Maryland's Tobacco Resource Center - Linking Professionals to Best Practices

OB/GYN

Smoking and Pregnancy

Smoking during pregnancy is an important problem for obstetricians and gynecologists to tackle.

  • 13% of women use tobacco during the last three months of pregnancy.1
  • Only 30% of women quit smoking when they find out they are pregnant.1
  • Pregnant women are 1.8 times more likely to be abstinent than when not pregnant2
  • However, 60% of women relapse within 6 months and 80% by 12 months2
  • Smoking in pregnancy accounts for an estimated 20-30% of low birth weight babies, up to 14% of preterm deliveries, and 10% of all infant deaths.3
  • If all pregnant women in the United States stopped smoking, there would be an estimated 11% reduction in stillbirths and a 5% reduction in newborn deaths.3

Action regarding these issues is clearly needed. Presented below is a comprehensive guide outlining:

Maternal Health Effects4

During Pregnancy

Postpartum

Long-term

  • Miscarriage
  • Premature birth
  • Ectopic pregnancy
  • Placental abnormalities
  • Bleeding
  • Premature rupture of membranes
  • Impaired lactation
  • Inhibited protection against Sudden Infant Death Syndrome (SIDS) from breast milk

 

  • Decreased life expectancy
  • Decreased fertility
  • Earlier menopause
  • Menstrual abnormalities
  • Heart disease
  • Emphysema
  • Cancer
  • Stroke

Health Effects on Fetus4

  • Fetal growth retardation
  • Small for gestational age
  • Increased fetal heart rate
  • Chronic fetal anoxia (an extreme decrease in the amount of oxygen)
  • Preterm delivery
  • Low birth weight
  • Fetal artery constriction
  • Lessened amounts of oxygen and nutrients in the fetus
  • Perinatal death

Issues Specific to Pregnant Women

Please visit our “Pregnancy” page (under Special Populations) to learn about…

  • More effects of tobacco use on the mother and baby
  • Characteristics of mothers who relapse after giving birth
  • Treatment considerations for mothers during both their pregnancy and following birth

Providers can follow the 5 A’s method to address smoking with their patients.

There are several treatment recommendations specific to pregnant women.

  • Emphasizing cessation to women who are considering pregnancy can help maximize the protection of the infant from the harmful effects of smoking. By talking with a patient who is considering childbearing, obstetricians and gynecologists may be able to help increase the patient’s motivation to quit for her own health along with the health of the baby.4
  • Newly pregnant women may be quitting for the baby and not for themselves.  “Spontaneous quitters” quit smoking as soon as they learn they are pregnant.  Most spontaneous quitters are able to maintain cessation throughout pregnancy, but up to 70% of these quitters resume smoking by six months after the birth of the baby.  It is important to assist these women in the cessation process.4
  • Having a partner who smokes appears to make a significant contribution to a woman’s continued smoking during pregnancy as well as the return to smoking postpartum for spontaneous quitters.  It is important to involve partners in the process of smoking cessation during and after pregnancy.4

Addressing Smoking Myths with Patients

Question: Why should I quit smoking during pregnancy?

Answer: Chemicals in tobacco smoke are passed from the mother to the fetus through the placenta.  Some of these chemicals are carcinogens.6 Smoking during pregnancy increases the risk of stillbirths, spontaneous abortions, premature births, and low birth weight babies.7  Women are believed to reduce risk the most if they stop smoking by sixteen weeks gestation.8

Question: Can I use nicotine replacement therapies?5

Answer: It is preferred to quit through counseling and behavioral modification, however, you can talk to your doctors about using any nicotine replacement therapies to find out if they are safe for you and your baby.5

Question: Is it okay if I just cut down on smoking?

Answer: There is no safe level of smoking.  Quitting smoking should be your overall goal. Cutting back on cigarettes offers some protection, but does not compare to the benefits of completely quitting smoking.4

Question: Is it too late to quit smoking?

Answer: There are benefits to quitting smoking at any stage during pregnancy.  If you quit now, you will be less likely to have a low birth weight baby.  You will also increase the chance that your baby’s lungs will work well.

