When Michael Engelbrecht* (39) from Port Elizabeth visited a pulmonologist three years ago, the physician asked him when he'd started smoking.
"She looked at me very dubiously when I told her I'd never smoked a thing in my life," he said. The doctor told him that his "dilapidated" lungs had less capacity than these of a 60-year-old man who had been a "lifelong chain-smoker".
Michael had suffered severe asthma attacks since early childhood. At just over two kilograms at birth, he was extremely underweight. As a child, he suffered regular bouts of bronchitis and pneumonia and from one allergy after the other.
"I basically grew up in hospital," he said. "I spent a few days and sometimes weeks in hospital almost every month until I was 16. Doctors injected huge amounts of cortisone into me. It was the only thing that allowed me to breathe." A hospital oxygen tent was Michael's other "lifeline."
"I read books in it, I slept in it, I felt secure in it, because to me it was the only place on Earth where I could breathe. I started to look at the world through the blurry lens of a plastic oxygen tent," he said. "I loved that oxygen tent, whereas I remember other kids in the hospital who weren't used to it hating its isolation."
Michael recalled asking a doctor when he was a teenager why he had such terrible asthma. He said the physician had replied: "Bad luck." But, like many asthma sufferers, Engelbrecht has realised that his condition has little to do with this -- although he has never smoked, his mother did.
While she was pregnant with him, she smoked 20 cigarettes a day -- and both his parents smoked heavily at home until Michael was 15, exposing him to second-hand smoke. On average, smoking during pregnancy doubles the chances that a baby will be born prematurely or very underweight.
Professor Guy Richards, a pulmonologist at the University of the Witwatersrand and head of the intensive care unit at Charlotte Maxenge Hospital in Johannesburg, said cigarette smoke contained more than 4 000 dangerous chemicals, including cyanide, lead and at least 60 cancer-causing compounds.
"When you smoke during pregnancy, these harmful chemicals, particularly nicotine and carbon monoxide, get into your bloodstream, your baby's only source of oxygen and nutrients," Richards said.
"Low birth weight is due to the fact that nicotine and carbon monoxide work together to reduce your baby's oxygen supply. Oxygen is very important for helping your baby grow healthy."
According to a respected child health website, Babycenter.com, "nicotine chokes off oxygen by narrowing blood vessels throughout your body, including the ones in the umbilical cord. It's a little like forcing your baby to breathe through a narrow straw. "To make matters worse, the red blood cells that carry oxygen start to pick up molecules of carbon monoxide instead. Suddenly, that narrow straw doesn't even hold as much oxygen as it should."
According to the website, a pack-a-day smoking habit during pregnancy will reduce a baby's birth weight by an average of 230g, an enormous amount for a newborn. Richards said that undersized babies tended to have underdeveloped bodies and their lungs might not be strong enough to function properly, so they were also much more vulnerable to asthma.
Richards said: "Even if Michael had a natural predisposition to asthma, his risk to develop the condition and consequent asthma attacks had been drastically increased by exposure to smoke in the womb."
Several studies have confirmed that children who suffer from asthma and whose parents smoke are at least twice as likely to display asthma symptoms and suffer from attacks all year round compared to the children of non-smokers. Also, for people exposed to second-hand smoke at home, as Michael was, the risk of developing asthma was five fold.
"It makes me really sad to think my condition was preventable," he said. "Had my mother not smoked when pregnant with me and after that maybe I would have been a more normal child and not missed out on so much school, which led to further struggles in my life."
But he was also aware that there was a "lot of ignorance" about smoking and its effects at the time of his birth. "I remember walking around hospitals as a kid and seeing lots of nurses and doctors smoking. It's unbelievable if you think about it now."
But his mother, Chantal*, said she didn't have "much excuse" for her past behaviour. "I feel ashamed and remorseful about what I did. When I was pregnant, I only thought of my own gratification. I didn't ever ask any doctor what harm smoking could do to my child."
Like many other pregnant women who smoke, Chantal found it difficult to quit when she heard she was pregnant. She, like her husband, was only 19, and she acknowledged they were "by no means ready to settle down". They struggled financially; they both had jobs that didn't pay well.
