Gravida ’ s knowledge concerning harmful effect of smoking on the fetus and the awareness of HPV infection impact on the development of cervical cancer

Barbara Kozakiewicz1,2, Małgorzata Chądzyńska3, Ewa Dmoch-Gajzlerska1 Received: 15.02.2016 Accepted: 30.03.2016 Published: 29.04.2016 © Curr Gynecol Oncol 2016, 14 (1), p. 13–22 DOI: 10.15557/CGO.2016.0002 Barbara Kozakiewicz, Małgorzata Chądzyńska, Ewa Dmoch-Gajzlerska


INTRODUCTION
T obacco -species name of Nicotiana tabacumis a plant of the Solanaceae family.Tobacco was brought to Europe by a sailor: Romano Pane, the participant of the second Christopher Columbus' voyage to America in 1496.The methods of using tobacco were discussed in Pane's work On the customs and habits of America's inhabitants.In 1669, Benedetto Stella published his book glorifying the good sides of tobacco, which he ascribed healing properties; it included recommendations to smoke for various ailments.Deputy Paweł Uchański brought tobacco from Turkey in the 16 th century.The habit of taking snuff and smoking tobacco became rapidly widespread throughout the whole Old Continent.Interest in tobacco has greatly increased in the 17 th century during the epidemic of plague, when it was deemed that tobacco smoke prevents contracting that disease.Not all the rulers were tobacco enthusiasts.Tsar Nicholas III sentenced smokers to deportation in the 17 th century, and the Emperor of the Ottoman Empire Murad IV impaled them or ordered to cut their hands off (1)(2)(3)(4) .Nowadays, smokers sentence themselves, while smoking gravidas -also their unborn children, to diseases and development disturbance.Tobacco smoke has 3-4 thousand ingredients created as a result of pyrolysis and distillation of tobacco and the cigarette paper at the temperature of 600-1000°C.Tobacco smoke is a full carcinogen with the content of 40 substances with documented action initiating the neoplastic process.Additionally, smoke contains promoting and co-carcinogenic substances -carcinogens (5)(6)(7) .

