British Medical Bulletin, 2015, 114:135–146
doi: 10.1093/bmb/ldv016
Advance Access Publication Date: 29 April 2015
A critical review of smoking, cessation, relapse
and emerging research in pregnancy and
post-partum
Clare Meernik* and Adam O. Goldstein
Tobacco Prevention and Evaluation Program, Department of Family Medicine, School of Medicine,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
*Correspondence address. Tobacco Prevention and Evaluation Program, Department of Family Medicine, School of Medicine,
University of North Carolina at Chapel Hill, CB 7595, 590 Manning Drive, Chapel Hill, NC 27599, USA. E-mail: cmeernik@email.
unc.edu
Accepted 17 March 2015
Abstract
Introduction: Smoking during pregnancy causes adverse health outcomes.
Though the prevalence of smoking among pregnant women has declined,
postpartum relapse rates remain high and smoking-related maternal, fetal
and infant morbidity and mortality remains a public health burden.
Sources of data: A comprehensive literature search on smoking in pregnancy was conducted to provide a practical review for health professionals.
Areas of agreement: Psychosocial support is an effective evidence-based
treatment for pregnant women. Bio-psycho-socio factors that influence likelihood of quitting and remaining quit should be addressed.
Areas of controversy: Electronic cigarettes are marketed as a harm reduction
tool, but research on safety and effectiveness are lacking for pregnant women.
Growing points: The safety and efficacy of pharmacotherapy for use among
pregnant women remains unclear. Clinicians should increase discussions
regarding all resources for tobacco use treatment and secondhand smoke
(SHS) exposure during pregnancy and postpartum and offer psychosocial
support to all pregnant women.
Areas timely for developing research: Research on developing stronger
tobacco control policies in low- and middle-income countries, increasing cessation and relapse prevention among pregnant smokers with mental health conditions and increasing the impact of evidence-based supports, such as the quitline,
among pregnant women can decrease consumption of tobacco in pregnancy.
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]
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C. Meernik and A.O. Goldstein, 2015, Vol. 114
Key words: smoking, tobacco, pregnancy, postpartum period, smoking cessation
Introduction
Results
The US Surgeon General reported evidence of health
effects of smoking during pregnancy in 1969, including associations with spontaneous abortion, stillbirth and neonatal death.1 Forty-five years later, the
2014 Surgeon General’s report provides evidence
suggesting a causal relationship not only with spontaneous abortion but also preterm delivery, fetal
growth restriction, placenta previa, placental abruption, ectopic pregnancy, sudden infant death syndrome (SIDS) and congenital anomalies.1 Prenatal
smoking accounts for 5–8% of preterm deliveries,
13–19% of low-birth-weight deliveries, 23–34% of
SIDS and 5–7% of preterm-related deaths in the
USA.2 Maternal smoking during and after pregnancy
is also associated with adverse effects on neurocognitive development of infants and children and may
lead to neurobehavioral disorders later in childhood,
such as attention-deficit hyperactivity disorder
(ADHD).1 Even with the extensive and growing
knowledge of the health effects associated with
smoking during and after pregnancy, smokingrelated maternal, fetal and infant morbidity and
mortality remains a public health burden throughout
the world.
Extent of problem
Methods
This article reviews current epidemiology on smoking
in pregnancy, smoking cessation, evidenced-based
guidelines, areas of controversy and needs for new
research. We conducted a comprehensive search of
the literature on smoking in pregnancy using
PubMed, Web of Science, the Cochrane Collaboration Database, Scopus and Google Scholar and
references of retrieved papers with the intention of
providing a practical review for clinicians and other
health professionals. Articles published in English
from 2005 to January 2015 were included, emphasizing findings from systematic reviews, randomized
controlled trials and clinical guidelines.
