ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE

Smoking and caffeine and alcohol intake during pregnancy in a northern population: effect on fetal growth John C. Godel, MD, FRCPC; Henry F. Pabst, MD, FRCPC; Phyllis E. Hodges, MSc (Nutr); Karen E. Johnson, BASc (Hon); Glory J. Froese, BScN; Michel R. Joffres, MD, MSPH, PhD Objectives: To assess the prevalence of smoking and of caffeine and alcohol intake during pregnancy in a northern population and to determine the relation of these factors to birth weight, length and head circumference. Design: Questionnaire survey and collection of maternal and newborn measurements. Setting: Ten communities in the Inuvik Zone, NWT. Patients: A total of 162 women (56 Inuit, 38 Indian, 37 white and 31 mixed race) who presented for prenatal care in their community and gave birth in Inuvik between September 1987 and January 1990 and their newborns. Results: In all, 64% (101/159) of the women smoked, 57% (88/154) ingested more than 300 mg of caffeine daily, and 34% (50/145) drank alcohol during their pregnancy. Smoking, caffeine intake and binge drinking were most frequent among the Inuit and Indian mothers. Smoking was significantly associated with decreased birth weight (p < 0.001) and length (p < 0.05). Alcohol intake, especially binge drinking, was significantly associated with decreased head circumference (p < 0.05). Caffeine was found not to be related to any of the outcome variables after smoking was controlled for through stepwise multiple regression. Conclusions: The marked prevalence of smoking and alcohol intake during pregnancy and their effects on the newborn are public health concerns in the Northwest Territories and warrant intensive countermeasures.

Objectifs: Evaluer la prevalence du tabagisme et de l'absorption de cafeine et d'alcool pendant la grossesse dans une population nordique et etablir le rapport entre ces facteurs et le poids, la taille et la circonference cranienne a la naissance. Conception: Sondage par questionnaire et mensuration des meres et des nouveaux-nes. Cadre: Dix collectivites de la zone d'Inuvik, dans les T.N.-O. Patients: Un total de 162 femmes (56 Inuit, 38 Indiennes, 37 blanches et 31 sang-melees) qui se sont presentees aux soins prenataux dans leur collectivite et ont accouche A Inuvik entre septembre 1987 et janvier 1990, ainsi que leurs nouveaux-nes. Resultats: Au total, 64 % (101/159) de ces femmes fumaient, 57 % (88/154) prenaient quotidiennement plus de 300 mg de cafeine et 34 % (50/145) ont consomme de l'alcool pendant leur grossesse. Le tabagisme, l'absorption de cafeine et la consommation Drs. Godel and Pabst are professors ofpediatrics at the University ofAlberta, Edmonton, Alta.; Ms. Hodges is coordinator of the Community Education Program, Health Promotion, Edmonton Local Board ofHealth, Edmonton, Alta.; Ms. Johnson is a nutritionist and Ms. Froese a public health nurse in the Department of Pediatrics, University ofAlberta, Edmonton, Alta.; and Dr. Joifres is a chronic disease epidemiologist, Alberta Ministry of Health, Edmonton, Alta.

Reprint requests to: Dr. John C. Godel, Department ofPediatrics, Charles Camsell General Hospital, 12804-114 Ave., Edmonton, AB TSM 3A4 JULY 15, 1992

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181

irreguliere excessive d'alcool etaient plus frequents chez les meres inuit et indiennes. Le tabagisme etait plus etroitement associe a un poids (p < 0,001) et a une taille (p < 0,05) moindres a la naissance. L'absorption d'alcool, particulierement la consommation excessive irreguliere, etait plus etroitement associee a un deficit au niveau de la circonference cranienne (p < 0,05). D'apres les resultats, la cafeine n'avait de rapport avec aucune des variables, apres integration du tabagisme par analyse de regression multiple sequentielle. Conclusions: La prevalence marquee du tabagisme et de la consommation d'alcool pendant la grossesse et leurs effets sur le nouveau-ne sont des problemes de sante publique dans les Territoires du Nord-Ouest et justifient des contre-mesures energiques.