Question: Will quitting smoking be stressful for my baby?

Answer: Quitting smoking will not have any negative effects on your baby.  Quitting smoking is one of the best things you can do for your health and the health of your baby.  If you quit smoking, you will protect your baby from SIDS and reduce the dangers of secondhand smoke.

 

How to Help your Patient Overcome Challenges and Barriers in the Cessation Process

Challenges and Barriers

Strategies to suggest to patients

Negative Moods

  • Engage in physical activity
  • Take 10 slow deep breaths
  • Talk with a friend
  • Remind yourself that you are a non-smoker

Being around other smokers

  • Spend more time with friends who do not smoke
  • Ask others not to smoke around you
  • Enforce a “smoke free” zone in your house
  • Remove yourself from the presence of smokers when you feel like smoking

Triggers

  • Identity and anticipate situations which produce cravings
  • Change your routine, for instance brush your teeth or take a walk immediately after waking or eating
  • Participate in distracting activities

Time pressures

  • Reduce stress by changing your behavior or lifestyle

Table Abstracted from: Smoking Cessation During Pregnancy: A Clinician’s Guide to Help Patients Quit Smoking9

Pharmacotherapy During Pregnancy

The United States Public Health Service Guidelines state that behavioral interventions should always be the first line of treatment for pregnant smokers.7

There are health concerns about the use of pharmacotherapy during pregnancy. It is also not clear if pharmacotherapy is effective during pregnancy.  Use of nicotine replacement therapies result in nicotine passing into breast milk.10 The highest dose of the nicotine patch (21 mg) results in the equivalent of 17 cigarettes in breast milk.11

Pharmacotherapy is a good option for post-partum women who are not lactating and for whom behavioral interventions have not worked.10

Teachable Moments During Pregnancyy12

1st Trimester12

Opportunities

Points to Reinforce

  • Informing the woman of a positive pregnancy test result
  • During each prenatal visit
  • During an ultrasound test
  • While reviewing her medical and social history
  • It’s never too late to quit.
  • All pregnancies are different.  Have a healthy baby or a baby that appears to be healthy despite smoking in the past, does not guarantee the same each time.
  • Even smoking a small number of cigarettes is associated with a low birth weight.
  • Smoking increases the risk of miscarriage.

 

2nd Trimester12

Opportunities

Points to Reinforce

  • Hearing the baby’s heartbeat for the first time
  • During an ultrasound test
  • During each prenatal visit and when checking for signs of intrauterine growth
  • During nutritional counseling
  • Reinforce the points discussed during the 1st trimester.
  • She may feel better now and can make an attempt to quit.
  • Smoking decreases the amount of blood, oxygen, and nutrients flowing to the baby, affecting its growth.

 

3rd Trimester12

Opportunities

Points to Reinforce

  • During each prenatal visit and when checking for signs of intrauterine growth
  • Childbirth classes
  • Hospital tour
  • Labor and delivery
  • Reinforce the points discussed during the 1st and 2nd trimesters.
  • Rapid growth of the baby makes this another beneficial time to quit.
  • The harmful effects of secondhand smoke for the baby are significant.
  • If she was able to quit smoking during pregnancy, she should be able to maintain this change after pregnancy.

 

Post-partum12

Opportunities

Points to Reinforce

  • At the hospital (after delivery)
  • Any telephone contacts
  • During the post-partum exam
  • Well-baby visits
  • Family planning appointments
  • Child immunizations
  • Parenting appointments

 

Please see our “Pediatrician” page for more information on working with parents of babies and young children

If the woman was able to quit during pregnancy:

  • Praise her ability to remain smoke-free during pregnancy.
  • Emphasize the importance of staying quit for her baby, other children in the house, and herself.

If she was able to cut down during pregnancy:

  • Encourage her to try and quit completely.
  • Pharmacotherapy may be recommended to help her quit completely.

If the woman still smokes:

  • Continue to provide her with smoking cessation counseling.
  • Counsel her not to smoke around the baby.
  • Pharmacotherapy may be recommended to help her quit.

