Skip to main content
NCBI home page
Sage Choice logoLink to Sage Choice
. 2022 Jun 19;49(4):403–411. doi: 10.1177/14653125221094337

The effect of maternal smoking and alcohol consumption on lip morphology

Kristian James Michael Davies 1,✉, Stephen Richmond 1, Renata Jorge Medeiros-Mirra 1, Hawraa Hassan Abbas 1, Caryl Eleri Wilson-Nagrani 1, Megan Gael Davis 1, Alexei Zhurov 1
PMCID: PMC9679570  PMID: 35723071

Abstract

Objective:

To determine whether maternal smoking and/or alcohol consumption has an influence on lip morphology. Maternal smoking is a known risk factor for orofacial clefts; however, its influence on normal lip variation is unknown. Recent research regarding normal lip morphology has been contradictory.

Design:

Retrospective cohort study.

Setting and participants:

A total of 4747 children from the Avon Longitudinal Study of Parents and Children (ALSPAC) who each had 3D facial scans carried out at 15 years of age were included in the study.

Methods:

Each of the participants was automatically categorised regarding predetermined lip morphological traits. Questionnaires completed by their mothers identified smoking and alcohol habits during pregnancy. Logistic regression analyses were applied to determine the effect of maternal smoking and alcohol consumption on lip morphology.

Results:

Maternal smoking has significant effects on upper and lower lip contours, Cupid’s bow, lower lip-chin shape and lower lip tone (all P < 0.05). There was also an indication of a potential epigenetic effect of smoking pre-pregnancy on upper lip contour (P = 0.0573). Alcohol consumption is significantly associated with philtrum shape, particularly when >6 units of alcohol are consumed per week (P = 0.0149, 32 weeks). Overall results suggest a deeply grooved philtrum is more likely if alcohol is consumed. Investigating the combined effect of smoking and alcohol consumption, lower lip contour (P = 0.00923) and lower lip-chin shape (P = 0.0171) are statistically significant, with lower lip contour more likely to be narrow in the midline, and lower lip-chin shape more likely to be an angular concavity.

Conclusion:

Maternal smoking influences a number of lip traits, including a possible epigenetic effect on upper lip contour. Maternal alcohol consumption, particularly at a high level, influences philtrum shape. Maternal smoking and alcohol consumption have a combined effect on lower lip contour and lower lip-chin shape.

Keywords: lip shape, lip morphology, facial shape, facial morphology, ALSPAC, 3D imaging, imaging and cephalometry, maternal smoking, maternal alcohol

Introduction

There is overwhelming evidence to support maternal smoking as a risk factor for non-syndromic cleft lip/palate (CLP) (Chung et al., 2000; Hackshaw et al., 2011; Little et al., 2004; Shi et al., 2007). Saito et al. (2005) have suggested that the deleterious effects of tobacco may be due to N-nitrosonornicotine (NNN), while Shaw et al. (1996) and Romitti et al. (1999) suggest a genetic variant of TGF-alpha. Possible genes involved include ANK3 (Haaland et al., 2019), GRID2 and ELAVL2 (Beaty et al., 2013). Despite the link between smoking and CLP, however, there is an apparent lack of evidence for the effect of smoking on lip morphology in non-cleft patients.

The role of maternal alcohol consumption in the formation of orofacial clefts is uncertain. A number of studies suggest a link (Chevrier et al., 2005; Dixon et al., 2011; Romitti et al., 1999), with Chevrier et al. (2005) suggesting polymorphism of the ADH1C gene, whereas others have either failed to find an association (Meyer et al., 2003) or concluded there may only be an effect if alcohol is consumed in high levels (Shaw and Lammer, 1999). The relationship between maternal alcohol consumption and other birth defects has been more widely reported, such as holoprosencephaly (Oullette et al., 1977) and fetal alcohol syndrome (FAS) (Abel, 1995; Ahlgren et al., 2002; Astley and Clarren, 1996; Jones and Smith, 1973). FAS is a continuum of birth defects with an incidence of 1 in 1000 (Abel, 1995) that presents with characteristic facial features such as a smooth philtrum, thin upper lip vermilion and short palpebral fissure length, as well as learning disabilities or behavioural problems (Hoyme et al., 2005). Identifying a link between maternal alcohol consumption and facial morphology may aid with the diagnosis of FAS, as this has been reported to be challenging (Astley, 2004; Morleo, et al., 2011; Wilson-Nagrani, 2016).

Two recent studies investigating the effects of maternal alcohol consumption on facial shape have been contradictory. A prospective cohort study by Muggli et al. (2017) found ‘a consistent association between alcohol and craniofacial shape’, including a suggestion that binge drinking may affect the lower lip. By contrast, a systematic review and meta-analysis by Mamluk et al. (2017) found no evidence of any detrimental effects, although there was only one study in the review addressing craniofacial morphology in non-cleft individuals. A more recent study by Howe et al. (2019) stratified subjects according to maternal alcohol intake and reported a possible dose-response relationship but no strong association. While the evidence is inconclusive, current advice in the UK is that it should be avoided completely during pregnancy (Chief Medical Officer, 2015).

