OB/GYN

Smoking and Pregnancy

Smoking during pregnancy is an important issue for obstetricians and gynecologists to address. 

• In 2020, 5.5% of all births were to women who reported smoking cigarettes at any time during pregnancy.¹³ 
• Women in certain demographic cohorts are more likely to smoke during pregnancy (Highest among women with a high school education or less¹⁴ and occupants of rural counties as compared to metropolitan areas.¹³) 
• Approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy. ¹ 
• Smoking during pregnancy is more common in the first trimester       than the second or third.¹⁴ 
• Smoking cessation at any point in gestation benefits the pregnant woman and her fetus. The greatest benefit is observed with     cessation before 15 weeks of gestation. ¹  
• An estimated 5–8% of preterm deliveries, 13–19% of term infants with low birth weight, 22–34% cases of sudden infant death syndrome, and 5–7% of preterm-related infant deaths have been attributed to prenatal maternal smoking. ¹ 
• Approximately 50–60% of women who quit smoking during pregnancy return to smoking within 1 year postpartum. ¹ 

• Maternal health effects 
• Health effects on fetus & child 
• Issues specific to pregnant women 
• Addressing smoking myths with pregnant patients  
• Overcoming cessation challenges 
• Pharmacotherapy 
• Teachable moments, and 
• Recommendations for obstetricians and gynecologists 

Maternal Health Effects^1,4

• Lessened amounts of oxygen and nutrients in the fetus 
• Fetal growth restriction 
• Increased fetal heart rate 
• Chronic fetal anoxia (an extreme decrease in the amount of oxygen) 
• Premature birth 
• Low birth weight 
• Fetal artery constriction 
• Birth Defects of the lip and mouth 
• Perinatal death 
• Increased risks of SIDS 

• Respiratory infections  
• Asthma 
• Colic 
• Bone fractures 
• Childhood obesity  

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
• Because smoking continuation during pregnancy is associated with the likelihood of other substance use, screening for alcohol and other substance use is an important component of care.¹ 

Addressing Smoking Myths with Patients⁵

Below we share answers to common patient questions: 

Question: Why should I quit smoking during pregnancy?

Answer: Chemicals in tobacco smoke are passed from the mother to the fetus via 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 maximize risk reduction if they stop smoking by 15 weeks gestation.¹

Question: Can I use nicotine replacement therapies?

Answer: It is preferred to quit through counseling and behavioral modification. Trials studying the use of nicotine replacement therapy in pregnancy have been attempted, but many of those conducted in the United States have been stopped because of either adverse pregnancy effects or failure to demonstrate effectiveness. Use of nicotine replacement therapy should be considered only after a detailed discussion with the patient of the known risks of continued smoking, the possible risks of nicotine replacement therapy, and need for close supervision. ¹

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. ⁵

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. ⁵

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

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 Pregnancy¹²

1^st Trimester¹²

2^nd Trimester¹²

3^rd Trimester¹²

Post-partum¹²

Recommendations for Obstetricians and Gynecologists⁹ 

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

• 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 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(link is external) 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.