Left Truncation Bias as a Potential Explanation for the Protective Effect of Smoking on Preeclampsia

BACKGROUND: We carried out a study to examine whether left truncation bias could explain the negative association between smoking and preeclampsia. METHODS: Monte Carlo and other simulation models were used to determine the effect of differential rates of early pregnancy loss among smokers on the relation between smoking and preeclampsia at ≥20 weeks’ gestation. Assumptions included no association between smoking and the abnormal placentation that characterizes preeclampsia, and higher rates of early pregnancy loss among smokers, pregnancies with abnormal placentation, and smokers with abnormal placentation. RESULTS: Monte Carlo simulation yielded a rate ratio for preeclampsia, given smoking of 0.85 (95% confidence interval = 0.73, 0.98). The protective effect of smoking was also evident in simulations that did not require assumptions about early pregnancy loss rates. CONCLUSION: Left truncation bias due to differential rates of early pregnancy loss among smokers is a plausible explanation for the inverse association between maternal smoking and preeclampsia.