The aim of this observational cohort study was to determine whether maternal smoking and/or alcohol consumption during pregnancy influences the lip morphology of the offspring, using an automated lip classification system (Abbas, 2017; Abbas et al., 2015, 2018, 2019).

Materials and methods

The sample comprised individuals from the Avon Longitudinal Study of Parents and Children (ALSPAC), a birth cohort study that recruited pregnant women living in the Bristol area during 1990–1992. Details about the study cohort have been reported by Fraser et al. (2013) and Boyd et al. (2013) and are discussed in a Davies et al., (In press). Questionnaires were completed by the pregnant mothers at 8, 18 and 32 weeks of gestation, seeking to determine the frequency and number of cigarettes smoked and/or amount of alcohol consumed before and during pregnancy. During 2006–2007, at age 15 years, 4747 of the individuals had 3D facial scans obtained for analysis. Of the scans, 4730 underwent automated lip trait categorisation by means of Kmeans++, a method discussed Davies et al., (In press). Ethical approval for the study was obtained from the ALSPAC Ethics and Law Committee and the Local Research Ethics Committees. This includes all questionnaire content, analysis of the pre-existing dataset and acquisition of the facial scans (reference: 06/Q2006/53 Avon Longitudinal Study of Parents and Children [ALSPAC], Hands on Assessments: Teen Focus 3 [Focus 15+] [7 August 2006; confirmed 15 September 2006]). Informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the recommendations of the ALSPAC Ethics and Law Committee at the time.

Data were analysed using the statistical software RStudio (R Core Team, 2018; RStudio Team, 2016) and descriptive statistics were first run to assess trends in the data. Due to the heavy right-skewed distribution of the continuous data for alcohol consumption and high proportion of zeros, the following variables were categorised into a binomial variable of ‘yes’ and ‘no’ for alcohol: ‘units’ consumed per week at eight weeks; frequency of alcohol consumption in the first three months; and ‘units’ consumed per week at 32 weeks. The sample contained a large number of pregnant mothers who consumed alcohol in low concentrations, and assuming a binomial approach, these individuals would be classed as a ‘yes’ for consuming alcohol. To this end, and in line with Howe et al. (2019), the sample was also stratified into ⩽6 ‘units’ and >6 ‘units’ of alcohol at 8 and 32 weeks of pregnancy, such that the effect of heavy versus light alcohol consumption could be investigated. Data about smoking habits were already presented binomially pre-pregnancy, during the first three months, and at 16–18 weeks. In order to evaluate a potential epigenetic effect of maternal smoking, an analysis was also carried out using only mothers who smoked before pregnancy but not during pregnancy. Logistic regression models were used to assess if the lip shape traits of the children could be used to predict smoking and drinking patterns of the mothers at various stages in the pregnancy.

In order to test whether smoking habits and the consumption of alcohol were independent, a t-test was carried out to compare the drinking patterns between smokers and non-smokers. Following this, in order to look at the combined effect of smoking and alcohol, a ‘profile’ of four categories (no drinking and no smoking, drinking but no smoking, smoking but no drinking, and drinking and smoking) was created at three months – the only timepoint for which comparable data were available. A multinomial logistic regression was carried out to investigate if this profile could be predicted by individual lip traits, thus suggesting a combined effect of smoking and alcohol consumption on lip shape.

Results

Prevalence of maternal smoking and alcohol consumption

Table 1 shows the smoking and alcohol habits of pregnant mothers in the sample at various timepoints. The prevalence of smoking in the sample was 23.0% before pregnancy but fell to 15.7% during the first three months of pregnancy, and further to 12.0% at 16–18 weeks of pregnancy. The prevalence of alcohol consumption in the sample was 94.1% before pregnancy but fell to 56.9% during the first three months of pregnancy, and slightly further to 52.8% when the mothers first felt the baby move. Before pregnancy, only 5.9% reported never consuming alcohol, and the majority of mothers reported consuming alcohol less than daily (81.9%). Of mothers, less than 0.2% consumed more than 10 glasses per day at any of the timepoints.

Table 1.

Changes to smoking and alcohol habits during pregnancy.

