant women.

A bright spot is that, so far, fewer women smoke (8 percent) than men (36 percent) — a statistic the tobacco industry is no doubt aware of. "Women represent an untapped market in many developing countries, and these industries salivate over such opportunities," says Thomas Novotny, professor of global health at San Diego State University and former Assistant Surgeon General. "It is critical to prevent smoking initiation among women in order to head off what we know will be an epidemic of tobacco-related diseases later on.

Indeed, the tobacco industry has a history of marketing to non-smokers, including women. In Japan, for example, "the tobacco industry is using the Virginia Slims strategy: female empowerment illustrated through tobacco use," says Karen K. Gutierrez, director of the Global Smoke-Free Workplace Challenge.

The tools for preventing an increase in smoking among women are in place. In 2003, the World Health Organization negotiated the first ever global public health treaty, the Framework Convention on Tobacco Control. The treaty cites interventions that work around the world.

Smoke-free policies in the workplace and public areas make smoking seem abnormal. "The more places people can't smoke, the more they won't smoke," says Gutierrez. Raising taxes on tobacco makes cigarettes increasingly unaffordable to young people; older smokers often decide that the high cost is just not worth it.

Educating pregnant women about the dangers to their developing fetuses is crucial. "Not every woman actually does know that it's dangerous to smoke during pregnancy," says Gutierrez. "And people minimize the risk by thinking that, sure it could happen, but there's a low likelihood."

Public health efforts that have succeeded in the U.S. might help in low-income countries. The public service message called "Amanda," created by the Centers for Disease Control and Prevention, brings home the point that smoking during pregnancy can lead to premature birth. In the ad, a young woman talks to her two-month premature infant through an opening in an incubator in a neonatal intensive care unit.

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