A healthy intrauterine environment is crucial to a fetus's well-being, and the importance of maternal lifestyle during pregnancy cannot be overemphasized. Smoking during pregnancy, found to decrease placental blood flow' through a sympathomimetic response,2 has been associated with intrauterine growth retardation (IUGR),3-s increased rates of perinatal death,6 complications of pregnancy6-8 and fetal anomalies such as cleft lip and palate.9 Caffeine in large doses, found to be teratogenic in mice'0 but not in humans, has been associated with IUGR in both species.4"' '3 In humans Kirkinen and associates'4 found that the intervillous blood flow in the placenta was decreased by 25% after only two cups of coffee. Alcohol intake can cause IUGR in fetal alcohol syndrome'5 and fetal alcohol effect and can be a major cause of mental retardation. Anecdotal evidence suggests a high prevalence of smoking and alcohol intake in northern Canada. Developmental delay and growth retardation are frequent reasons for pediatric referral in the Inuvik Zone of the Northwest Territories (population about 7750). This study, which is part of a comprehensive study of perinatal nutrition in that region, was designed to examine the prevalence of reported smoking and of caffeine and alcohol consumption in three racial subgroups and to determine the relation of these factors to birth weight, length and head

circumference.

Methods Study population We included 162 women who presented for prenatal care in 10 communities in the western region of the Northwest Territories and who gave birth in Inuvik between September 1987 and January 1990. In all, 56 (35%) of the women were Inuit, 38 (24%) native Indian, 37 (23%) white and 31 (19%) mixed race; this was determined through self-identification and the use of a medical number that identified registered natives. All of the women were eligible for the study regardless of age, parity or health status. Informed 182

CAN MED ASSOC J 1992; 147 (2)

consent was obtained in the local language. We excluded women who did not give consent and those for whom follow-up might be a problem. Of the 185 women who entered the study 14 moved before delivery or were lost to follow-up, 5 had incomplete prenatal data, 3 miscarried, and 1 refused to complete the study.

Data collection A questionnaire on medical history, lifestyle, eating habits and food intake in the last 24 hours was completed by the mother with the help of a nutritionist prenatally and at delivery. Measurements of maternal height and weight at each visit were supplemented with measurements obtained from hospital and nursing-station charts. Skinfold measurements over the triceps and subscapular muscles were obtained in a standardized manner with the use of the Lange Skinfold Caliper (Cambridge Scientific Industries, Inc., Cambridge, Md.).'6 The birth weight, length and head circumference of each newborn as recorded by the nursery staff and the attending physician were obtained from the newborn record. The procedures followed were in accordance with the standards of the Ethics Committee of the University of Alberta and the Helsinki Declaration. "I Because data for certain variables were missing, mainly because of incomplete patient records, the numbers of subjects available for assessing bivariate and multivariate relations varied. The questionnaire included a section used to identify smokers and nonsmokers (including former smokers). Smokers were asked how many cigarettes they smoked daily and how long they had been

smoking. Caffeine intake was estimated through the use of the questionnaire and dietary assessment; there was good correlation between the two methods (r = 0.84). The mothers were asked to estimate the amount of coffee, tea and colas they drank, a standard serving being 180 mL for a cup of coffee and tea and 355 mL for a can or bottle of cola. Daily caffeine intake was calculated on the basis of 120 mg per serving of coffee, 65 mg per serving of tea and 35 mg per serving of cola.'8 Coffee contains variLE 15 JUILLET 1992

of caffeine depending on the method of preparation; we did not obtain information on which methods the women used to make coffee and therefore established 120 mg per serving as an arbitrary mean. The questionnaire included a section used to assess alcohol intake. Four categories (abstinence and moderate, frequent and "binge" drinking) were used depending on how often the mother drank and how much she drank on each occasion. Moderate drinking referred to fewer than five drinks once a week or less often, frequent drinking to fewer than five drinks more than once a week and binge drinking to five drinks or more on any occasion regardless of how often. A standard drink referred to a bottle or can of beer, a 120-mL glass of wine or a 30-mL shot of liquor with or without mixer. We wanted to distinguish drinkers from nondrinkers and the effects of binge drinking from those of moderate or frequent drinking.