No. of cigarettes smoked per day pre-pregnancy, during the first 3 months and at 16–18 weeks asked at 18 weeks of gestation
Number smoked Pre-pregnancy First 3 months 16–18 weeks
0 3378 (77.0) 3714 (84.3) 3878 (88.0)
1–4 156 (3.6) 196 (4.4) 152 (3.5)
5–9 180 (4.1) 175 (4.0) 128 (2.9)
10–14 195 (4.4) 151 (3.4) 117 (2.7)
15–19 208 (4.7) 91 (2.1) 70 (1.6)
20–24 190 (4.3) 55 (1.2) 46 (1.0)
25–29 51 (1.2) 20 (0.5) 10 (0.2)
30+ 29 (0.7) <5 (<0.2) <5 (<0.2)
(Not answered) (343) (324) (325)
Alcohol consumption pre-pregnancy, during the first 3 months, and since the baby first moved asked at 18 weeks of gestation
Alcohol consumption Pre-pregnancy First 3 months Baby first moved
Never 258 (5.9) 1899 (43.1) 2042 (47.2)
Less than 1 glass per week 1664 (37.7) 1825 (41.4) 1596 (36.9)
At least 1 glass per week 1949 (44.2) 607 (13.8) 632 (14.6)
1-2 glasses every day 476 (10.8) 64 (1.5) 51 (1.2)
3-9 glasses every day 61 (1.4) 8 (0.2) <5 (<0.2)
At least 10 glasses every day <5 (<0.2) <5 (<0.2) <5 (<0.2)
(Not answered) (320) (326) (406)
Open in a new tab

Values are given as n (%).

Stratifying the sample at 6 ‘units’ per week to account for heavy versus light drinking, the following spread of data was observed (Table 2). The vast majority of pregnant mothers consumed ⩽6 ‘units’ of alcohol per week at both 8 weeks and 32 weeks of pregnancy (3694, 92.8% and 2361, 92.1% respectively). The proportion of mothers who drank heavily (>6 ‘units’ of alcohol per week) changed very little between the timepoints (7.2% to 7.9%).

Table 2.

Stratified alcohol consumption by ‘units’ consumed per week.

8 weeks of pregnancy 32 weeks of pregnancy
⩽6 ‘units’ of alcohol per week 3694 (92.8) 2361 (92.1)
>6 ‘units’ of alcohol per week 286 (7.2) 203 (7.9)
Incomplete data 750 2166
Open in a new tab

Values are given as n (%).

The effect of maternal smoking

Analysing the variable for smoking during the first three months of pregnancy, there were statistically significant associations between smoking and upper lip contour (LRT = 8.446, df = 3, P = 0.0377), lower lip contour (LRT = 12.318, df = 3, P = 0.00637), lower lip-chin shape (LRT = 12.776, df = 4, P = 0.0124) and lower lip tone (LRT = 12.696, df = 4, P = 0.0129). Predicted probabilities were assessed (Figure 1), and while confidence intervals for the predicted probabilities overlap for most of the lip traits, the odds ratios (ORs) are significant for many of the comparisons, and hence they are good predictors of whether the mothers smoked. Descriptors for the different types of each lip trait are outlined in Davies et al., (In press). ORs for upper lip contour Types 1 and 3 (concave and pseudo-convex) were significantly larger than Types 2 and 4 (straight and convex). For lower lip contour, the OR for Type 2 (curved) was significantly lower than the other types. For lower lip-chin shape, the ORs for Types 2 and 4 (both angular concavities) were significantly larger than Types 3 and 5 (convex and flat). For lower lip tone, the ORs for Types 2 and 3 (both with central concavities) were significantly larger than Type 4 (wide concavity). At 16–18 weeks of pregnancy, there were again statistically significant associations between smoking and upper lip contour (LRT = 8.933, df = 3, P = 0.0302) and lower lip tone (LRT = 15.465, df = 4, P = 0.00383), with an additional association identified between smoking and Cupid’s bow (LRT = 6.847, df = 2, P = 0.0326).

Figure 1.

Figure 1.

Open in a new tab

Predicted probabilities of smoking for upper lip contour, lower lip contour, lower lip-chin shape and lower lip tone during the first three months of pregnancy.

An analysis was carried out for smoking pre-pregnancy, for mothers who stopped smoking during pregnancy only (307 mothers). This model reveals a possible effect on the upper lip contour, with marginal non-significance (LRT = 7.511, df = 3, P = 0.0573). ORs for the potential epigenetic effect of smoking pre-pregnancy on the upper lip contour (Table 3) indicate a higher probability of smoking pre-pregnancy than never smoking, with upper lip contour Type 1 (concave) than Type 4 (convex). No other comparisons were significant.

Table 3.

Odds ratios for upper lip contour, smoking pre-pregnancy.

Upper lip contour type OR 95% CI
1 1.000 1.000
2 0.750 0.552–1.016
3 0.852 0.647–1.179
4 0.622 0.420–0.902
LRT = 7.511, df = 3, P = 0.0573
Open in a new tab

CI, confidence interval; OR, odds ratio.

Bold values are where the 95% CI does not include 1, therefore a statistically significant result.

