In the November issue of Obstetrics & Gynecology, The American College of Obstetricians and Gynecologists (ACOG) has issued recommendations to providers regarding efforts to support smoking cessation in pregnant and postpartum women.

The article states that while about half of women smokers stop smoking during pregnancy, about 13% of women in the United States continue to smoke while pregnant.  Smoking has been associated with a number of negative outcomes, including ectopic pregnancy, intrauterine growth retardation, low birth weight, placenta previa, placental abruption, premature rupture of membranes, preterm delivery, and reduced maternal thyroid function. Maternal smoking is also implicated in approximately 23% to 34% of all cases of sudden infant death syndrome (SIDS) and 5% to 7% of preterm-related infant deaths. In addition, children born to mothers who smoke during pregnancy are at increased risk for asthma, colic, and childhood obesity.

The report points out that women who are pregnant or planning to conceive are highly motivated with regard to smoking cessation. The authors also note that while quitting smoking before 15 weeks of gestation carries the greatest health benefits for the pregnant woman and the fetus, quitting at any point can be beneficial.  ACOG recommends that clinicians use a brief counseling session based the five A’s of smoking cessation, a process that includes: (1) Asking every patient about tobacco use, (2) Advising all smokers to quit, (3) Assessing smokers’ willingness to quit, (4) Assisting smokers with treatment and referrals, and (5) Arranging follow-up contacts.

Referral to a smoker’s quit line may provide further benefit.  Quit lines offer information, direct support, and ongoing counseling, and have been shown to be very successful in promoting smoking cessation among pregnant women. By dialing the national quit line network (1-800-QUIT NOW) the caller is immediately routed to her local smokers’ quit line.

Quit rates are typically lower in women who are heavily addicted, and these women, as well as those who fail the above interventions, may benefit from pharmacologic treatment.  There continues to be controversy regarding the use of nicotine replacement products for smoking cessation during pregnancy. The data regarding the reproductive safety of nicotine replacement therapy (NRT) is limited.  A recent meta-analysis indicated that NRT use in pregnancy significantly decreases the risk of preterm delivery and low birth weight as compared to that observed in smokers.  Information regarding the risk of malformations in NRT-exposed infants remains sparse.

The authors note that trials assessing the use of nicotine replacement therapy in pregnancy have been attempted, yet all of those conducted in the United States have been stopped before their completion because of adverse pregnancy outcomes or failure to demonstrate effectiveness.  The authors thus recommend that nicotine replacement therapy should be undertaken only with close supervision and after careful consideration of the known risks of continued smoking versus the possible risks of nicotine replacement therapy.

Alternative smoking cessation agents include varenicline (Chantix) and bupropion (Wellbutrin).  At this point, there is no information regarding the reproductive safety of varenicline; thus it is generally not used in pregnancy.  In contrast, there is data to support the use of bupropion in pregnancy; the pooled data demonstrate no increase in the risk of adverse outcomes in infants exposed to bupropion in pregnancy.

While this report did not specifically address the issue of smoking among pregnant women with psychiatric illness, previous studies have indicated that rates of smoking are significantly higher among pregnant women who suffer from depression.  Rates of smoking during pregnancy are particularly high (greater than 50%) among pregnant women with schizophrenia.    Furthermore, these populations are less likely to be able to successfully stop smoking during pregnancy and are more likely to resume smoking.

Smoking clearly carries significant risk for the pregnant mother and the fetus, as do untreated mood and anxiety disorders in the mother.  There is also some overlap in the types of risk observed.  For example, adverse outcomes associated with antenatal depression and anxiety include preterm delivery and low birth weight, which are also more common in pregnant smokers.  This may suggest that women who smoke and have comorbid psychiatric illness may be at particularly high risk for adverse outcomes.  These statistics indicate that it is important for mental health professionals to address the issue of smoking in women of child-bearing age.  The strategies outlined in the ACOG report – the use of the 5 A’s of smoking cessation – may easily be incorporated into a routine visit.

Ruta Nonacs, MD PhD

 

Resources for Providers:

ACOG Smoking Cessation Information for PROVIDERS

Health Care Providers: How You Can Help Patients Quit (CDC)

Resources for Patients:

Become an EX(smoker) website for pregnant and postpartum smokers