Tobacco smoke ingredients have local and systemic action.
Local action is limited to the influence on the oral cavity and the respiratory system, while systemic pertains to the organs and tissues which substances included in the smoke reach after being absorbed to the blood.The composition of the smoke inhaled by the smoker and the composition of the smoke emitted to the environment differ to a great extent.Tobacco smoke is the sum of two streams: the main one -inhaled by the smoker, and the secondary one -created during the breaks in smoking.Incomplete burning of the cigarette ingredients leads to difference in the field of chemical composition and the concentration of toxic substances in tobacco smoke.The concentration of some chemical substances, e.g.carbon oxide, in the secondary stream is even several times higher than in the main one.Therefore, smoking negatively affects not only the smoker but also their environment.Passive smoking leads to the development of diseases and deaths to no smaller extent than active one (8)(9)(10)(11) .Nicotine is absorbed to the bloodstream from the mucous membrane of the oral cavity and alveoli and through uninjured skin.It undergoes biotransformation to cotinine, γ-(3-pyridyl)-γ-hydroxybutyric acid, 3-pyridylacetic acid and N-nicotine oxide.It is one of micsrosomal enzyme inductor.It is excreted mainly with urine (untransformed as well as metabolites, especially cotinine) and in a smaller amount with saliva and excreted to the gastric juice.All the ingredients of the tobacco smoke penetrating to the blood cross the placenta barrier and have an impact on the fetus in the same manner as on the mother.They are also present in breast milk (7,12,13) .Smoking actively in pregnancy may result in child's physical, intellectual and emotional development retardation.Survey conducted among 17 thousand girls and boys aged 7 and 11 showed that the children of mothers who smoked when pregnant 10 and more cigarettes a day were 3-5 months retarded in intellectual development (reading, solving mathematical exercises) as compared to children of non-smoking mothers.The degree of retardation increased along with the number of cigarettes smoked.Passive smoking is as harmful during pregnancy as active smoking and entails consequences at every stage of the child's life.Infants are born with a lower body weight; additionally the incidence of recurring bronchitis and otitis media increases and the development of the lung tissue is inhibited, which results in the recurrence of upper respiratory tract infections (12)(13)(14) .There is no safe level of smoking -every number of cigarettes smoked by the mother and exposure to the environmental tobacco smoke (ETS) have an unfavorable effect on the child.Until recently, the evaluation of the influence of nicotine on the incidence of neoplasms covered only epidemiological observations.However, in 1996, scientists from the USA described molecular tests over the impact of tobacco smoke on the bodies of animals and people.They observed that the direct cause of neoplasms are changes in the DNA structure of a cell.Chemical compounds in tobacco smoke CURR GYNECOL ONCOL 2016, 14 (1), p. 13-22 DOI: 10.15557/CGO.2016.0002 Związki chemiczne z dymu tytoniowego wywołują uszkodzenia DNA, przez co powstaje błędny kod genetyczny.Szczególną rolę odgrywa benzopiren, który powoduje mutacje genu supresorowego TP53 i w ten sposób inicjuje powstanie wielu nowotworów.W końcówce lat 90.Światowa Organizacja Zdrowia uznała istotną rolę wirusa brodawczaka ludzkiego (human papillomavirus, HPV) w zachorowaniu na raka szyjki macicy.Obecnie wiadomo na pewno, że infekcja ta, zwłaszcza spowodowana wirusami t ypu 16. i 18., stanowi przyczynę zachorowania na raka szyjki macicy (u 95% chorych), raka sromu i prącia (1) .Lata obserwacji pacjentek zainfekowanych HPV pokazały, że palenie tytoniu przez zakażone kobiety prowadzi do szybszego pojawienia się stanów śródnabłonkowej neoplazji, a w konsekwencjido zachorowania na inwazyjnego raka szyjki macicy (13) .Ponadto rośnie liczba doniesień o wpływie infekcji HPV na zachorowania na nowotwory spoza okolic narządów rozrodczych: głowy i szyi, odbytnicy, a nawet płuc (7)(8)(9) .U palaczek zainfekowanych HPV działanie nikotyny jest szczególnie szkodliwe, gdyż nikotyna wpływa na naskórkowy czynnik wzrostu (epidermal growth factor, EGF), który -indukując czynnik wzrostu śródbłonka naczyń krwionośnych (vascular endothelial growth factor, VEGF)powoduje proliferację komórek, co prowadzi m.in.do wzrostu guza nowotworowego.Wzmożenie ekspresji receptora VEGF-C przyczynia się do szybszego rozsiewu raka przez wpływ na angiogenezę (10,11) .Celami niniejszej pracy są: ocena stanu wiedzy ciężarnych na temat szkodliwości tytoniu, poznanie zachowań tych kobiet i ich rodzin w zakresie palenia oraz zbadanie wiedzy o wpływie infekcji HPV na zachorowania na raka.

WYNIKI
Spośród 127 badanych 96 (76%) nigdy nie paliło tytoniu, 10 (8%) rzuciło palenie, a 21 (16%) nadal paliło mimo ciąży.Za niepalące w trakcie badania uznano 106 (84%) kobiet.Przebywanie wśród dymu tytoniowego w roli biernych palaczek potwierdziło 36 (28%) uczestniczek.Średni czas narażenia ciężarnych na bierne damage the DNA, thus creating an erroneous genetic code.Benzopyrene is of special importance, since it results in the suppressor gene TP53 mutation, thus initiating the development of many neoplasms.At the end of the 1990s, the World Health Organization considered the crucial role of the human papillomavirus (HPV) in cervical cancer incidence.At present, it is undoubtedly certain that the infection, especially induced by viruses of type 16 and 18, constitutes the reason for cervical cancer incidence (in 95% of patients), vulvar cancer or penile cancer (1) .Years of observation of patients infected with HPV showed that smoking tobacco by infected women leads to faster conditions of intraepithelial neoplasia and -as a consequence -to the incidence of invasive cervical cancer (13) .In addition, there are more and more reports concerning the influence of the HPV infection on the rate of neoplasm incidence beyond the region of the reproductive organs: head, neck, rectum and even lungs (7)(8)(9) .Among smokers infected with HPV, the operation of nicotine is particularly harmful, since nicotine has an impact on the epidermal growth factor (EGF), which -by inducing the vascular endothelial growth factor (VEGF) -leads to the proliferation of cells, which is the cause e.g. of neoplastic tumor growth.Increased expression of the VEGF-C receptor contributes to faster dissemination of the cancer through its impact on angiogenesis (10,11) .The aims of this paper are: to evaluate the knowledge of gravidas on the harmful effect of tobacco, learning the behavior of these women and their families as regards smoking and verifying knowledge as regards the HPV infection on the incidence of cancer.