The effect of maternal alcohol consumption

For alcohol consumption during the first three months of pregnancy, a significant association was identified for philtrum shape (LRT = 16.126, df = 6, P = 0.0131). There were marginal non-significant associations for Cupid’s bow (LRT = 5.114, df = 2, P = 0.0776) and lower lip contour (LRT = 6.304, df = 3, P = 0.0977). Following stepwise deletion, philtrum shape remained significant (LRT = 14.940, df = 6, P = 0.0207) and Cupid’s bow also remained near significant (P = 0.0601). The ORs for philtrum shape are displayed in Table 4. The results suggest that while philtrum shape appears to be influenced by maternal alcohol consumption, the highest probability for alcohol consumption when pregnant was seen with philtrum shape Type 4 (deep groove). At 32 weeks of pregnancy, the result for philtrum shape also approached statistical significance (LRT = 11.083, df = 6, P = 0.0858). There were otherwise no other statistically significant associations between maternal alcohol consumption and lip morphology, with all other P values ⩾ 0.104.

Table 4.

ORs for philtrum shape, alcohol consumption during the first 3 months of pregnancy.

Philtrum shape type OR 95% CI
1 0.776 0.624–0.965
2 0.727 0.551–0.958
3 0.670 0.493–0.909
4 1.000
5 0.699 0.382–1.291
6 0.882 0.689–1.130
7 0.599 0.462–0.776
LRT = 16.126, df = 6, P = 0.0131
Open in a new tab

CI, confidence interval; OR, odds ratio.

Bold values are where the 95% CI does not include 1, therefore a statistically significant result.

The effect of ‘heavy drinking’

Data were stratified at ⩽6 ‘units’ and >6 ‘units’ per week at 8 weeks and 32 weeks of pregnancy. At 32 weeks, there was a statistically significant association between heavy drinking and philtrum shape (LRT = 15.790, df = 6, P = 0.0149), and a potentially significant association between heavy drinking and upper lip border (LRT = 5.371, df = 2, P = 0.0682). As with the binomial data for the effect of alcohol consumption on philtrum shape, ORs were investigated to determine which philtrum shape types are more common among the ‘heavy drinking’ group. For this set of data, the model parameters exhibited a poor fit, and the confidence intervals were too large to be able to make any reliable conclusions. Of note is the fact that the distribution across the different classes of philtrum shape is poor. For philtrum shape Type 5 – smooth and wide – there are only 73 individuals in the class, and all their mothers consumed alcohol while pregnant.

The combined effect of smoking and alcohol

Table 5 demonstrates that large numbers of pregnant mothers either did not smoke or drink at all (n=1649, 37.58%) or consumed alcohol but did not smoke (n=2050, 46.72%). A t-test was carried out to investigate the difference in drinking patterns between smokers and non-smokers. On average, mothers who smoked before pregnancy consumed significantly more alcohol at eight weeks of pregnancy, 2.28±0.17 ‘units’, than those who did not smoke, 1.31±0.05 ‘units’ (t = 5.4774, df = 1067.4, P < 0.0001). Multinomial logistic regression analyses were applied to test the variable ‘profile’ for each of the lip morphological traits to investigate the combined effect of smoking and alcohol. The reference category was set as ‘no smoking or alcohol’ such that ORs could be investigated for smoking only, alcohol consumption only and the combined effect of both in relation to the reference category. Statistically significant results were obtained for combined smoking and alcohol consumption for lower lip contour (LRT = 21.890, df = 9, P = 0.00923) and lower lip-chin shape (LRT = 24.534, df = 12, P = 0.0171). ORs for each of the lower lip contour and lower lip-chin shape types are outlined in Table 6. The results suggest a higher probability of combined maternal smoking and alcohol consumption for lower lip contour Type 1 (narrow in the midline) than Types 2 or 3, and for lower lip-chin shape Type 4 (an angular concavity) than Type 5 (flat).

Table 5.

Smoking and alcohol consumption during the first 3 months profile.

No smoking or alcohol 1649
Smoked only 246
Consumed alcohol only 2050
Smoked and consumed alcohol 443
Incomplete data 342
Open in a new tab

Table 6.

ORs for lower lip contour and lower lip-chin shape, combined smoking and alcohol consumption during the first 3 months of pregnancy.

Lower lip contour
Lower lip contour type OR (95% CI)
Smoking only Alcohol only Combined
1 1.000 1.000 1.000
2 0.365
(0.205–0.652)		 0.728
(0.556–0.940)		 0.547
(0.344–0.868)
3 0.860
(0.392–1.887)		 0.813
(0.552–1.198)		 0.485
(0.270–0.871)
4 1.10
(0.666–1.823)		 0.962
(0.753–1.230)		 0.893
(0.610–1.308)
LRT = 21.890, df = 9, P = 0.00923
Lower lip-chin shape
Lower lip-chin shape type OR (95% CI)
Smoking only Alcohol only Combined
1 0.800
(0.448–1.431)		 0.922
(0.688–1.235)		 0.710
(0.454–1.109)
2 2.218
(1.041–4.724)		 1.340
(0.910–1.974)		 0.991
(0.528–1.860)
3 0.562
(0.279–1.134)		 0.906
(0.641–1.280)		 0.683
(0.403–1.159)
4 1.000 1.000 1.000
5 0.754
(0.391–1.454)		 1.001
(0.720–1.392)		 0.581
(0.346–0.976)
LRT = 24.534, df = 12, P = 0.0171
Open in a new tab

CI, confidence interval; OR, odds ratio.

