Tobacco Use in Pregnancy

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Tobacco remains the leading cause of preventable disease, disability, and death in the USA, despite overall decreasing rates of smoking!

  • 14% of US adults smoke cigarettes. This rate is lower in pregnancy, around 7.2%; however, young women are a high risk group for cigarette smoking compared to the general population.

  • Tobacco use in pregnancy specifically is linked to higher risk of:

    • Ectopic pregnancies

    • Cleft lip/palate

    • Fetal growth restriction and low birth weight (13-19% of term infants with tobacco exposures)

    • Placenta previa

    • Placental abruption

    • PPROM

    • Preterm delivery (5-8% attributable risk)

    • Increased perinatal mortality (5-7% attributable risk)

    • Increased risk of sudden infant death syndrome (22-34% attributable risk)

  • Tobacco use also has lifelong health implications!

    • Pregnancy can be a great motivator to quit smoking and make significant changes for lifelong health -- 54% of those who smoke during/pre-pregnancy will quit at least for pregnancy!

  • Data regarding e-cigarettes/vaping, cigars, and hookah are limited, though are also risky.

    • However, these may have somewhat different risks, though many (particularly hookah and vaping) are perceived to be safer -- they are not!

    • The CO 807 has a great table comparing amounts of nicotine in each varying method of consumption -- worth keeping handy when you’re looking to prescribe/suggest replacement therapy:

ACOG CO 807

How do I intervene as a clinician?

  • Ask!

    • Be sure to ask about alternative forms of nicotine consumption as well -- patients may not disclose vaping/hookah/etc. Use unless specifically asked. 

  • Use motivational interviewing techniques

    • Cognitive behavioral therapy and motivational interviewing are beneficial to initiate and sustain tobacco use cessation.

    • Even if not ready to quit, consistent motivational approaches may be beneficial over time.

  • You can use a tool, like the 5As:

    • Ask -- characterizing use at the same time

    • Advise -- if still using, provide advice about risks of continued use

    • Assess -- whether patient is willing to quit. This can be continued with motivational strategy at future visits if not ready at the first.

    • Assist -- if ready to quit, provide materials and options to help get the quit started. Suggest importance of having a tobacco-free space at home, seeking out a “quitting buddy,” and/or using a service like 1-800-QUIT-NOW to provide ongoing support.

    • Arrange -- continue follow up visits to track/encourage success 

  • 50-60% of those who quit smoking during pregnancy will resume within 1 year postpartum.

    • Keep up and continue to ask at future visits.

    • Encourage whole family to quit smoking as well to have family-motivated success.

Pharmacotherapy for tobacco cessation

  • If used during pregnancy, note data is limited for most methods. 

  • Nicotine replacement:

    • Provide a stable, controlled dose of nicotine in the form of gums, patches, or lozenges

      • Gums may provide some benefit psychologically due to oral fixation

    • Have not been demonstrated to be effective in pregnancy, unfortunately.

      • Any planned use should be with clear resolve of patient to quit in mind, as these methods still deliberately expose maternal-fetal dyad to nicotine and likely some continued form of risk.

  • Pharmacologic cessation agents

    • Varencicline (Chantix)

      • Dose pack to start therapy.

      • Partial agonist for nicotinic receptors in brain

      • Limited data in pregnancy, but that which exists does not demonstrate teratogenicity.

    • Bupropion (Wellbutrin)

      • Most studies have looked at a dose of 150mg BID for 7-12 weeks.

      • Antidepressant

      • Also limited data in pregnancy, but no known risk of fetal anomalies or adverse pregnancy outcomes.