Background:
Limited data exists regarding tobacco use during pregnancy, particularly in Middle Eastern countries. We examined tobacco use patterns and beliefs regarding secondhand smoke exposure (SHS) before and during pregnancy among Egyptian women.

Methods:
Pregnant women were recruited during their last trimester from maternity hospitals in Cairo, Egypt from June, 2015 to May, 2016. Two hundred women were interviewed about their tobacco use before and during pregnancy, as well as their attitudes and beliefs regarding tobacco use and SHS.

Results:
Participants had a mean age of 27 (+4.6) years. Before pregnancy, 30% of the women reported using tobacco. Among tobacco users, 60% were dual users of cigarettes and hookah, 35% were exclusive cigarette smokers, and 5% were exclusive hookah smokers. Prevalence of daily cigarette smoking decreased during pregnancy (-62.9%, p< .0001), but daily hookah use did not change (-7.4%, p=0.215). Most dual users (75%) transitioned to exclusive hookah smoking during pregnancy. Only 13% of smokers quit all products, whereas 28% continued their same smoking behaviors. Social acceptability of hookah and cigarette smoking was high among tobacco users and did not differ by product. The majority of women agreed that tobacco use is harmful during pregnancy (92%) and SHS is harmful to a newborn (94%), and this did not differ by smoking status. However, only 68% agreed that a pregnant woman's SHS was harmful to herself and her unborn child.

Conclusions:
Among this sample of pregnant women, dual use of hookah and cigarettes was common before pregnancy. The transition from dual to exclusive hookah smoking during pregnancy suggests that hookah may be perceived as less harmful than cigarettes and could serve as a substitute for conventional cigarettes. Future work is needed to understand and address hookah smoking during pregnancy and misperceptions about the harmful effects of SHS among women of child-bearing age in Cairo, Egypt.