(SDs) that were independent of gestational age and that followed normal distribution curves. An extensive review of the literature by Kramer20 identified smoking as the most important factor in IUGR in a developed country; poor nutrition during pregnancy, low weight before pregnancy, primiparity, female sex of the fetus, maternal short stature and race were found to have significant effects as well. The relations between a number of these factors and infant size were tested by means of analysis of variance (ANOVA), Pearson's correlation and regression analysis. If significant correlations were found their effects relative to those of smoking and of caffeine and alcohol intake were determined through ANOVA or stepwise multiple regression analysis. Statistical analyses were carried out on an IBM-compatible computer with the use of the Complete Statistical System.

Statistical analysis

Prevalence of smoking and of caffeine and alcohol intake

ous

amounts

The size of an infant at birth is dominated by two factors: the duration of gestation and the intrauterine growth rate. To assess the latter by itself we had to control for gestational age. Growth during pregnancy is not linear, and therefore correction with the use of linear regression was not appropriate. We decided to control for gestational age by establishing ratios of observed to standard weights,

Results

Data regarding smoking and caffeine and alcohol intake are displayed in Table 1. The prevalence of smoking and the reported caffeine intake were significantly lower among the white women than among those in other racial groups. Although there was no statistical difference between the racial groups in the proportion of women who drank alcohol Inuit and Indian mothers were more likely than the others to be binge drinkers.

lengths and head circumferences for gestational age in a manner similar to that of Brooke and collaborators4 using standards for white newborns at sea level published by Usher and McLean.'9 This produced Biologic factors affecting newborn size birth-weight ratios, length ratios and head circumferInfant size correlated well with length of gestaence ratios with means and standard deviations Table 1: Prevalence rates of smoking and of caffeine and alcohol intake among women during pregnancy in a northern population by race

Race

Inuit Indian White

Mixed Total

Factor; no. (and %) of women Alcohol intake Caffeine intake Smoking (n =145) (n= 154) (n =159) 11 (22) 40 (73)* 39 (70)* (n = 49) (n = 55) (n = 56) 12 (34) 23 (62)t 27 (75)* (n = 35) (n = 37) (n = 36) 14 (41) 9 (28) 12 (32) (n = 34) (n = 32) (n = 37) 16 (53)t 23 (77)* 13(48) (n - 27) (n = 30) (n =30) 50 (34) 88 (57) 101 (64)

*p 0

52.0 51.0

E 13 c (U) 41-

35.0

34.5

34.5

E 40 There are several potential sources of error in this study. Smoking and alcohol intake tend to be .~33.5 underreported in surveys.22 Furthermore, no infor1-5 6 -10 11 - 20 > 20 None mation was obtained about irregular smoking or caffeine or alcohol intake, especially since the effect No. of cigarettes per day of alcohol can vary depending on the stage of fetal development at the time of exposure. Although we Fig. 1: Relation between smoking during pregnancy and considered the effect of past smoking we did not mean birth weight, length and head circumference of enquire whether smoking had stopped before or newborns. Number of infants in each group is shown in during pregnancy. The small size of the four ethnic parenthesis. Analysis of variance shows that differences groups reduces the precision in estimating differ- between a and b, a and d, a and e, and f and g are significant ences. However, there were obvious logistic difficul- (p < 0.05). JULY 15, 1992

CAN MED ASSOC J 1992; 147 (2)

