{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T18:09:38Z","timestamp":1791223778805,"version":"4.1.0"},"reference-count":53,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2020,4,23]],"date-time":"2020-04-23T00:00:00Z","timestamp":1587600000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100015082","name":"Universidad Cat\u00f3lica de Valencia San Vicente M\u00e1rtir","doi-asserted-by":"publisher","award":["UCV.PRO.18-19.AII.10"],"award-info":[{"award-number":["UCV.PRO.18-19.AII.10"]}],"id":[{"id":"10.13039\/501100015082","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Background: Despite the fact that tobacco use during pregnancy produces adverse perinatal effects, some women continue to smoke. Health literacy (HL) is essential for health outcomes in adults. However, little is known about HL in pregnant women or postpartum women. The study aimed to analyse the relationship between the degree of HL of women during the early puerperium and tobacco use during pregnancy. Methods: A multicentre, descriptive, cross-sectional study was carried out with women in the early puerperium in a region of eastern Spain, between November 2017 and May 2018. Their HL level was obtained using the Newest Vital Sign (NVS) tool. Multivariate logistic models were adjusted to estimate the magnitude of association with tobacco use in pregnancy. Odds ratios (OR) were estimated with a 95% confidence interval. Results: 193 were included in the total. 29.5% (57) of pregnant women smoked tobacco during pregnancy, with a smoking cessation rate of 70.1% (40) while pregnant. 42.0% (81) of pregnant women had inadequate or limited HL. A low level of HL was strongly associated with tobacco use, adjusted by catchment area and age of first pregnancy (LRT p &lt; 0.001; ROC curve = 0.71, 95% CI: 0.64\u20130.79). Conclusion: A low HL is associated with tobacco consumption during pregnancy. Whether low HL reflects the wide constellation of already-known socioeconomic, political and commercial determinants of tobacco use, or whether incorporating HL support interventions strengthens tobacco cessation activities in pregnancy, warrants further research. Still, it should be considered as essential to understanding the health disparities related to its consumption.<\/jats:p>","DOI":"10.3390\/ijerph17082910","type":"journal-article","created":{"date-parts":[[2020,4,23]],"date-time":"2020-04-23T10:46:22Z","timestamp":1587638782000},"page":"2910","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Influence of Puerperal Health Literacy on Tobacco Use during Pregnancy among Spanish Women: A Transversal Study"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3734-2480","authenticated-orcid":false,"given":"Rafael","family":"Vila-Candel","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynaecology, La Ribera University Hospital, FISABIO, Crta. Corbera km 1, 46600 Valencia, Spain"},{"name":"Department of Nursing, Faculty of Nursing and Podiatry, University of Valencia, Jaume Roig, s\/n, 46010 Valencia, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esther","family":"Navarro-Illana","sequence":"additional","affiliation":[{"name":"Department of Nursing, Catholic University of Valencia \u201cSan Vicente M\u00e1rtir\u201d, Espartero 7, 46007 Valencia, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1596-3064","authenticated-orcid":false,"given":"Desir\u00e9e","family":"Mena-Tudela","sequence":"additional","affiliation":[{"name":"Department of Nursing, Jaume I University, Av de Vicent Sos Baynat, s\/n, 12071 Castell\u00f3 de la Plana, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2118-9792","authenticated-orcid":false,"given":"Pilar","family":"P\u00e9rez-Ros","sequence":"additional","affiliation":[{"name":"Department of Nursing, Catholic University of Valencia \u201cSan Vicente M\u00e1rtir\u201d, Espartero 7, 46007 Valencia, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3351-9496","authenticated-orcid":false,"given":"Enrique","family":"Castro-S\u00e1nchez","sequence":"additional","affiliation":[{"name":"NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections (HCAI) and Antimicrobial Resistance (AMR) at Imperial College London, Du Cane Road, London W12 0NN, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6210-6471","authenticated-orcid":false,"given":"Francisco Javier","family":"Soriano-Vidal","sequence":"additional","affiliation":[{"name":"Department of Nursing, Faculty of Nursing and Podiatry, University of Valencia, Jaume Roig, s\/n, 46010 Valencia, Spain"},{"name":"Department of Obstetrics and Gynaecology, Lluis Alcanyis Hospital, FISABIO. Crta X\u00e0tiva, s\/n, 46800 Valencia, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6947-7531","authenticated-orcid":false,"given":"Jose Antonio","family":"Quesada","sequence":"additional","affiliation":[{"name":"Department of Clinical Medicine, Miguel Hern\u00e1ndez University, Av de la Universitat d\u2019Elx s\/n, 03202 Elche, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,4,23]]},"reference":[{"key":"ref_1","first-page":"CD005992","article-title":"Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption","volume":"2","author":"Frazer","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_2","unstructured":"WHO (2020, April 03). WHO Report on the Global Tobacco Epidemic. Available online: http:\/\/www.who.int\/tobacco\/mpower\/2009\/en\/."