MATERIAL AND METHOD
The study covered 127 healthy gravidas provided with specialist care of the gynecology clinic.The study was conducted from March to June 2015 with the utilization of a diagnostic survey.To that end, a questionnaire was drafted autonomously, which covered 23 questions: 17 closed-end and 6 open questions.The age, place of residence and education of the respondents is presented in Tab. 1.The majority (95%) of the respondents were aged 19-40, mean being 25.3.Over half of the respondents (51%) were primiparas, 23% -secundiparas, 12% -tertiparas; the remaining women were multiparas (over two pregnancies).

RESULTS
From among 127 respondents, 96 (76%) never smoked tobacco, 10 (8%) quitted smoking, while 21 (16%) continued to smoke despite being pregnant; 106 (84%) women were deemed non-smokers in the course of the study.Being present -when there was tobacco smoke around -in the role of passive smokers was confirmed by 36 (28%) of the respondents.The average time of gravidas' exposure to passive CURR GYNECOL ONCOL 2016, 14 (1), p. 13 Women would choose particular approaches with different frequency (Kruskal-Wallis test: chi-square = 30.33;df = 3; p v < 0.001).Thirty-two per cent of the respondents quitted smoking, yet groups similar in terms of size only limited smoking or moved to "light" cigarette (29% and 32%, respectively).The least frequently (6%), the respondents decided to use nicotine patches to limit the number of cigarettes smoked.

Miejsce zamieszkania
Place of residence Twenty-one gravidas did not stop smoking.The largest group (8 people, 38%) smoked 5 cigarettes a day, 4 women (19%) -10 to 20, the remaining -1 to 2. Smoking 5 cigarettes a days was deemed not harmful to the child by 6% of all the respondents (8/127) and 9% of active smokers (2/21).Women who accepted smoking up to 5 cigarettes a day were aged 19-30, declared to have higher school vocational education, lived in the city and had both smoking and non-smoking parents.High awareness of the harmful effect of smoking was observed among the respondents.The fact that smoking is addictive was known by 116 (91%) of the respondents.Moreover, the majority of women (114, 90%) were aware of the fact that nicotine penetrates to the fetus through placenta.In turn, 97 (76%) of gravidas were aware that toxic substances penetrate also to breast milk.
One hundred and nineteen respondents (94%) claimed that smoking has a harmful effect on the child and causes increase in the risk of incidence of various diseases.Diseases that in the opinion of gravidas may occur in children are shown in Tab. 5.
The knowledge of the respondents on the impact of the HPV infection on the development of neoplasms should be undoubtedly assessed as negative.Only 6% of the women knew about the impact of the HPV infection on the incidence of cervical cancer, but none of them combined the infection with other neoplasms.None of them was vaccinated against HPV, and 70% were not aware of the existence of such a vaccine.In 2 smoking gravidas who failed to resign from smoking during pregnancy, the cytological smear according to PAP (five-degree scale of Papanicolaou) modified in accordance with the Bethesda System, in the eighth week of pregnancy diagnosed CIN I (cervical intraepithelial neoplasia I).None of the patients was provided with an explanation concerning the result -only taking the smear again after delivery was ordered.The discussed part of the study shows the size of negligence as regards informing young people about health dangers concerning this age group.