Bold values are where the 95% CI does not include 1, therefore a statistically significant result.

Discussion

National data published in 2019 reported that 10.4% of pregnant mothers in England are self-reported smokers at the time of delivery (NHS Digital, 2019), compared to 12.0% at 16–18 weeks of pregnancy in this sample. Regarding alcohol consumption, 94.1% consumed alcohol before pregnancy in this sample, slightly higher than reported by Popova et al. (2017). These differences reflect changing attitudes to smoking and alcohol consumption from the early 1990s to the present day. Overall, more women gave up smoking completely than gave up alcohol completely.

This study addresses the apparent lack of evidence into the effect of maternal smoking on lip morphology in non-cleft individuals and adds to existing evidence into the effect of maternal alcohol consumption. The results suggest that maternal smoking influences upper lip contour, lower lip contour, lower lip tone, lower lip-chin shape and Cupid’s bow. A statistically significant result was obtained for upper lip contour and lower lip tone at all of the timepoints assessed, but only at one timepoint for the other traits. Despite little variation, predicted probabilities reveal a tendency for lower lip contour Type 2 (curved) and lower lip tone Type 4 (wide concavity) to be associated with a lower probability of smoking, and lower lip-chin shape Types 2 and 4 (both angular concavities) to be associated with a greater probability of smoking. As the confidence intervals overlap for each of the lip trait types, the predicted probabilities serve as an indication of how smoking might affect lip morphology while suggesting that the effects are not likely to be very strong. ORs suggest that should there be a true epigenetic effect, smoking before pregnancy would more likely result in a concave upper lip contour (Type 1) than convex (Type 4). While epigenetic effects of smoking and alcohol have been reported in the literature (Cantacorps et al., 2019; Kaur et al., 2019), the extent of which environmental influences on lip morphology are epigenetic is unclear.

While assessing data binomially does not facilitate investigation of the relevance of number of cigarettes smoked, there is evidence to suggest that approximately 70% of women who smoke during pregnancy smoke every day rather than occasionally (Lange et al., 2018). It has also been suggested that smoking is harmful even at low levels (Schane et al., 2010).

Stratifying alcohol data to above or below 6 ‘units’ per week seemed to provide convincing evidence for the influence of alcohol on philtrum shape. The majority of mothers who drank heavily initially continued to do so, whereas a higher number of mothers who consumed alcohol at lighter levels gave up completely.

Initial interpretation of these results raised the question why at eight weeks of pregnancy there was no apparent effect of maternal alcohol consumption, considering that the early stages of pregnancy are critical for craniofacial development, and that lip development and fusion takes place in the weeks leading up to, and including, eight weeks in utero (Yoon et al., 2000). It is of importance, however, to note that the data at timepoints 8 weeks, 3 months and 32 weeks are not independent of each other. It could be argued that a more reliable result would have been obtained if the timepoints were not investigated separately, and non-drinkers were compared with those who consumed alcohol all the way through pregnancy. The ORs suggest that the most likely philtrum shape type to present for mothers who consumed alcohol is Type 4 – a deep groove. This does not correlate with extensive research into FAS, which reports that individuals with FAS often present with a wide, smooth philtrum (Abel, 1995; Ahlgren et al., 2002; Astley and Clarren, 1996; Jones and Smith, 1973), and that FAS is associated with reduced philtrum depth (Blanck-Lubarsch et al., 2019). It is important to note, however, that it was not possible to analyse ORs for heavy drinking – which is associated with a diagnosis of FAS – and that this cohort of patients were a normal population, not known FAS individuals.

The combined effect of smoking and alcohol seems to be on the lower lip contour and lower lip-chin shape, with statistical significance being achieved for both lip traits. The results suggest that the effect may be an increased likelihood of a lower lip contour that is narrow in the central region (Type 1), and a lower lip-chin shape that has an angular concavity (Type 4).

In agreement with Muggli et al. (2017) but in contrast to Mamluk et al. (2017), the results of the present study suggest that maternal alcohol consumption may influence facial shape, specifically the lip region, although the results are not as conclusive as the Muggli et al. (2017) study. Howe et al. (2019) failed to find a strong association between maternal alcohol and facial shape, despite using the same large sample as used in the present study; however, the study by Howe et al. (2019) used facial landmarks for analysis, whereas surface contours are used in the present study.