185

Of the three lifestyle factors considered smoking had the greatest effect on fetal growth. Our data suggest that smoking affects fetal growth through both IUGR and decreased gestation. Simpson3 pointed out the relation of smoking and prematurity as early as 1957. Some of those infants may have suffered from IUGR rather than prematurity. Several investigators4-6 have confirmed the relation between smoking and low birth weight and noted the association with early onset of labour. The suggestion that smoking mothers eat less, gain less during pregnancy and therefore have smaller babies24,25 is supported neither by our data, which showed similar energy intake in the smoking and nonsmoking groups, nor by the data from other studies.26'27 More likely, smoking exerts a direct hypoxic effect on the fetus partly because of an increase in carbon monoxide and partly because of decreased placental circulation."4 Our data tend to support this hypothesis, since the effect of smoking on infant size (the greatest decrease having been observed in birth weight) was similar to the pattern found in other cases of placental insufficiency. The relation between maternal age, smoking and birth weight deserves special consideration. Women 13 to 18 years of age had the smallest babies and were also significantly thinner than the other women. It is tempting to suggest that poorer nutrition may have been a factor. However, since most of the young mothers smoked, the low birth weight in this group may have been due to smoking. Caffeine intake, prevalent in all but the group of white mothers, appeared to be relatively innocuous when smoking was controlled for; this confirms the findings from previous studies.4'28 Moderate alcohol intake during pregnancy did not appear to have a detrimental effect on fetal growth. Rosett and colleagues29 found no IUGR in

offspring of moderate drinkers. However, although decreases in all three fetal measurements have been found in babies of heavier drinkers29'30 we observed a significant decrease in head circumference only, especially in infants of binge drinkers. In those studies, as in ours, there was a high correlation between smoking and drinking, and the authors were unable to differentiate between the effects of alcohol and smoking on fetal growth. Our study documents a high incidence of smoking, caffeine intake and drinking in a northern population. Most disturbing was the high rate of smoking, especially among native mothers, and the high incidence of binge drinking. The resulting degree of microcephaly underscores what has become a serious public health problem in North America. Alcohol exposure during pregnancy is one of the leading causes of mental retardation in the United States3' and in northern British Columbia and the Yukon Territory.32 Animal research has shown that exposure to alcohol when the brain is undergoing rapid growth and development (during the second and third trimesters in humans) commonly results in behavioural difficulties and learning problems.33-31 Although the threshold alcohol intake has not been established, some evidence suggests that mild to moderate intake does not cause damage.29 However, Streissguth, Barr and Sampson38 have shown a change of 7 points in the intelligence quotient in children aged 7 years whose mothers had as few as two drinks a day during pregnancy. More important than the average intake may be the peak blood alcohol level. A high blood alcohol level, especially if "pulsed," as seen in binge drinking, has been found to be an important inhibiting factor in brain growth;39 the relative microcephaly that we found to be related to binge drinking may attest to this. Small

fable 3: Relation between alcohol 'ntake and both intant measurements an7 materrai smokin' nabits

Aicohl t a k,yTa r.alLj ;r:iLra, None to moderatsl: (in 116)

Variable

infant measurement Birth weight. g Length. cm Head circumference, cm Birth-weight ratio Length ratio Head circumference ratio Gestational age at delivery. wk Maternal smoking Prevalence rate, % Mean no. of cigarettes per day tB3qe drinkilkr

186

refers to five drinks

CAN MED ASSOCJ 1992; 147(2)

more on any occasion ir

3444 52.1 34.7 1.02 1.03 1.00 39.8

(518) (2.9)

tOKlC, fiuent Ci qa V 28'

3367 (472) 53.0 (2.9) 33.9 (1.6)

p value

(1.5)

1.00 (0.13)3 -1.03 (0.05) 0.97 (0.04) 39.6 (1.5t

NS NS 0.01 NS NS 0.0 , N IS

55 5.3 (6.9)

86 9.6 (10.7)

0.0 0. 05,

(1.5) (0.05)

(0.13)