When Chantal fell pregnant, she said her husband gave her "very little" support. "He left me on my own to deal with everything. I always worried about money and I often didn't know when he would return home after work. He would regularly stay out until the early morning hours, trying to escape the idea that he was about to have a family."
Chantal said smoking became her crutch, a way of coping with her stressful and unhappy life. "It gave me relief. I didn't think about it much further than that. From doing administrative work at a medical firm, I knew it was at least partly dangerous but I just blocked this out."
According to research published in the international journal, Women and Birth, the younger and poorer a pregnant woman is, and the lower her level of education and occupational status, the more likely she is to continue to smoke during pregnancy. In this study, only 20% to 30% of women in Australia who fell pregnant as smokers abstained partly during their pregnancy.
Juanne Vogus, a senior clinical psychologist at the Stikland Hospital in Bellville, said there were "no clear-cut answers" to the question why women who knew that smoking was dangerous for their unborn babies continued with the habit during pregnancy. "One possible answer, however, is that pregnant women don't yet see their babies as separate living beings, making the direct impact of doing something harmful to them harder to realise," she said.
Some studies suggest that strategies designed to prevent pregnant women from smoking would be more successful if their focus was changed from harm to the unborn child to making the pregnant woman realise smoking was harmful to herself. Chantal agreed.
"I drastically reduced my smoking with my second and third children because I realised smoking had not only harmed Michael but was also harming me," she said. "It dawned upon me that many of the allergies and breathing problems I myself sometimes experienced could be because of smoking. Also, if smoking killed me before my time, I thought, my children would not have a mother —"
But Michael's chronic asthma was not enough to compel Chantal to quit smoking. She continued to smoke when she "absolutely needed to" during her other two pregnancies.
Dr Despina Learmonth, a health and counselling psychologist at the University of Cape Town, said that the "feel-good" experience that nicotine provided made it extremely difficult for woman to give up smoking during a very stressful time such as pregnancy, when a woman might feel she needed it even more.
Finally, in 1986, Chantal and her husband gave up smoking. She said: "Not smoking was hell for a month. I had severe night sweats, I couldn't sleep and I constantly craved nicotine. But I knew if I touched another cigarette, I would be addicted again. I was just tired of being a slave to cigarettes."
But the damage had been done -- to both her and Michael. She suffers severely from one of the most common effects of smoking -- emphysema, which will eventually destroy her lungs. Although Michael's asthma has eased over the years, his health problems as a result of his mother's smoking may not be over, according to health experts.
Research shows that children of mothers who smoked are more likely to experience heart problems at a later stage in life. Michael's wife fell pregnant a year ago. During her term, he said he was "obsessed" with keeping her away from smoke.
Today, he "pulls" his daughter Emma "away from anyone who's smoking. I just don't want her to go through what I did." Back in her Port Elizabeth flat, Chantal reflected on the consequences of her choices. "I hope someone learns from me," she said. "I hope they read my story and decide not to do what I did. I was young, immature and selfish, and I hope others try to do better than what I did."
* Not their real names
Weighing up the oddsSmoking women are 30% less likely to fall pregnant, and smoking during pregnancy doubles the chances that a baby will be born prematurely or weigh less than 2.5kg.
Smoking by mothers can cause sudden infant death syndrome (Sids) -- cot deaths. Compared with unexposed infants, babies exposed to second-hand smoke after birth are at twice the risk of Sids, and infants whose mothers smoked before and after birth are at three to four times greater risk.
Babies of mothers who smoked during pregnancy are more likely to have a heart defect at birth and are vulnerable to asthma. Children of pregnant smokers are likely to have learning disorders, attention deficit and hyperactivity disorder, behavioural problems and relatively low IQs.
Expecting moms who quit smoking in the first trimester actually raise their odds of delivering a healthy full-term baby to about the same as that of a non-smoker. Moms who quit in the second trimester improve their odds, but not as much.
Mia Malan works for the Health Journalism Centre at Rhodes University.
[This article was originally published on 8 July 2011]
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