As awareness of the health effects of cigarette
smoking during pregnancy has risen over the past
decades, the prevalence of tobacco use among pregnant women has declined in high-income countries
such as the USA (Fig. 1).3,4 While the prevalence of
smoking in the USA during the 3 months before
pregnancy has not changed since 2000 (∼23%),
statistically significant decreases in the prevalence
of smoking during the last 3 months of pregnancy
(from 13.3 to 12.3%; P = 0.04) and 4 months after
delivery (from 18.6 to 17.2%; P < 0.01) have occurred, resulting from continued declines in smoking
initiation rates and increased efficacy of tobacco use
cessation and prevention during and after pregnancy.3,5 Many other high-income countries report
similar declining rates of smoking during pregnancy over the past 20 years, including Canada
and Australia.3,6
However, certain populations still have disproportionately high prenatal and postnatal smoking
rates. For instance, women in the USA enrolled in
Medicaid—who are more likely to be of lower socioeconomic status and have lower education levels7—
have the highest smoking prevalence before (34.4%),
during (17.6%) and after pregnancy (24.3%) compared with women covered by other insurance.5 Also
of concern, smoking rates among pregnant women
are increasing in countries where the tobacco industry has targeted women for market growth, such as
Japan, which has seen a doubling of smoking rates
during pregnancy over a period of 10 years.3
Declines in maternal smoking observed in many
countries are due to effective population tobacco
control policies, such as media campaigns and tax
increases.5 However, to attain the reductions in
smoking rates during pregnancy targeted by
national agendas such as Healthy People 2020 in
the USA and England’s Healthy Lives, Healthy
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Smoking in pregnancy, 2015, Vol. 114
Fig. 1 Prevalence of tobacco use among pregnant women in the USA, 1990–2013. Percentage of live births in which mothers
reported tobacco use during pregnancy in the USA excludes mothers with an unknown smoking status. The tobacco use
question on the 2003 Revision of the US Standard Certificate of Live Birth was modified from the 1989 Revision to indicate
smoking status by trimester rather than reporting tobacco use as ‘Yes/No’ during pregnancy, resulting in a lack of
comparability between data based on the 2003 and 1989 revisions. 1990–2006 prevalence is based on data from states using
the 1989 Revision of the US Certificate of Live Birth. 2007–2013 prevalence is based on data from states using the 2003
Revision of the US Certificate of Live Birth.4
People, improvements in tobacco use interventions
at the clinical level are needed to complement
population-level measures.8,9 Population- and clinicbased studies report quit rates during pregnancy
ranging from 4 to 70% in developed countries, but
roughly half of those women return to smoking a
few months after delivery, and up to 90% relapse
after 1 year.5,10,11 These data stress the need for
improved relapse prevention efforts, including the
importance of covering costs of evidence-based
treatment for disparate populations.5 Implementing
more comprehensive tobacco use treatment coverage
for pregnant women across the world is critical, such
as policies requiring the provision of tobacco cessation counseling and medication without cost sharing
as required by the Affordable Care Act in the USA
for women with Medicaid and NHS Stop Smoking
Service coverage in the UK offering free behavioral
support and smoking cessation prescription medication during pregnancy and for 12 months after
delivery1,5,12,13
Health effects on mother and offspring
Though the adverse health consequences of smoking
during pregnancy have been documented for over 50
years, knowledge continues to accumulate on the
associations between smoking in pregnancy and
reproductive health outcomes for mother and infant
and neurobehavioral disorders in childhood.1 Evidence suggests causal relationships between maternal
prenatal smoking and outcomes such as congenital
malformations (e.g. atrial septal heart defects), ectopic
pregnancy, spontaneous abortion and behavioral
disorders in children (e.g. ADHD).1 Positive associations have also been established between maternal
smoking during pregnancy and other birth outcomes
such as clubfoot and musculoskeletal, facial, eye and
gastrointestinal defects.14
Adverse health outcomes can also be caused by
SHS. Any fetal smoke exposure during the prenatal
period can result in spontaneous abortion, low birth
weight, congenital malformations and infant death.15
Further, postnatal SHS can result in SIDS, lower