(0.04)

regardless of tiow ofter-

LE 15 JUILLET 1992

head size at birth has been linked to school performance,40 mental retardation and decreased cognitive abilities. Smoking may aggravate these effects. Halmesmaki4' found that the biparietal diameter was smaller in infants of moderate smokers than in those of nonsmokers; this effect was more severe in the offspring of heavy drinkers and women with alcoholism. Furthermore, smoking and alcohol have recently been linked to an increased risk of febrile convulsions.42 The effects of drinking and smoking on the fetus are completely avoidable, and a planned preventive approach should be aimed mainly at children and young adults. This requires a combination of research43"44 (to give baseline information about prevalence, attitudes and influences upon which to base programs and evaluation) and effective communication45-47 (to provide accurate information about the dangers of smoking and drinking). The associated poverty, unemployment and helplessness in communities that spawn drinkers must also be addressed. Although public health departments and the federal government should guide the way, native groups, health boards, women's groups and local communities should be encouraged to accept responsibility for assessing their problems and taking action. We thank Pacific Western Airways (now Canadian North) for transportation of the study personnel and blood samples between Inuvik and Edmonton as well as Aklak Airways, Inuvik, for transportation between northern settlements. This study was supported in part by the Alberta Heritage Foundation for Medical Research, Special Funds (Research and Trust), University of Alberta, and grants from the National Health Research and Development Program, Department of National Health and Welfare, and Bristol-Myers Canada Inc.

References 1. Asmussen I: Ultrastructure of the villi and fetal capillaries in placentas from smoking and nonsmoking mothers. Br J

Obstet Gynaecol 1980; 87: 239-245 2. Suzuki K, Minie UJ, Johnson EE: Effect of nicotine upon uterine blood flow in the pregnant rhesus monkey. Am J Obstet Gynecol 1980; 136: 1009-1113 3. Simpson W: A preliminary report on cigarette smoking and the incidence of prematurity. Am J Obstet Gynecol 1957; 73: 808-815 4. Brooke OG, Anderson HR, Bland JM et al: Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors and psychosocial stress. BMJ 1989; 298: 795-801 5. Shi Wu Wen MS, Goldenberg RL, Cutter GR et al: Smoking, maternal age, fetal growth and gestational age at delivery. Am. J Obstet Gynecol 1990; 162: 53-58 6. Meyer MB, Jonas BS, Tonascia JA: Perinatal events associated with maternal smoking during pregnancy. Am J Epidemiol 1976; 103: 464-476 7. Naeye RL: Abruptio placentae and placenta praevia frequency, perinatal mortality and cigarette smoking. Obstet Gynecol 1980; 55: 701-704 JULY 15,1992

