Tobacco Use in Pregnancy
/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:
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.