138
respiratory illness, impaired respiratory function,
middle ear diseases, impaired cognitive development
and growth and childhood cancer.1,15 Given these
potential consequences from SHS, clinicians should
identify any source of smoke exposure to the child,
including mothers living with a partner who smokes—
an important risk factor that helps identify women
who may need more support in quitting because of
their social environment.16
Epigenetic mechanisms are now thought to underlie many of these adverse health outcomes on fetal
growth and development. Recent studies report atypical DNA methylation patterns during embryonic
development in critical tissues (e.g. the placenta and
the brain) associated with primary and SHS exposure
during pregnancy, which may have long-term cognitive, behavioral and other health consequences on
the fetus and into adolescence.17 Cigarette smoke
exposure can also affect fetal lung development
and immune function through epigenetic pathways,
increasing the risk of asthma and respiratory disease
in childhood.18 Further research on DNA methylation and other epigenetic mechanisms such as altered
microRNA expression is ongoing to better understand the pathways underlying smoking-related fetal
and child health outcomes.17
Promoting smoking cessation to pregnant women
is critical not only for the health of the mother and
child but also because of the potential impact that
smoking during and after pregnancy may have on
future nicotine dependence in offspring. Compared
with young adults whose mothers never smoked,
those with mothers who smoked during pregnancy
are more likely to be regular smokers and start
smoking before the age of 14.19 Other studies have
reported similar findings on maternal prenatal
smoking as a risk factor for nicotine dependence and
heavy smoking in adolescent offspring, though some
only report such effects for females.20,21 Possible
causal pathways between prenatal and postnatal
tobacco exposure and later nicotine dependence are
complex and are still being elucidated, including the
effects of social patterning and the disruption of
neural pathways during development that can lead
to nicotine sensitivity and susceptibility to smoking later in life.20 Clinicians should inform their
C. Meernik and A.O. Goldstein, 2015, Vol. 114
pregnant patients about all short- and long-term
health outcomes of smoke exposure during and after
pregnancy to further emphasize the importance
of smoking cessation for both themselves and their
children.
Guidelines for tobacco use treatment
in pregnancy
The WHO provides recent international recommendations on reducing tobacco use and SHS exposure
in pregnancy.16 These guidelines recommend that
healthcare providers identify tobacco use and SHS
exposure during and after pregnancy and offer psychosocial interventions to encourage cessation and
prevent relapse. Recommendations for pharmacological interventions either cannot be made [i.e. for
nicotine replacement therapy (NRT)] or are not
recommended (i.e. for bupropion and varenicline).16
All healthcare facilities, work and public places
should be smoke-free to limit SHS exposure during
pregnancy, and healthcare providers should engage
partners and other household members to encourage
smoke-free homes.16 National clinical practice guidelines in the UK and the USA correspond to the WHO
recommendations: health professionals should identify pregnant women who smoke and offer psychosocial interventions beyond minimal advice early
and often during pregnancy; tobacco dependence
medication is not recommended during pregnancy
for lack of observed efficacy and safety concerns.22,23
The American College of Obstetricians and Gynecologists (ACOG) specifically encourages healthcare providers to utilize the 5A’s intervention (Ask, Advise, Assess,
Assist and Arrange) to support smoking cessation
during pregnancy.23
Factors influencing smoking behavior
in pregnancy
Women with certain risk factors are more likely to
smoke before, during and after pregnancy. Women
from disparate populations (e.g. women with low
socioeconomic status, Medicaid insurance and
mental health conditions) and women who are
younger, underweight, unmarried, first-time mothers
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Smoking in pregnancy, 2015, Vol. 114
and have an unintended pregnancy and initiate prenatal care later are more likely to smoke during pregnancy and relapse postpartum.1,24 It is important for
clinicians to recognize these risk factors in their pregnant patients and be cognizant that these women
may need more intensive cessation support as they
will likely experience more difficulty in quitting and
remaining quit.
