Background: Smoking during pregnancy and prenatal secondhand smoke exposure increase the risk of preterm birth. As Kentucky has the second highest rate of smoking in the United States and no statewide smoke-free law, an examination of the effect of municipal smoke-free legislation on preterm birth is warranted. Objective: This study used state-level live birth data and county-level municipal smoke-free legislation status to assess the association between the presence and strength of smoke-free laws and the likelihood of preterm birth. Moreover, this study hypothesized that pregnant persons living in counties with comprehensive municipal smoke-free laws prohibiting smoking inside all workplaces and enclosed public places would exhibit a lower likelihood of preterm birth than those living in counties with weak or moderate laws (ie, smoke-free laws with exemptions that do not cover all workplaces and enclosed public places) or no smoke-free law. Study Design: Using live birth data from the Kentucky Office of Vital Statistics with birth years ranging from 2004 to 2020, a total of 894,372 live births were recorded that indicated that a childbearing person was between the ages of 18 and 49 years and a resident of Kentucky; these live births formed the sample for the study. Municipal ordinances implemented during a given calendar year were coded in the model as present starting with the following calendar year, as the birth records were time deidentified except for the year of birth. This lagged law convention maximized the likelihood that pregnant persons included in the study were exposed to the smoke-free policy for at least a portion of their pregnancy. Multilevel logistic regression was used to assess the effect of smoke-free ordinances on the likelihood of preterm birth, with personal- and county-level variables included as potential covariates and pregnant persons nested within the county of residence. Data analysis was conducted using SAS (version 9.4; SAS Institute, Cary, NC), with an alpha level of. 05. Results: Nearly all personal-level variables were associated with preterm birth status. Personal factors associated with an increased likelihood of preterm birth included being older (relative to 18–24 years old; odds ratios [95% confidence intervals]: 1.02 [1.01–1.04] and 1.27 [1.24–1.31] for ages 25–34 and 35–49 years, respectively); having a history of preterm birth (odds ratio, 4.65; 95% confidence interval, 4.53–4.78); and smoking before pregnancy (odds ratio, 1.14; 95% confidence interval, 1.12–1.16). Pregnant persons living in counties with comprehensive laws were 9% less likely to have a preterm birth than those living in counties without a smoke-free ordinance (odds ratio, 0.91; 95% confidence interval, 0.89–0.94; P<.001). There was no difference in the likelihood of preterm birth between those living in counties with moderate or weak laws and those unprotected by any smoke-free ordinance in their county of residence. Conclusion: This study demonstrated that comprehensive municipal smoke-free laws are associated with reduced risk of preterm birth and that moderate or weak smoke-free laws are not. The findings have major implications for public health policy and underscore the potential influence of healthcare providers’ advocacy for strong smoke-free policies, prohibiting smoking in all workplaces (including restaurants, bars, and casinos), to support healthy pregnancies.

Original languageEnglish
Pages (from-to)767.e1-767.e10
JournalAmerican Journal of Obstetrics and Gynecology
Issue number5
StatePublished - Nov 2022

Bibliographical note

Publisher Copyright:
© 2022 Elsevier Inc.


  • birth records
  • community intervention
  • population health strategy
  • pregnancy
  • preterm birth
  • secondhand smoke
  • smoke-free laws
  • smoking
  • tobacco use

ASJC Scopus subject areas

  • Obstetrics and Gynecology


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