8. Handler A, Davis F, Ferre C et al: The relationship of smoking and ectopic pregnancy. Am J Public Health 1989; 79: 1239-1242 9. Khoury MJ, Gomez-Farios M, Mulinare J: Does maternal cigarette smoking during pregnancy cause cleft lip and palate in offspring? Am J Dis Child 1989; 143: 333-337 10. Nishimura H, Nakai K: Congenital malformations in offspring of mice treated with caffeine. Proc Soc Exp Biol Med 1960; 104: 140-142 11. Furuhashi N: Effects of caffeine consumption during pregnancy. Gynecol Obstet Invest 1985; 19: 187-191 12. Marten TR, Bracken MB: The association between low birth weight and caffeine consumption during pregnancy. Am J Epidemiol 1987; 126: 813-821 13. Caan BJ, Goldhaber MK: Caffeinated beverages and low birthweight: a case-control study. Am J Public Health 1989; 79: 1299-1300 14. Kirkinen P, Jouppila P, Kowula A et al: The effect of caffeine on placental and fetal blood flow in human pregnancy. Am J Obstet Gynecol 1983; 147: 939-942 15. Jones KL, Smith DW, Ulleland CN et al: Pattern of malformations of alcoholic mothers. Lancet 1973; 1: 1267-1271 16. Blackburn GL, Bistrian BR, Maini BS et al: Nutritional and metabolic assessment of the hospitalized patient. JPEN 1977; 31: 11-22 17. Dickens BM (ed): Guidelines on the Use of Human Subjects, Office of Research Administration, U of Toronto, Toronto, 1979: 54-63 18. Pennington AT, Church HV: Food Values of Portions Commonly Used, Har-Row, New York, 1985: 223 19. Usher R, McLean F: Intrauterine growth of live-born Caucasian infants at sea level: standards obtained from measurements in 7 dimensions of infants born between 25 and 44 weeks of gestation. JPediatr 1969; 74: 901-910 20. Kramer MS: Intrauterine growth and gestational duration determinants. Pediatrics 1987; 80: 502-511 21. Complete Statistical System, 4th ed, Statsoft Inc, Tulsa, Okla, 1989 22. Emhart CB, Morrow-Tluca M, Sokol RJ et al: Underreporting of alcohol use in pregnancy. Alcohol Clin Exp Res 1990; 12: 506-511 23. Report of the Alberta Heart Health Survey, Alberta Dept of Health, Edmonton, 1991 24. Rush D: Examination of the relationship between birth weight, cigarette smoking during pregnancy and maternal weight gain. J Obstet Gynaecol Br Commonw 1974; 81: 746752 25. Davies DP, Gray OP, Ellwood PC et al: Cigarette smoking in pregnancy. Association with maternal weight gain and fetal growth. Lancet 1976; 1: 385-387 26. Haworth JC, Ellestad-Sayed JJ, King J et al: Fetal growth in cigarette smoking is not due to decreased maternal food intake. Am J Obstet Gynecol 1983; 147: 719-723 27. Papoz R, Eschwege E, Peguinet G et al: Maternal smoking and birth weight in relation to dietary habits. Am J Obstet Gynecol 1982; 142: 870-876 28. Linn S, Schoenbaum SC, Monson RR et al: No association between coffee consumption and adverse outcomes of pregnancy. N Engl J Med 1983; 306: 141-145 29. Rosett HL, Weiner L, Lee A et al: Patterns of alcohol consumption and fetal development. J Obstet Gynecol 1983; 61: 539-545 30. Chernick V, Childiaeva R, Ioffe S: Effects of maternal alcohol intake and smoking on neonatal electroencephalogram and anthropometric measurements. Am J Obstet Gynecol 1983; 146: 41-47 31. Abel EL, Sokol EJ: Incidence of fetal alcohol syndrome and economic impact of FAS-related abnormalities. Drug Alcohol Depend 1987; 19: 51-70 32. Asaute KO, Nelms-Matzke J: Report on the Survey of Children with Chronic Handicaps and Fetal Alchol Syndrome in CAN MED ASSOC J 1992; 147 (2)

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the Yukon and Northwest British Columbia, Mills Memorial Hospital, Terrace, BC, 1985 Conry J: Neuropsychological defects in fetal alcohol syndrome and fetal alcohol effects. Alcohol Clin Exp Res 1990; 14: 650-655 Riley EP: The long-term behavioral effects of prenatal alcohol exposure on rats. Ibid: 670-673 Hansen JL, Hiscock M: Attention deficits in children exposed to alcohol prenatally. Ibid: 656-661 Miller MJ: Effect of prenatal exposure to ethanol on the development of cerebral cortex: 1. Neuromal generation. Alcohol Clin Exp Res 1988; 12: 440-449 Clarren SK, Astley SJ, Bowden DM et al: Neuroanatomic and neurochemical abnormalities in non-human primate infants exposed to weekly doses of ethanol during gestation. Alcohol Clin Exp Res 1990; 14: 674-683 Streissguth AP, Barr HM, Sampson PD: Moderate prenatal alcohol exposure: effects on child IQ and learning problems at age 71/2 years. Ibid: 662-669 Pierce DR, West JR: Blood alcohol concentration: a critical factor for producing fetal alchol effects. Alcohol 1986; 3: 269272

Conferences continuedfrom page 167 Sept. 11-14, 1992: Canadian Paediatric Society 69th Annual Meeting (in conjunction with the Royal College of Physicians and Surgeons of Canada 61 st Annual Meeting) Chateau Laurier, Ottawa Preliminary program begins Sept. 9. Dr. Victor Marchessault, executive vice-president, Canadian Paediatric Society, 401 Smyth Rd., Ottawa, ON KIH 8L1; (613) 737-2728, fax (613) 737-2794 Sept. 11-14, 1992: 61st Annual Meeting of the Royal College of Physicians and Surgeons of Canada (in association with the Canadian Society for Clinical Investigation and approximately 33 other national specialty societies) Ottawa Congress Centre Anna Lee Chabot, head, Meetings and Assemblies Section, Office of Fellowship Affairs, Royal College of Physicians and Surgeons of Canada, 74 Stanley St., Ottawa, ON KIM 1P4; (613) 746-8177, fax (613) 746-8833