Given the multiple domains influencing a mother’s
ability to quit smoking, growing evidence supports
the use of a more inclusive framework, such as the
bio-psycho-socio model, to encourage smoking cessation during pregnancy and prevent postpartum
relapse.25 Psychological wellbeing, relationships with
others, the changing connection between the mother
and the baby over time and the risks of smoking can
act as both barriers and facilitators to cessation
during pregnancy and postpartum.26 Specific factors
associated with a lower likelihood of quitting during
pregnancy include a low social status (i.e. low level of
education and/or low income), high nicotine dependence, smoking as a form of stress management and
living with another smoker or having a smoking
partner.10,11 Similarly, postpartum relapse is associated with factors such as easy accessibility to cigarettes, lack of financial and social support, limited
stress management skills, low confidence and selfefficacy, no long-term intention to quit and the presence of other smokers in the household.25,27 Smoking
status at delivery is the best predictor of later smoking
status, emphasizing the need for integrated prenatal
and postnatal tobacco use treatment.27
Clinicians can focus on cessation and relapse prevention interventions, such as case management,
early in pregnancy and continue interventions into
the postpartum period. These services address physical, mental, behavioral and social contexts influencing a mother’s likelihood of quitting and remaining
quit, including the development of practical skills to
manage challenges of childrearing.25 The utilization
of a risk assessment tool by clinicians to identify
high-risk women (e.g. women intending to remain
smoke-free only during pregnancy or living with
another smoker) would allow for more effective
treatment interventions that help sustain behavior
change long term by emphasizing concrete actions
and skill development (e.g. encouraging a smoke-free
home and enhancing self-efficacy) rather than relying
solely on motivation related to fetal health, which
may dissipate after delivery.6,25 More research is needed
on longer-term efficacy of integrated cessation and
relapse prevention methods tailored according to
maternal risk factors, including the evaluation of
optimal timing and duration of interventions during
pregnancy and after delivery.
Psychosocial support
A recent Cochrane systematic review of randomized
controlled trials (RCTs) on smoking abstinence in
late pregnancy provides evidence that psychosocial
support is an effective cessation treatment strategy
for women during pregnancy, improving fetal health
outcomes without physical or psychological effects
on the mother (Table 1).28 Counseling and peer
support during pregnancy increased cessation rates
by 35–50% compared with less intensive interventions, but evidence is limited on which type of specific counseling strategy is most effective.28 For
instance, the efficacy of telephone counseling (i.e.
quitlines) for prenatal smoking cessation and preventing postpartum relapse is unclear, especially for
heavy smokers and women with low motivation to
quit,29 though some national advocacy groups still
recommend clinicians refer patients to a quitline for
adjunct cessation counseling.23
The largest smoking cessation effect sizes are seen
for incentive-based interventions offered during pregnancy, increasing quit rates several fold, though these
results are based on only two studies and require
further evaluation.28 Findings indicate that health
education and advice alone are insufficient, emphasizing that psychosocial support should include multiple
components to most effectively assist pregnant
women in quit attempts, including counseling, incentives, feedback and social support.28 Notably, pooled
results from 14 studies demonstrate that psychosocial
interventions reduced preterm births and infants born
with low-birth weight by 18%,28 indicating that
behavioral support for smoking cessation can not
only reduce prenatal smoking rates but can also have
a substantial benefit on birth outcomes.
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C. Meernik and A.O. Goldstein, 2015, Vol. 114
Table 1 Effectiveness of smoking cessation and relapse prevention interventions during and after pregnancy
Type of intervention
Smoking cessation during pregnancy28
Counseling
Incentive-based and social support
Incentive-based contingent on smoking status
Feedback and other strategies
Health education
Peer support
Partner support
NRT30
Relapse prevention during pregnancy28
Counseling
Health education
Social support
Timing of relapse prevention31
During pregnancy
During pregnancy and continued postpartum
Postpartum
Comparison
No. of studies
Effectiveness
Usual care
Less intensive
Less intensive
Not contingent on smoking status
Usual care
Less intensive
Usual care
Less intensive
Less intensive
Less intensive
Placebo-controlled
Non-placebo-controlled
27
16
1
1
2
2
3
2
5
1
4
2
+
+
++
++
++
NS
NS
NS
+
NS
NS
++
Usual care
Less intensive
Usual care
Less intensive
8
4
1
1
NS
NS
NS
NS
5
4
4
NS
NS
NS
+: lower bound 95% confidence interval ≥1.0; ++: lower bound of 95% confidence interval ≥1.4; NS: not significant at 95% confidence level.