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1093\/aje\/kwv301","article-title":"Systematic Review and Meta-Analyses of Perinatal Death and Maternal Exposure to Tobacco Smoke during Pregnancy","volume":"184","author":"Pineles","year":"2016","journal-title":"Am. J. Epidemiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e420","DOI":"10.1016\/S2468-2667(17)30144-5","article-title":"Effect of tobacco control policies on perinatal and child health: A systematic review and meta-analysis","volume":"2","author":"Faber","year":"2017","journal-title":"Lancet Public Health"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Smedberg, J., Lupattelli, A., M\u00e5rdby, A.-C., and Nordeng, H. (2014). Characteristics of women who continue smoking during pregnancy: A cross-sectional study of pregnant women and new mothers in 15 European countries. BMC Pregnancy Childbirth, 14.","DOI":"10.1186\/1471-2393-14-213"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e769","DOI":"10.1016\/S2214-109X(18)30223-7","article-title":"National, regional, and global prevalence of smoking during pregnancy in the general population: A systematic review and meta-analysis","volume":"6","author":"Lange","year":"2018","journal-title":"Lancet Glob. Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e134","DOI":"10.1016\/j.wombi.2015.06.003","article-title":"Tobacco use in the third trimester of pregnancy and its relationship to birth weight. A prospective study in Spain","volume":"28","year":"2015","journal-title":"Women Birth"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e021311","DOI":"10.1136\/bmjopen-2017-021311","article-title":"Human Early Life Exposome (HELIX) study: A European population-based exposome cohort","volume":"8","author":"Maitre","year":"2018","journal-title":"BMJ Open"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1136\/jech.2010.116756","article-title":"Active and passive smoking during pregnancy and ultrasound measures of fetal growth in a cohort of pregnant women","volume":"66","author":"Ballester","year":"2012","journal-title":"J. Epidemiol. Community Health"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Anderson, C.L., Becher, H., and Winkler, V. (2016). Tobacco Control Progress in Low and Middle Income Countries in Comparison to High Income Countries. Int. J. Environ. Res. Public Health, 13.","DOI":"10.3390\/ijerph13101039"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"S\u00f8rensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., Brand, H., and (HLS-EU) Consortium Health Literacy Project European (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health, 12.","DOI":"10.1186\/1471-2458-12-80"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1111\/j.1525-1497.2006.00540.x","article-title":"The meaning and the measure of health literacy","volume":"21","author":"Baker","year":"2006","journal-title":"J. Gen. Intern. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2072","DOI":"10.1016\/j.socscimed.2008.09.050","article-title":"The evolving concept of health literacy","volume":"67","author":"Nutbeam","year":"2008","journal-title":"Soc. Sci. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1080\/10810730.2014.936571","article-title":"Health literacy measurement: An inventory and descriptive summary of 51 instruments","volume":"19","author":"Haun","year":"2014","journal-title":"J. Health Commun."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.1093\/eurpub\/ckv043","article-title":"Health literacy in Europe: Comparative results of the European health literacy survey (HLS-EU)","volume":"25","author":"Pelikan","year":"2015","journal-title":"Eur. J. Public Health"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Perez-Rios, M., Fernandez, E., Schiaffino, A., Nebot, M., and Lopez, M.J. (2015). Changes in the Prevalence of Tobacco Consumption and the Profile of Spanish Smokers after a Comprehensive Smoke-Free Policy. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0128305"},{"key":"ref_17","first-page":"146","article-title":"[Influenza vaccination in pregnant women. Coverage, practices and knowledge among obstetricians]","volume":"134","year":"2010","journal-title":"Med. Clin."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1111\/j.1475-6773.2010.01119.x","article-title":"Short Assessment of Health Literacy-Spanish and English: A comparable test of health literacy for Spanish and English speakers","volume":"45","author":"Lee","year":"2010","journal-title":"Health Serv. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1016\/j.ijid.2015.12.019","article-title":"Health literacy and infectious diseases: Why does it matter?","volume":"43","author":"Chang","year":"2016","journal-title":"Int. J. Infect. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1264","DOI":"10.1177\/0009922814541674","article-title":"Measuring health literacy in caregivers of children: A comparison of the newest vital sign and S-TOFHLA","volume":"53","author":"Morrison","year":"2014","journal-title":"Clin. Pediatr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1177\/0009922813504025","article-title":"Can the Newest Vital Sign be used to assess health literacy in children and adolescents?","volume":"53","author":"Warsh","year":"2014","journal-title":"Clin. Pediatr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1370\/afm.405","article-title":"Quick assessment of literacy in primary care: The newest vital sign","volume":"3","author":"Weiss","year":"2005","journal-title":"Ann. Fam. Med."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Morris, N.S., MacLean, C.D., Chew, L.D., and Littenberg, B. (2006). The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability. BMC Fam. Pract., 7.","DOI":"10.1186\/1471-2296-7-21"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1097\/01.NAJ.0000431271.83277.2f","article-title":"Health literacy and nursing: An update","volume":"113","author":"Dickens","year":"2013","journal-title":"Am. J. Nurs."},{"key":"ref_25","first-page":"118","article-title":"Health Literacy in Primary Care Practice","volume":"92","author":"Hersh","year":"2015","journal-title":"Am. Fam. Physician"},{"key":"ref_26","first-page":"123","article-title":"Impact of smoke-free regulations on smoking prevalence trends in Spain","volume":"27","author":"Colell","year":"2017","journal-title":"Eur. J. Public Health"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1016\/j.addbeh.2017.06.016","article-title":"Impact of the Spanish smoking laws on tobacco consumption and secondhand smoke exposure: A longitudinal population study","volume":"75","author":"Fu","year":"2017","journal-title":"Addict. Behav."},{"key":"ref_28","unstructured":"(2020, April 03). Tobacco and Inequities. Guidance for Addressing Inequities in Tobacco-Related Harm. Available online: http:\/\/www.euro.who.int\/en\/health-topics\/disease-prevention\/tobacco\/publications\/2014\/tobacco-and-inequities.-guidance-for-addressing-inequities-in-tobacco-related-harm-2014."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.ijnurstu.2016.07.012","article-title":"Determinants of tobacco-related health literacy: A qualitative study with early adolescents","volume":"62","author":"Parisod","year":"2016","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_30","first-page":"1265","article-title":"[Association of health literacy and smoking behaviors among middle school students in six cities of China]","volume":"53","author":"Yang","year":"2019","journal-title":"Zhonghua Yu Fang Yi Xue Za Zhi"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1016\/j.wombi.2018.11.012","article-title":"Smoking during pregnancy, stigma and secrets: Visual methods exploration in the UK","volume":"33","author":"Grant","year":"2020","journal-title":"Women Birth"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1801","DOI":"10.2105\/AJPH.92.11.1801","article-title":"A reexamination of smoking before, during, and after pregnancy","volume":"92","author":"Kahn","year":"2002","journal-title":"Am. J. Public Health"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"III16-21","DOI":"10.1136\/tc.9.suppl_3.iii16","article-title":"The process of pregnancy smoking cessation: Implications for interventions","volume":"9","author":"DiClemente","year":"2000","journal-title":"Tob. Control"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"e20","DOI":"10.2196\/resprot.3059","article-title":"Preventing postpartum smoking relapse among inner city women: Development of a theory-based and evidence-guided text messaging intervention","volume":"3","author":"Wen","year":"2014","journal-title":"JMIR Res. Protoc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Delano\u00eb, A., L\u00e9pine, J., Leiva Portocarrero, M.E., Robitaille, H., Turcotte, S., L\u00e9vesque, I., Wilson, B.J., Gigu\u00e8re, A.M.C., and L\u00e9gar\u00e9, F. (2016). Health literacy in pregnant women facing prenatal screening may explain their intention to use a patient decision aid: A short report. BMC Res. Notes, 9.","DOI":"10.1186\/s13104-016-2141-0"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1089\/jayao.2015.0059","article-title":"Health Literacy in Adolescents and Young Adults: An Updated Review","volume":"5","author":"Lin","year":"2016","journal-title":"J. Adolesc. Young Adult Oncol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e023929","DOI":"10.1136\/bmjopen-2018-023929","article-title":"Health literacy, cognitive ability and smoking: A cross-sectional analysis of the English Longitudinal Study of Ageing","volume":"8","author":"Starr","year":"2018","journal-title":"BMJ Open"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1111\/ajo.12148","article-title":"Smoking rates and smoking cessation preferences of pregnant women attending antenatal clinics of two large Australian maternity hospitals","volume":"54","author":"Hoekzema","year":"2014","journal-title":"Aust. N. Z. J. Obstet. Gynaecol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1006\/pmed.2000.0815","article-title":"Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women","volume":"32","author":"Arnold","year":"2001","journal-title":"Prev. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"101066","DOI":"10.1016\/j.pmedr.2020.101066","article-title":"School Health Board of the Hidaka Medical Association Association of household smoking status in childhood with young adults\u2019 educational attainment and smoking status: Results from a series of population-based cross-sectional surveys in Japan","volume":"18","author":"Kitano","year":"2020","journal-title":"Prev. Med. Rep."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"6485","DOI":"10.3390\/ijerph10126485","article-title":"Smoking and Pregnancy\u2014A Review on the First Major Environmental Risk Factor of the Unborn","volume":"10","author":"Mund","year":"2013","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"e43","DOI":"10.2105\/AJPH.2012.301062","article-title":"Associations between health literacy and established predictors of smoking cessation","volume":"103","author":"Stewart","year":"2013","journal-title":"Am. J. Public Health"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Stewart, D.W., Cano, M.A., Correa-Fern\u00e1ndez, V., Spears, C.A., Li, Y., Waters, A.J., Wetter, D.W., and Vidrine, J.I. (2014). Lower health literacy predicts smoking relapse among racially\/ethnically diverse smokers with low socioeconomic status. BMC Public Health, 14.","DOI":"10.1186\/1471-2458-14-716"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1080\/15265160701638520","article-title":"Health literacy, health inequality and a just healthcare system","volume":"7","author":"Volandes","year":"2007","journal-title":"Am. J. Bioeth."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1080\/10810730.2011.604391","article-title":"Interventions for individuals with low health literacy: A systematic review","volume":"16","author":"Sheridan","year":"2011","journal-title":"J. Health Commun."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e022132","DOI":"10.1136\/bmjopen-2018-022132","article-title":"Influence of health literacy on acceptance of influenza and pertussis vaccinations: A cross-sectional study among Spanish pregnant women","volume":"8","year":"2018","journal-title":"BMJ Open"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"97","DOI":"10.7326\/0003-4819-155-2-201107190-00005","article-title":"Low health literacy and health outcomes: An updated systematic review","volume":"155","author":"Berkman","year":"2011","journal-title":"Ann. Intern. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1093\/abm\/kax042","article-title":"Enhancing Smoking Risk Communications: The Influence of Health Literacy and Message Content","volume":"52","author":"Hoover","year":"2018","journal-title":"Ann. Behav. Med."},{"key":"ref_49","first-page":"403","article-title":"[Midwives, vaccines and health literacy: An underexplored relationship?]","volume":"30","year":"2016","journal-title":"Gac. Sanit."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"546","DOI":"10.1016\/j.contraception.2018.02.005","article-title":"The use of a low-literacy version of the Medicaid sterilization consent form to assess sterilization-related knowledge in Spanish-speaking women: Results from a randomized controlled trial","volume":"97","author":"Natavio","year":"2018","journal-title":"Contraception"},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Morony, S., Weir, K.R., Bell, K.J.L., Biggs, J., Duncan, G., Nutbeam, D., and McCaffery, K.J. (2018). A stepped wedge cluster randomised trial of nurse-delivered Teach-Back in a consumer telehealth service. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0206473"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.pec.2010.06.009","article-title":"Entertainment education for breast cancer surgery decisions: A randomized trial among patients with low health literacy","volume":"84","author":"Volk","year":"2011","journal-title":"Patient Educ. Couns."},{"key":"ref_53","first-page":"2","article-title":"Effect of Health Literacy Education on Self-Care in Pregnant Women: A Randomized Controlled Clinical Trial","volume":"7","author":"Solhi","year":"2019","journal-title":"Int. J. Community Based Nurs. Midwifery"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/8\/2910\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T13:45:17Z","timestamp":1760363117000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/17\/8\/2910"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,4,23]]},"references-count":53,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2020,4]]}},"alternative-id":["ijerph17082910"],"URL":"https:\/\/doi.org\/10.3390\/ijerph17082910","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,4,23]]}}}