By using the ALSPAC dataset that was obtained for the present study, there was no opportunity to influence or manipulate the means by which the data were recorded. The questions relating to maternal smoking and alcohol consumption completed at 8, 18 and 32 weeks were inconsistent, in that some asked for number of ‘units’ consumed (continuous), some asked for frequency (ordinal) and some smoking questions required ‘yes/no’ answers (binomial). One ‘unit’ of alcohol as described by ALSPAC was not entirely consistent with the standard UK unit (10 mL or 8 g of ethanol). Timepoints were not comparable for smoking and alcohol consumption, which inevitably made data analysis challenging. All information about maternal smoking and alcohol consumption in this study was self-reported by means of questionnaire, which may result in an underestimation of the number of cigarettes smoked or amount of alcohol consumed due to societal pressures, although Swamy et al. (2011) suggest that most pregnant women do, in fact, disclose their true smoking status. A number of potential confounders also need to be taken into consideration, for example those associated with maternal deprivation, age, and socioeconomic status (Alati et al., 2013).

Future studies designed explicitly to investigate the effect of maternal smoking and alcohol consumption on offspring lip morphology may wish to pay attention to the following points. Consideration could be given to other methods of reporting and recording smoking and alcohol consumption, including the urine sample method described by Dhalwani et al. (2015), and exhaled carbon monoxide measurement, which is both non-invasive and reliable (Coultas et al., 1988). Alternative statistical analyses could be considered to answer the research question. The study could be designed such that statistical analysis can include continuous data rather than binomial data alone, in order to better predict the effect of heavy smoking and alcohol consumption. There was no power calculation carried out before the present study, as it was felt that the sample size of 4730 participants would be sufficient to identify an association between smoking and alcohol consumption and lip morphology, should there be one; however, there were very few pregnant mothers who consumed a large amount of alcohol. As such, it may be more appropriate to carry out a cohort-type study to investigate the effects of maternal smoking and alcohol consumption.

Conclusion

Following the descriptive analysis of the data collected for this project, it is possible to conclude that self-reported smoking and alcohol consumption during pregnancy were relatively high at the time of data collection. The proportion of women who smoked and consumed alcohol fell on discovering that they were pregnant and continued to fall during pregnancy. Maternal smoking influences upper and lower lip contours, Cupid’s bow, lower lip-chin shape and lower lip tone, with a possible epigenetic effect on the upper lip contour. Maternal alcohol consumption (particularly at a high level) influences philtrum shape, and the combined effects of smoking and alcohol consumption during pregnancy are on lower lip contour and lower lip-chin shape.

Acknowledgments

We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The UK Medical Research Council and Wellcome (Grant ref: 217065/Z/19/Z) and the University of Bristol provide core support for ALSPAC. This publication is the work of the authors, and they will serve as guarantors for the contents of this paper. A comprehensive list of grants funding is available on the ALSPAC website (http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf). The research relating to 3D face shape scanning was specifically funded by Cardiff University.

ORCID iD: Kristian James Michael Davies Inline graphic https://orcid.org/0000-0001-8780-3735