DISCUSSION
Smoking tobacco has been the subject of many scientific researches for years.Every year, there is more evidence proving its harmful effect, yet the number of smokers among young people is growing.As regards the number of cigarettes smoked per one person, Poland occupies one of the first places in the world.In 1938, an average Pole smoked 270 cigarettes, while in 1986 -as many as 2585.Contact with cigarettes is acknowledged by 70% of 15-yearold girls.Approx.40% of smoking women in Poland smoke their first cigarette right after waking up -this is the type of conduct regarded as nicotine addiction (10)(11)(12)(13) .
In the authors' opinion, a smoking gravida is a women of no age preference, with high school education (43%), living in the city (86%).A similar characteristic of smoking gravidas was presented in Poland by Florek (18) and Gomółka et al. (17) , and in the USA -Williams et al. (27) These authors also added one more feature -smoking gravidas are children to tobacco smokers.The presented study did not confirm that dependence.Strong mental addiction is observed among smokers.Tolerance to nicotine develops very quickly.Many people absorb daily the amount of nicotine many times exceeding the lethal dose.It seems that among some people also slight physical addiction is observed (10) .
The study showed that a significant majority of women (91%) is aware of the addictive nature of smoking and its negative impact on the fetus.Gravidas also know (90%) that toxins from the smoke penetrates through the placenta, and a great number of the respondents (76%) is aware that toxins also penetrate to breast milk.The awareness, however, had no impact on resigning from cigarettes -only 32% of the smokers ceased to smoke, 67% only limited it.Two respondents quitted smoking using patches.The method has so far been deemed a safe one when fighting with the addiction.However, the latest report of scientists from California questions such a manner of fighting nicotinism among gravidas.The authors showed that the children of mothers using nicotine patches are predestined to suffer from hypertension and vascular changes at a later age (27) .Many gravidas are exposed to passive smoking.Contact with the smoke most often occurs at home (36%), at work (19%) and in family house (11%).Among as many as 74% of the respondents, people sharing the apartment were the ones to smoke tobacco.A similarly high rate (80%) of gravidas' smoking families was reported by Pirogowicz et al. (19) Nicotine penetrates easily through the placenta and the concentration in the fetus may be even 15% higher than in the mother.Carbon oxide, the ingredient of tobacco smoke, inhibits the release of oxygen to the tissues of the  (29) .Podobne dane zawiera raport Centrum Badania Opinii Społecznej stworzony na podstawie badania ankietowego przeprowadzonego w marcu 2002 roku.Wykazało ono niską świadomość kobiet w zakresie profilaktyki raka szyjki i małą aktywność personelu medycznego uczestniczącego w profilaktyce tego nowotworu (30) .W badaniu Pacewicz i wsp.mężczyźni i kobiety oceniali swoją wiedzę o przyczynach zachorowań na raka szyjki macicy.Uznali, że niedostatecznie dużo wiedzą na ten temat.Jednocześnie wyrazili wolę, aby edukacja wśród dziewcząt rozpoczynała się w gimnazjum (tak wypowiedziały się kobiety) lub w liceum (tak wypowiedzieli się mężczyźni) (31) .WNIOSKI  (20) .Other authors showed the relation between smoking cigarettes by pregnant mothers and IQ among 4-year-olds.The children of women who smoked all the time during pregnancy, smoked 10 or more cigarettes a day, their IQ was lower than among non-smoking children (28) .The World Health Organization recommends combating smoking tobacco, which would have an impact on extending the life and improving the health condition of citizens of industrialized countries more effectively than any other medical preventive actions (10) .In the group of smoking gravidas, the majority only limits smoking -despite the knowledge on the destructive impact of tobacco smoke on the unborn children.It allows one to think that women have a motivation issue, and the operation of defense mechanisms hinders the identification of own situation with the possessed general knowledge.It may prove useful to consider a compulsory program of psychological advice directed only at addiction treatment, addressed to all the pregnant smokers and smokers planning their pregnancy.It is imperative to educate in that field the medical personnel taking care over gravidas and the mothers, so that nurses and midwives could support their patients when quitting or limiting the number of cigarettes smoked within the period of pregnancy and breast feeding.
Moreover, the presented study proved that gravidas lack the knowledge concerning the HPV infection related dangers.Study by Uhman-Włodarz et al. conducted among women older than the studied group reporting at the K clinic, showed that an average Polish woman lacks the sufficient knowledge on the reasons for cervical cancer incidence (29) .Similar data can be found in the report of the Public Opinion Research Center drafted based on a questionnaire carried out in March 2002.It proved little awareness among women as regards the prophylaxis of cervical cancer and low activity of the medical personnel participating in the neoplasm prevention (30) .In the study by Pacewicz et al., men and women evaluated their knowledge concerning the reasons for cervical cancer incidence.They concluded that they lack the sufficient knowledge in the field.At the same time, they expressed their will for education among girls to start as early as in junior high school (as women stated) or in high school (as men stated) (31) .

CONCLUSIONS
1. Women, despite the awareness of the harmful effect of smoking, relatively rarely abandon smoking when pregnant.Maybe, being provided with specific knowledge, smoke inhalation amounts to 4 hours per day.Places of being exposed to smoke are indicated in Tab. 2. The distribution of the frequency of exposure to tobacco smoke in particular places was not equal (Kruskal-Wallis test: chi-square = 35.00;df = 5; p v < 0.001).