Sept. 13-18, 1992: 7th APLAR Congress of Rheumatology (under the auspices of the Asia Pacific League Against Rheumatism and the International League Against Rheumatism) Bali, Indonesia Congress manager, 7th APLAR Congress of Rheumatology, Flat L3, Kompleks BNI 1946, Jalan Let. Jen. S Parman, Slipi, Palmerah, Jakarta 11410, Indonesia; telephone 011-0062-21-330166, fax 01 10062-21-336736 Sept. 18, 1992: Breastfeeding Seminar for Health Professionals (sponsored by the La Leche League of Quebec and Eastern Ontario) Ottawa Civic Hospital Agnes Vargha, conference coordinator, 25 Bernier Terr. Kanata, ON K2L 2V1; (613) 592-2379 188

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40. Desch LW, Anderson SK, Snow JH: Relationship of head circumference to measures of school performance. Clin Pediatr (Phila) 1990; 29: 389-392 41. Halmesmaki E: Alcohol counselling of 85 pregnant problem drinkers: effect on drinking and fetal outcome. Br J Obstet Gynaecol 1988; 95: 243-247 42. Cassano PA, Koepsell TD, Farwell JR: Risk of febrile seizure in childhood in relation to prenatal cigarette smoking and alcohol intake. Am JEpidemiol 1990; 132: 462-473 43. Resnick MD: Study group report on the impact of televised drinking and alcohol advertising on youth. J Adolesc Health Care 1990; 11: 25-30 44. Bray DL, Anderson PD: Appraisal of the epidemiology of fetal alcohol syndrome among Canadian native peoples. Can JPublic Health 1989; 80: 42-45 45. McGinnis JM: Communication for better health [E]. Public Health Rep 1990; 105: 217-218 46. Atkin CK: Effects of televised alcohol messages on teenage drinking patterns. J Adolesc Health Care 1990; 1 1: 10-24 47. Convessor RB, Vallinger RE, Wilbur R: Using national news events to stimulate local awareness of public policy issues. Public Health Rep 1990; 105: 257-260

Sept. 21-25, 1992: Interaction '92 - Annual Scientific Meeting of the Occupational Medical Association of Canada (held in conjunction with the Ontario Occupational Health Nurses Association) Ottawa Executive director, 605-302 The East Mall, Etobicoke, ON M9B 6C7; (416) 239-6462 Sept. 22-25, 1992: 1st International Symposium on Brain Death International Conference Center, Havana, Cuba Official languages: English and Spanish 1 er Simposio Internacional sobre Muerte Encefalica, Palacio de las Convenciones, Apartado 16046, La Habana, Cuba Du 1 au 3 oct.: L'Association canadienne pour la prevention du suicide (ACPS) Congres 1992 - Le suicide et la famille Delta Bessborough Hotel, Saskatoon Congres 1992 de la ACPS, 1410-12th St. W, Saskatoon, SK S7M 0Z4; (306) 664-4525, fax (306) 664-1974

Oct. 1-3, 1992: Canadian Association for Suicide Prevention (CASP) '92 Conference - Suicide and the Family Delta Bessborough Hotel, Saskatoon CASP Conference '92, 1410-20th St. W, Saskatoon, SK S7M 0Z4; (306) 664-4525, fax (306) 664-1974 Oct. 2-3, 1992: The Meeting of Medical Traditions in New Spain (a joint project of the National Library of Medicine and the University of California) University of California - Los Angeles Susanne M. Kahle, assistant to the director, 1992 Quincentenary Programs, 212 Royce Hall, University of California - Los Angeles, 405 Hilgard Ave., Los Angeles, CA 90024; (310) 206-1305

continued on page 200 For

prescribing information see page 216-