References

  1. Abbas HH. (2017) 3D Face Morphology Classification for Medical Applications. PhD Thesis. Cardiff: Cardiff University. [Google Scholar]
  2. Abbas H, Hicks Y, Marshall D. (2015) Automatic classification of facial morphology for medical applications. Procedia Computer Science 60: 1649–1658. [Google Scholar]
  3. Abbas H, Hicks Y, Marshall D, Zhurov AI, Richmond S. (2018) A 3D morphometric perspective for facial gender analysis and classification using geodesic path curvature features. Computational Visual Media 4: 17–32. [Google Scholar]
  4. Abbas HH, Hicks Y, Zhurov A, Marshall D, Claes P, Wilson-Nagrani C, et al. (2019) An automatic approach for classification and categorisation of lip morphological traits. PLoS ONE 14: e0221197. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Abel EL. (1995) An update on incidence of FAS: FAS is not an equal opportunity birth defect. Neurotoxicology and Teratology 17: 437–443. [DOI] [PubMed] [Google Scholar]
  6. Ahlgren SC, Thakur V, Bronner-Fraser M. (2002) Sonic hedgehog rescues cranial neural crest from cell death induced by ethanol exposure. Proceedings of the National Academy of Sciences of the U S A 99: 10476–10481. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Alati R, Davey Smith G, Lewis SJ, Sayal K, Draper ES, Golding J, et al. (2013) Effect of prenatal alcohol exposure on childhood academic outcomes: contrasting maternal and paternal associations in the ALSPAC study. PLoS ONE 8: e74844. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Astley SJ. (2004) Diagnostic Guide for Fetal Alcohol Spectrum Disorders. 3rd ed. Seattle, WA: University of Washington. [Google Scholar]
  9. Astley SJ, Clarren SK. (1996) A case definition and photographic screening tool for the facial phenotype of fetal alcohol syndrome. Journal of Pediatrics 129: 33–41. [DOI] [PubMed] [Google Scholar]
  10. Beaty TH, Taub MA, Scott AF, Murray JC, Marazita ML, Schwender H, et al. (2013) Confirming genes influencing risk to cleft lip with/without cleft palate in a case-parent trio study. Human Genetics 132: 771–781. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Blanck-Lubarsch M, Dirksen D, Feldmann R, Sauerland C, Kirschneck C, Hohoff A. (2019) 3D analysis of philtrum depth in children with fetal alcohol syndrome. Alcohol and Alcoholism 54: 152–158. [DOI] [PubMed] [Google Scholar]
  12. Boyd A, Golding J, Macleod J, Lawlor DA, Fraser A, Henderson J, et al. (2013) Cohort Profile: The ‘children of the 90s’—the index offspring of the Avon Longitudinal Study of Parents and Children. International Journal of Epidemiology 42: 111–127. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Cantacorps L, Alfonso-Loeches S, Guerri C, Valverde O. (2019) Long-term epigenetic changes in offspring mice exposed to alcohol during gestation and lactation. Journal of Psychopharmacology 33: 1562–1572. [DOI] [PubMed] [Google Scholar]
  14. Chevrier C, Perret C, Bahuau M, Nelva A, Herman C, Francannet C, et al. (2005) Interaction between the ADH1C polymorphism and maternal alcohol intake in the risk of nonsyndromic oral clefts: An evaluation of the contribution of child and maternal genotypes. Clinical and Molecular Teratology 73: 114–122. [DOI] [PubMed] [Google Scholar]
  15. Chief Medical Officer (UK) (2015) Alcohol Guidelines Review. London: Department of Health. [Google Scholar]
  16. Chung KC, Kowalski CP, Kim HM, Buchman SR. (2000) Maternal cigarette smoking during pregnancy and the risk of having a child with cleft lip/palate. Plastic and Reconstructive Surgery 105: 485–491. [DOI] [PubMed] [Google Scholar]
  17. Coultas DB, Howard CA, Peake GT, Skipper BJ, Samet JM. (1988) Discrepancies between self-reported and validated cigarette smoking in a community survey of New Mexico Hispanics. American Review of Respiratory Disease Returns 137: 810–814. [DOI] [PubMed] [Google Scholar]
  18. Davies KJM, Richmond S, Medeiros-Mirra RJJ, Abbas HH, Wilson-Nagrani C, Davis GM, et al. (In Press) Applying an Automated Method of Classifying Lip Morphological Traits. Journal of Orthodontics. doi: 10.1177/14653125221106489. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Dhalwani NN, Szatkowski L, Coleman T, Fiaschi L, Tata LJ. (2015) Nicotine replacement therapy in pregnancy and major congenital anomalies in offspring. Pediatrics 135: 859–867. [DOI] [PubMed] [Google Scholar]
  20. Dixon MJ, Marazita ML, Beaty TH, Murray JC. (2011) Cleft lip and palate: synthesizing genetic and environmental influences. Nature Reviews Genetics 12: 167–173. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Fraser A, Macdonald-Wallis C, Tilling K, Boyd A, Golding J, Smith GD, et al. (2013) Cohort Profile: The Avon Longitudinal Study of Parents and Children: ALSPAC mothers cohort. International Journal of Epidemiology 42: 97–110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Haaland ØA, Romanowska J, Gjerdevik M, Lie RT, Gjessing HK, Jugessur A. (2019) A genome-wide scan of cleft lip triads identifies parent-of-origin interaction effects between ANK3 and maternal smoking, and between ARHGEF10 and alcohol consumption. F1000Research 8: 960. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hackshaw A, Rodeck C, Boniface S. (2011) Maternal smoking in pregnancy and birth defects: a systematic review based on 173687 malformed cases and 11.7 million controls. Human Reproduction Update 17: 589–604. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Howe LJ, Sharp GC, Hemani G, Zuccolo L, Richmond S, Lewis SJ. (2019) Prenatal alcohol exposure and facial morphology in a UK cohort. Drug and Alcohol Dependence 197: 42–47. [DOI] [PubMed] [Google Scholar]