Relapse prevention interventions
More effective interventions, especially those integrating prenatal and postpartum behavioral support
interventions at clinical visits during and after
pregnancy, are necessary to lower high postpartum
relapse rates. Comprehensive Cochrane reviews report
that psychosocial interventions to prevent relapse for
women who quit smoking during pregnancy demonstrate no significant effects (Table 1).28 There is also
no clear evidence regarding intervention timing—
either during pregnancy or postpartum—to draw
conclusions about the optimal initiation period for
relapse prevention treatment.31
The lack of efficacy evidence for existing relapse
prevention interventions is concerning not only for
the long-term health of the mother but also the infant;
nicotine exposure via breast milk and SHS places infants at risk for adverse health consequences, including
developmental problems and severe asthma attacks.32
A review on relapse prevention interventions in the
postpartum period revealed no consistent treatment
effects on maintained long-term cessation, though
many interventions, such as pharmacological and
behavioral support, increased quit rates during pregnancy and early postpartum.33
Programs offering behavioral strategies in combination with incentives appear to have the most
potential to reduce long-term postpartum relapse.33
The BABY & ME—Tobacco Free program provides
a successful model of a continuing care approach,
offering prenatal and postnatal counseling and biomarker feedback with incentives (i.e. diaper vouchers) contingent on smoking status for 1 year after
delivery; women receiving counseling from a certified
tobacco cessation specialist achieved a prenatal quit
rate of 97%, with 44% remaining abstinent 1-year
postpartum, significantly higher than smoking cessation rates reported by population-based surveillance
systems.5,34 Similar findings from six controlled
Smoking in pregnancy, 2015, Vol. 114
trials support the use of financial incentives among
economically disadvantaged women as an aid for
abstinence, and three of those trials found positive
fetal health outcomes, including increased fetal
growth and fewer low-birth-weight births.35 Further,
the National Institute for Health and Clinical Excellence estimated incentive-based interventions provide
a net benefit of $3482, the highest net cost benefit
when compared with other inventions, including cognitive behavioral strategies, feedback and
pharmacotherapy. 36
Emerging evidence supports the use of incentivebased interventions in terms of efficacy, safety and
cost-effectiveness. Future research should examine
optimal implementation of incentive-based interventions to identify for which populations they are
most effective, what form of incentive should be
used, how often it should be delivered and the challenges associated with relapse once the incentive is
removed. Regardless of the particular intervention, a
flexible continuing care model should be increasingly
utilized to follow women from pregnancy through
postpartum and offer ongoing support for the heightened challenges and stressors experienced after
delivery.32
Developing research and pharmacotherapy
Though cessation pharmacotherapy is recommended
as safe and effective in the general population, evidence is lacking on the use of pharmacotherapy
during pregnancy.7 International and national clinical guidelines refrain from making recommendations on the use of NRT and advise against the use of
varenicline and bupropion, supporting the use of
NRT during pregnancy under the guidance of a
healthcare professional only after behavioral support
has proven ineffective—though debate remains on
the optimal form of NRT to be given, with some
recommending an intermittent form (e.g. gum) or
using a 16-h rather than a 24-h patch to minimize
potential harm to the fetus from constant nicotine
exposure.6,7,16,22
The lack of clear evidence stems from limited
research conducted in this population of smokers.
A Cochrane review identified only six studies on
141
pharmacotherapy in pregnancy eligible for inclusion
(i.e. RCTs that allow independent effects of any
pharmacotherapy to be examined), with all six
testing NRT and none investigating varenicline or
bupropion.30 Pooled results provide insufficient evidence on the efficacy of NRT for smoking cessation
in pregnancy or the effects on birth outcomes (i.e.
miscarriage, stillbirth, preterm birth, low-birthweight births, NICU admissions or neonatal
deaths).30 It is important to note that non-placebo
RCTs tended to overestimate the efficacy of NRT
compared with placebo RCTs (Table 1), emphasizing the need for future research using placebo-RCTs
to limit bias when investigating pharmacological use
during pregnancy.30
The examination of higher doses of NRT and
combination NRT is particularly important, as the
increased metabolism of nicotine during pregnancy
may result in underdosing and reduced efficacy of
NRT in pregnant smokers compared with the
general population.16 Use of combination NRT (i.e.
