Obtained necessary approvals to conduct the study:

• California Health and Human Services Agency Committee for the Protection of Human Subjects — assures ethical conduct of the study

• Office of Vital Records, Office of Statewide Health Planning and Development — birth records data

• Department of Developmental Services — autism diagnosis data

• California Biobank Program — newborn screening specimens, screening data, cross-generational linkage data

Engage community stakeholders and post research briefs and updates throughout the study.

Collected data from multiple sources, including birth records, hospital discharge, newborn screening and developmental services records, and neighborhood-level data on social context, air pollution, and walkability.

Linked multigenerational data from the California Biobank Program to hospital discharge and developmental services records to identify cases with chronic hypertension or autism spectrum disorder, as well as to neighborhood-level data via geocodes. Before study exclusions, the multigenerational cohort has over 145,000 White women and 56,000 Black women born in California since 1982 who delivered a baby between 2007 and 2011.

Using a case-cohort sampling, selected a small subset of Black and White mothers from the multigenerational cohort whose newborn screening specimens would be analyzed for the tobacco biomarker cotinine (~2,400 subjects total).

Created study variables, described sampled groups, assessed representativeness, identified multigenerational predictors of the four study outcomes, and tested our statistical methods.

The California Biobank Program pulled 2,385 maternal and 293 paternal archived newborn screening specimens from freezer storage and shipped them to our partnering laboratory at UCSF.

The UCSF Tobacco Biomarker Core Facility has completed cotinine analysis on maternal and paternal newborn screening specimens and reported results to study investigators.

The investigative team described patterns of in utero exposure to prenatal smoking, and its association with later obesity and chronic hypertension, and very preterm birth and autism in the third generation. The team also assessed the impact of in utero exposure to smoking on racial and socioeconomic health disparities.

Manuscripts are being drafted for publication, covering patterns and predictors of in utero exposure to prenatal smoking and effects of in utero exposure to smoking on maternal obesity, chronic hypertension, very preterm birth, and autism, including impact on health disparities.

Two online communication forums were held, in 2022 and 2023, to disseminate findings and gain understanding of how participants anticipating using the study results.