 

Recommendations for Obstetricians and Gynecologists13

Newly pregnant women may be quitting for the baby and not themselves.  It is important to assist these women in the cessation process.

There are several steps obstetricians and gynecologists can take to assist patients with smoking cessation.

  • Emphasize cessation to women who are considering pregnancy to help maximize the protection of the infant from the harmful effects of smoking and help increase the patient’s motivation to quit for her own health along with the health of the baby.
  • Reach out to the expecting mothers as early in the pregnancy to promote smoking cessation.
  • Provide access to smoking cessation resources and medical care for all pregnant women.
  • Offer intervention methods for women who continue to smoke throughout the pregnancy which enforce helpful behaviors including, smoking reduction, abstinence during critical periods of the pregnancy, and encouraging vitamins and exercise.
  • Talk with the women’s partner about smoking cessation. Regardless of smoking status, the partner can be considered a major risk factor for the women’s behaviors and should be included in the interventions offered. 
  • Use the 5A's to help pregnant women quit smoking.

Resources

American College of Obstetricians and Gynecologists provides smoking cessation resources for patients and providers.

The State of Maryland's DHMH offers this easy to use toolkit for smoking and pregnancy, available here.  

Smokefree Women provides information on smoking cessation specifically targeted to women.

 

Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? MDQuit has an online training to teach you the strategies that can be utilized with all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ and entering the training code, "medicaid". 

 
References: 

References

  1. AHRQ (2014). Smoking Cessation Interventions in Pregnancy and Postpartum Care. Evidence Report/Technology Assessment Number 214. Retrieved from http://effectivehealthcare.ahrq.gov/ehc/products/517/1871/smoking-pregnancy-infants-report-140226.pdf
  2. Gadomski, A., Adams, L., Tallman, N., Krupa, N. & Jenkins, P. Effectiveness of a Combined Prenatal and Postpartum Smoking Cessation Program. Journal of Maternal & Child Health, 15:188–197 DOI 10.1007/s10995-010-0568-9

  3. Centers for Disease Control. (2004). Highlights: Smoking among adults in the United States: Reproductive health. Retrieved September 20, 2012 from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/highlights/reproductive/index.htm
  4. United States Department of Health and Human Services. (2004). The health consequences of smoking: A report of the surgeon general. Retrieved September 20, 2012 from http://www.cdc.gov/tobacco/data_statistics/sgr/2004/pdfs/chapter5.pdf
  5. U.S. Department of Health and Human Services (n.d.).Prescription for Quitting. Retrieved from: http://women.smokefree.gov/smokefree-mom/prescription-for-quitting.aspx
  6. Health Canada. Risks of smoking. Retrieved September 25, 2012 from http://www.healthycanadians.gc.ca/init/quit-cesser/risks-risques-eng.php
  7. Fiore, M.C., Bailey, W.C., & Cohen, S.J. (2000). Treating tobacco use and dependence: Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
  8. Society of Obstetricians and Gynecologists of Canada. Clinical Practice Guidelines. (1998). Healthy beginnings: Guidelines for care during pregnancy and childbirth. Journal of Obstetrics and Gynecology Canada, 20: 52-58.
  9. Smoking Cessation During Pregnancy: A Clinician’s Guide to Help Patients Quit Smoking (2011) Retrieved September 25, 2012 from http://www.acog.org/~/media/Departments/Tobacco%20Alcohol%20and%20Substance%20Abuse/SCDP.pdf?dmc=1&ts=20120925T1305085153
  10. University of North Carolina Center for Maternal and Infant Health. (2012). Smoking cessation: An essential women’s health intervention. Retrieved September 25, 2012 from http://YouQuitTwoQuit.com
  11. National Institutes of Health. (2011). Nicotine. LACTMED: Drug and Lactation Database.
  12. North Carolina Division of Public Health. (2008). A guide for counseling women who smoke. Retrieved from http://whb.ncpublichealth.com/provpart/pubmanbro.htm 
  13. American College of Obstetricians and Gynegologists (2011). Smoking Cessation During Pregnancy A Clinician’s Guide to Helping Pregnant Women Quit Smoking. Retrieved from: https://www.acog.org