  25. Hoyme HE, May PA, Kalberg WO, Kodituwakku P, Gossage JP, Trujillo PM, et al. (2005) A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 institute of medicine criteria. Pediatrics 115: 39–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Jones K, Smith D. (1973) Recognition of the fetal alcohol syndrome in early infancy. The Lancet 302: 999–1001. [DOI] [PubMed] [Google Scholar]
  27. Kaur G, Begum R, Thota S, Batra S. (2019) A systematic review of smoking‑related epigenetic alterations. Archives of Toxicology 93: 2715-2740. [DOI] [PubMed] [Google Scholar]
  28. Lange S, Probst C, Rehm J, Popova S. (2018) National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis. The Lancet Global Health 6: e769–776. [DOI] [PubMed] [Google Scholar]
  29. Little J, Cardy A, Munger RG. (2004) Tobacco smoking and oral clefts: a meta-analysis. Bulletin of the World Health Organization 82: 213–218. [PMC free article] [PubMed] [Google Scholar]
  30. Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore THM, et al. (2017) Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently ‘safe’ levels of alcohol during pregnancy? A systematic review and meta-analyses. BMJ Open 7: e015410. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Meyer KA, Werler MM, Hayes C, Mitchell AA. (2003) Low maternal alcohol consumption during pregnancy and oral clefts in offspring: the Slone Birth Defects Study. Clinical and Molecular Teratology 67: 509–514. [DOI] [PubMed] [Google Scholar]
  32. Morleo M, Woolfall K, Dedman D, Mukherjee R, Bellis MA, Cook PA. (2011) Under-reporting of foetal alcohol spectrum disorders: an analysis of hospital episode statistics. BMC Pediatrics 11: 14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Muggli E, Matthews H, Penington A, Claes P, O’Leary C, Forster D, et al. (2017) Association between prenatal alcohol exposure and craniofacial shape of children at 12 months of age. JAMA Pediatrics 171: 771–780. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. NHS Digital (201. 9) Statistics on Women’s Smoking Status at Time of Delivery: England Quarter 1, 2019-20. London: Health and Social Care Information Centre (NHS Digital). Available at: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-women-s-smoking-status-at-time-of-delivery-england/statistics-on-womens-smoking-status-at-time-of-delivery-england-quarter-1-2019-20 (accessed 6 November 2019). [Google Scholar]
  35. Ouellette EM, Rosett HL, Rosman NP, Weiner L. (1977) Adverse effects on offspring of maternal alcohol abuse during pregnancy. New England Journal of Medicine 297: 528–530. [DOI] [PubMed] [Google Scholar]
  36. Popova S, Lange S, Probst C, Gmel G, Rehm J. (2017) Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis. The Lancet Global Health 5: e290–299. [DOI] [PubMed] [Google Scholar]
  37. R Core Team (2018) R: A language and environment for statistical computing. Vienna: R Foundation for Statistical Computing. Available at: https://www.R-project.org/ (accessed 9 September 2020). [Google Scholar]
  38. Romitti PA, Lidral AC, Munger RG, Daack-Hirsch S, Burns TL, Murray JC. (1999) Candidate genes for nonsyndromic cleft lip and palate and maternal cigarette smoking and alcohol consumption: evaluation of genotype-environment interactions from a population-based case-control study of orofacial clefts. Teratology 59: 39–50. [DOI] [PubMed] [Google Scholar]
  39. RStudio Team (2016) RStudio: Integrated Development for R. Boston, MA: RStudio, Inc. Available at: http://www.rstudio.com/ (accessed 9 September 2020). [Google Scholar]
  40. Saito T, Cui XM, Yamamoto T, Shiomi N, Bringas P, Jr, Shuler CF. (2005) Effect of N’-nitrosonornicotine (NNN) on murine palatal fusion in vitro. Toxicology 207: 475–485. [DOI] [PubMed] [Google Scholar]
  41. Schane RE, Ling PM, Glantz SA. (2010) Health effects of light and intermittent smoking: a review. Circulation 121: 1518–1522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Shaw GM, Lammer EJ. (1999) Maternal periconceptional alcohol consumption and risk for orofacial clefts. Journal of Pediatrics 134: 298–303. [DOI] [PubMed] [Google Scholar]
  43. Shaw GM, Wasserman CR, Lammer EJ, O’Malley CD, Murray JC, Basart AM, et al. (1996) Orofacial clefts, parental cigarette smoking, and transforming growth factor–alpha gene variants. American Journal of Human Genetics 58: 551–561. [PMC free article] [PubMed] [Google Scholar]
  44. Shi M, Christensen K, Weinberg CR, Romitti P, Bathum L, Lozada A, et al. (2007) Orofacial cleft risk is increased with maternal smoking and specific detoxification–gene variants. American Journal of Human Genetics 80: 76–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Swamy GK, Reddick KL, Brouwer RJ, Pollak KI, Myers ER. (2011) Smoking prevalence in early pregnancy: comparison of self-report and anonymous urine cotinine testing. Journal of Maternal-Fetal & Neonatal Medicine 24: 86–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Wilson-Nagrani C. (2016) Matching genotype to phenotype in a detailed assessment of lip morphology. PhD Thesis. Cardiff: Cardiff University. [Google Scholar]
  47. Yoon H, Chung IS, Seol EY, Park BY, Park HW. (2000) Development of the lip and palate in staged human embryos and early fetuses. Yonsei Medical Journal 41: 477–484. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Orthodontics are provided here courtesy of SAGE Publications

RESOURCES