Some of the most commonly visited posts on our website are related to smoking in pregnant and postpartum women.  While smoking is a potential problem for all women, rates of tobacco use are higher among 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.

When women present for consultations regarding the treatment of psychiatric illness during pregnancy,  we discuss the risks associated with various psychotropic medications used during pregnancy, as well as the risks associated with untreated illness in the mother.  Clinicians must also address the use of tobacco, alcohol and recreational drugs in this population and discuss the risks associated with the use of these substances during pregnancy and the postpartum period.

While about half of women smokers stop smoking during pregnancy, about 13% of women in the United States continue to smoke while pregnant.  In addition, about half of the women who manage to stop smoking during pregnancy relapse during the postpartum period.

Risks of Smoking During Pregnancy

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.

Although many people view electronic or e-cigarettes as being safer than regular cigarettes, we know very little about their safety during pregnancy.  Just like regular cigarettes, they contain nicotine, and exposure to nicotine during pregnancy carries significant risks.  Previous studies have shown that exposure to nicotine increases the risk of miscarriage, stillbirth, preterm birth, and low birth weight.  Other studies suggest that nicotine can affect the development of the fetal brain.  In addition, e-cigarettes may contain chemicals (e.g., acetone, formaldehyde, acetaldehyde, benzopyrene) and heavy metals, like lead and cadmium, which may also be harmful to the fetus.

Risks of Smoking While Breastfeeding

Nicotine and other chemicals from the tobacco are transferred into the breast milk at relatively high levels.  The amount of nicotine to which the infant is exposed depends on the number of cigarettes consumed by the mother per day and also on the time interval between the last cigarette and the beginning of breastfeeding. Nicotine also accumulates in the breast milk (milk/plasma ratio 2.9), and some might be surprised to learn that the amount of nicotine transferred into the breast milk is more than double the quantity transferred through the placenta during pregnancy.

Studies indicate that smoking more than 10 cigarettes per day decreases milk production and alters milk composition. Furthermore, breastfed babies whose mothers smoke more than 5 cigarettes daily exhibit behaviors (e.g. colic and crying) that, in addition to low milk supply, may promote early weaning.

In addition, because smoking is associated with sleep disturbances in adolescents and adults, researchers have begun to look at the sleeping patterns of babies breastfed by mothers who smoke. They found that the infants of mothers who smoke just before nursing have shorter sleep times and altered sleep architecture.

Most studies focus only on the effects of nicotine on the nursing infant; we have little information on how the breastfeeding infant may be affected by the other toxic chemicals in found in the breast milk of women who smoke, including arsenic, cyanide, formaldehyde, and lead.

In addition to exposure to nicotine and tobacco byproducts in the breast milk, there is well-defined literature regarding the risks children incur as a result of  passive, or secondhand, exposure to smoke, including increased susceptibility to Sudden Infant Death Syndrome (SIDS), development and/or exacerbation of allergic diseases, such as asthma, and more recurrent and chronic respiratory illnesses.  Less understood are the risks of thirdhand smoke, the residual nicotine and potentially toxic tobacco-derived chemicals left behind by tobacco smoke on surfaces including hair, skin, clothes, furniture, carpets, and walls.

Encouraging Smoking Cessation During Pregnancy and the Postpartum Period

Smoking clearly carries significant risk for the pregnant mother and her child.  The American College of Obstetricians and Gynecologists  issued a report recommending that focus on smoking cessation during pregnancy and the postpartum period.

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.  

In order to help healthcare professionals improve their skills in helping patients to quit smoking during pregnancy and the postpartum period,  an interactive online training developed by Dartmouth College Interactive Media Laboratory in collaboration with ACOG and the Centers for Disease Control and Prevention (CDC).  The curriculum teaches a best practice approach for smoking cessation and is based on current clinical recommendations, including 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,
  5. Arranging follow-up contacts.

The program offers interactive case simulations and comprehensive discussions of the cases, short lectures on relevant topics from leading experts, interviews with women who have quit smoking, and a dedicated website of pertinent links and office resources. The training is accredited for up to 4.5 hours of continuing education credits.  Clinicians can access the training, by visiting www.smokingcessationandpregnancy.org.

Ruta Nonacs, MD PhD

Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short-term effects on infant feeding and sleep.Pediatrics. 2007 Sep;120(3):497-502.

Primo CC, Ruela PB, Brotto LD, Garcia TR, Lima Ede F. Effects of maternal nicotine on breastfeeding infants.  Rev Paul Pediatr. 2013 September; 31(3): 392–397.

Wong MK, Barra NG, Alfaidy N, Hardy DB, Holloway AC.  Adverse effects of perinatal nicotine exposure on reproductive outcomes.  Reproduction. 2015 Dec;150(6):R185-93.   Free Article

 

Resources for Providers:

ACOG Smoking Cessation Information for PROVIDERS (PDF)

Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. FREE FULL TEXT

Centers for Disease Control and Prevention, Division of Reproductive Health — Highlight of data on tobacco use during pregnancy and resources.

The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program — An evidence-based program that can be implemented in offices to help pregnant women quit smoking.

Resources for Patients:

1-800-QUIT-NOW — (1-800-784-8669); TTY 1-800-332-8615. Provides support in quitting, including free quit coaching, a free quit plan, free educational materials, and referrals to local resources.

Smokefree Women — Provides information and resources on quitting smoking targeted at pregnant and nonpregnant women.

Become an EX: For pregnant and postpartum smokers — A quit smoking program developed by the American Legacy Foundation.

Stay Away from Tobacco — Smoking cessation resources for patients and providers.