nicotine patch plus a faster acting form such as gum,
lozenge or inhaler) in pregnant smokers was recently
associated with a higher odds of quitting compared
with no medication in an observational study, highlighting an area for further examination in future
RCTs.37 Clinical trials are currently underway in
various countries to examine the efficacy and/or
safety of different pharmacologic agents during pregnancy, including a prospective population-based
cohort study on varenicline and placebo-controlled
trials on bupropion and NRT.38 It will be important
for future studies to identify barriers to medication
use during pregnancy and examine hypotheses for
the observed lack of efficacy of NRT in pregnant
women relative to the general population. Factors
such as non-adherence, level of nicotine dependence
and inadequate dosing of NRT need further exploration to better understand the effectiveness or lack
thereof of NRT in pregnant women. Though making
a quit attempt using NRT limits exposure to thousands of toxicants found in cigarettes, nicotine is
thought to mediate many of the adverse reproductive
and developmental outcomes caused by smoking
cigarettes, and prenatal nicotine exposure may lead
to increased risk for nicotine dependence in the
142
offspring later in life.1,20 Clinicians, therefore,
should discuss all risks associated with NRT use in
relation to the risks of continued smoking throughout pregnancy with their patients.
Discussion of tobacco use treatment
in clinics
The first priority of tobacco use interventions for
pregnant women is to identify which women are in
need of treatment, a task hindered by the high rate of
nondisclosure of smoking status among pregnant
women—estimated at 23–25% from populationbased samples in the USA and Scotland, compared
with a 9% nondisclosure rate among non-pregnant
women.39 The true burden of smoking among pregnant women is likely underestimated, especially for
women 20–24 years old who have a substantially
higher nondisclosure rate (estimated at 77% in the
USA), resulting in many women not being offered
tobacco use treatment while pregnant.39 Based on
factors associated with nondisclosure of smoking
status in the general population (e.g. younger, have
less than a high school education, experience smokingrelated stigma and discomfort in discussing smoking
with a clinician),40 it is likely that many of the
women not being identified as smokers by clinicians
are higher-risk women. The clinical significance of
this issue suggests the need for practitioners to
develop skills to have more open discussions about
tobacco use with their pregnant patients, especially
younger women and those with lower education
levels.
Recent reports on the levels of discussion and
implementation of tobacco use treatment during prenatal and postnatal visits are underwhelming.
Though pregnant women who smoke are identified at
most physician visits, less than one in four of these
women receive counseling at those visits.7 The 5A’s
best practice counseling intervention recommended
by ACOG—with the first step to ‘Ask’ about smoking
status—was fully implemented by only one-third of
prenatal care providers in North Carolina, a state
with a relatively high maternal smoking rate.41 Similarly, only 30% of pregnant smokers enrolled in a telephone counseling cessation trial reported discussing
C. Meernik and A.O. Goldstein, 2015, Vol. 114
pharmacotherapy with their obstetrician-gynecologist
(ob-gyn) during or after pregnancy.42 After identifying pregnant patients who smoke, clinicians should
offer psychosocial support, followed by discussion of
NRT as a treatment option for patients experiencing
difficulty quitting, especially among women who are
heavy smokers and may benefit from the use of NRT
under close clinical guidance. It is also important for
clinicians to be aware of any changes in health insurance coverage that may affect the availability of
tobacco use treatment for their pregnant patients,
such as the Affordable Care Act in the USA mandating the coverage of tobacco cessation counseling and
medication without cost sharing for pregnant women
enrolled in Medicaid.5,12 Heightened awareness of
insurance coverage can help facilitate discussion of
affordable tobacco use treatment with patients. Given
the association between maternal smoking during pregnancy and susceptibility to future nicotine dependence in offspring,19–21 it is imperative to offer evidencebased smoking cessation both during and after
pregnancy to ensure the short- and long-term health
of women and their children.
Tobacco use among disparate populations
Prioritizing tobacco use treatment for disparate
populations that are at a higher risk for tobacco use
and tobacco-related disease, such as women with
mental illness, is particularly important. In a crosssectional study across 15 European countries, roughly
one-third of pregnant women reported depression,
with those women half as likely to quit smoking
during pregnancy as women not reporting depression.43 Higher prevalence of continued smoking during pregnancy among these women may stem from
concerns expressed by health professionals that delivering tobacco use treatment to women with mental
illness may adversely affect women’s psychological
wellbeing; however, recent studies have proven
otherwise and support the use of psychosocial interventions during pregnancy for this population.28
Behavioral support for pregnant women is an effective
evidence-based treatment, but additional research,
including studies that focus on improving psychological wellbeing as a means of smoking cessation, is
143
Smoking in pregnancy, 2015, Vol. 114
needed to further establish efficacy in pregnant
women with mental illness.22,28
The WHO has expressed concern regarding the
rising use of tobacco among young females in lowincome, high-population countries—a growing epidemic with the potential to cause alarming levels of
tobacco-related disease and death in the coming decades
as the tobacco industry taps into this new market of
consumers.44 Though rates of smoking and other
tobacco use among women in low- and middleincome countries (LMICs) are still relatively low—
with prevalence of any tobacco use among pregnant
women ranging from 0 to 15% (Fig. 2)45—social
and cultural factors may influence increasing use
among pregnant women as overall prevalence
rises.46 For instance, the use of tobacco products is
perceived as beneficial among some pregnant women
in India to relieve morning sickness and control
labor pains.46 Misconceptions surrounding tobacco
use in LMICs call for tobacco prevention and control
programs emphasizing education to increase knowledge
of tobacco-related harms, especially among pregnant
women. To further combat exploitation of vulnerable
populations of women, population-based tobacco
control measures, such as marketing restrictions and
tax increases, should be enacted by governments in
LMICs, similar to policies implemented in developed
regions.44
Controversy and electronic cigarettes
The growing use of electronic nicotine delivery
systems (ENDS), such as electronic cigarettes (ecigarettes), in the general population has triggered
debate surrounding the safety of these products and
their efficacy as a cessation aid. E-cigarettes are
battery operated devices that heat a liquid, typically
consisting of propylene glycol and/or glycerol, into
an aerosol or vapor for inhalation and nicotine delivery.47 Though proponents market e-cigarettes as a
harm reduction tool, the WHO cautions pregnant
women about the use of ENDS due to potential consequences on fetal health and brain development.47
Nicotine has the ability to cross the placenta and is
regarded as a reproductive toxin that mediates the
effects of adverse health outcomes associated with
combustible tobacco, such as preterm delivery and
stillbirth.1
Though nicotine is known to have reproductive
health effects, belief that e-cigarettes may be a useful
Fig. 2 Prevalence of tobacco use among pregnant women in low- and middle-income countries by WHO Region. Data from the
most recent Demographic and Health Survey in every country, spanning 2003–2013.45
144
cessation aid remains, even among clinicians. Ob-gyns
across the USA report mixed opinions and practices
surrounding e-cigarettes.48 For instance, 29% of respondents reported that e-cigarettes adversely affect health
during pregnancy but are safer than cigarettes, whereas
14% reported that e-cigarettes do not adversely affect
health and 37% were unsure of the health effects.48
As only 5% of ob-gyns considered themselves fully
informed regarding noncombustible tobacco products,48 it should be a priority to determine the potential health effects of e-cigarettes during pregnancy.
While recent evidence from two RCTs in the general
population comparing e-cigarettes with placebo
e-cigarettes containing no nicotine determined that
e-cigarettes may assist smokers in quitting, the
quality of these results was considered ‘low’ by GRADE
standards due to small sample sizes.49 Given the
paucity of evidence regarding the efficacy of e-cigarettes
as a cessation aid—especially for pregnant women—
and still undetermined long-term effects of inhalation
of toxicants in this vaporized form,47 clinicians should
refrain from recommending the use of these devices
during pregnancy. Psychosocial support should be the
first line of treatment offered, followed by NRT under
close clinical guidance if needed.
C. Meernik and A.O. Goldstein, 2015, Vol. 114
2.
3.
4.
5.
6.
7.
8.
Conclusions
Though rates of smoking among pregnant women
are declining in high-income countries, tobacco use
treatment during pregnancy remains a public health
priority due to the adverse effect of smoking on
maternal, fetal and child health and the rising use of
tobacco among women in low- and middle-income
countries. Psychosocial cessation treatment should
be offered to all women during and after pregnancy,
with support tailored according to bio-psycho-socio
risk factors. Placebo-controlled trials are needed to
determine the safety and efficacy of pharmacotherapy
and alternative tobacco products, such as e-cigarettes,
during pregnancy.
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