REVIEW PAPER
Smoking cessation in pregnancy: An update for maternity care practitioners
 
More details
Hide details
1
School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
2
Department of Midwifery, University of West Attica, Athens, Greece
3
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
4
Center for Health Services Research, Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
5
1st Department of Respiratory Medicine, ‘Sotiria’ Chest Disease Hospital, Athens, Greece
6
Evgenidio Hospital, Athens, Greece
7
First ICU, Evangelismos Hospital, Athens, Greece
CORRESPONDING AUTHOR
Paraskevi A. Katsaounou   

First ICU, Evangelismos Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
Publish date: 2019-08-02
 
Tob. Induc. Dis. 2019;17(August):57
KEYWORDS
TOPICS
ABSTRACT
Introduction:
This paper provides an up-to-date summary of the effects of smoking in pregnancy as well as challenges and best practices for supporting smoking cessation in maternity care settings.

Methods:
We conducted a qualitative review of published peer reviewed and grey literature.

Results:
There is strong evidence of the effects of maternal tobacco use and secondhand smoke exposure on adverse pregnancy outcomes. Tobacco use is the leading preventable cause of miscarriage, stillbirth and neonatal deaths, and evidence has shown that health effects extend into childhood. Women who smoke should be supported with quitting as early as possible in pregnancy and there are benefits of quitting before the 15th week of pregnancy. There are a variety of factors that are associated with tobacco use in pregnancy (socioeconomic status, nicotine addiction, unsupportive partner, stress, mental health illness etc.). Clinical-trial evidence has found counseling, when delivered in sufficient intensity, significantly increases cessation rates among pregnant women. There is evidence that the use of nicotine replacement therapy (NRT) may increase cessation rates, and, relative to continued smoking, the use of NRT is considered safer than continued smoking. The majority of women who smoke during pregnancy will require support throughout their pregnancy, delivered either by a trained maternity care provider or via referral to a specialized hospital or community quit-smoking service. The 5As (Ask, Advise, Assess, Assist, Arrange) approach is recommended for organizing screening and treatment in maternity care settings. Additionally, supporting smoking cessation in the postpartum period should also be a priority as relapse rates are high.

Conclusions:
There have been several recent updates to clinical practice regarding the treatment of tobacco use in pregnancy. It is important for the latest guidance to be put into practice, in all maternity care settings, in order to decrease rates of smoking in pregnancy and improve pregnancy outcomes.

CONFLICTS OF INTEREST
The authors declare that they have no competing interests, financial or otherwise, related to the current work. S. Papadakis reports grants from Global Bridges (Pfizer Education and Change), outside the submitted work. The rest of the authors have also completed and submitted an ICMJE form for disclosure of potential conflicts of interest.
FUNDING
There was no source of funding for this research.
AUTHORS' CONTRIBUTIONS
Based on an initial review of the literature, A.D. and P.K. produced a first draft of the review paper. The manuscript was circulated among all the authors. Each author provided further comments and suggestions on the manuscript. An updated draft was produced by P.A.K. and S.P. The revised manuscript was then circulated to all authors for final comments and approval.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
REFERENCES (69)
1.
Coleman T, Chamberlain C, Davey M, Cooper SE, Leonardi-Bee J. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2015;(12):1-52. doi:10.1002/14651858.cd010078.pub2.
 
2.
Holbrook BD. The effects of nicotine on human fetal development. Birth Defects Res C Embryo Today. 2016;108(2):181-192. doi:10.1002/bdrc.21128.
 
3.
Vivilaki VG, Diamanti A, Tzeli M, et al. Exposure to active and passive smoking among Greek pregnant women. Tob Induc Dis. 2016;14(April). doi:10.1186/s12971-016-0077-8.
 
4.
World Health Organization. WHO recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy. https://www.who.int/tobacco/pu.... Published 2013. Accessed January 9, 2019.
 
5.
World Health Organization. Gender, Women, and the Tobacco Epidemic. World Health Organization; 2010: i-xii, 1-253. https://www.who.int/tobacco/pu.... Accessed January 9, 2019.
 
6.
Lange S, Probst C, Rehm J, Popova S. National, regional, and global prevalence of smoking during pregnancy in the general population: a systematic review and meta-analysis. Lancet Glob Health. 2018;6(7). doi:10.1016/S2214-109X(18)30223-7.
 
7.
Riaz M, Lewis S, Naughton F, Ussher M. Predictors of smoking cessation during pregnancy: a systematic review and meta-analysis. Addiction. 2018;113(4). doi:10.1111/add.14135.
 
8.
Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update: A U.S. Public Health Service report. Am J Prev Med. 2008;35(2):158-176. doi:10.1016/j.amepre.2008.04.009.
 
9.
Ebert L, van der Riet P, Fahy K. What do midwives need to understand/know about smoking in pregnancy? Women Birth. 2009;22(1):35-40. doi:10.1016/j.wombi.2008.11.001.
 
10.
Christie B. Smoke-free legislation in England has reduced stillbirths, neonatal mortality, and low birth weight. BMJ. 2015;351(August):h4469. doi:10.1136/bmj.h4469.
 
11.
The American College of Obstetricians and Gynecologists (ACOG) Comittee Opinion 2017. Smoking cessation during pregnancy. Obstet Gynecol. 2017;130(4):e200-e204. doi:10.1097/aog.0000000000002353.
 
12.
Behrakis PK, Vardavas CI, Papadakis SE, eds. TOB.g. Tobacco Cessation Guidelines for High Risk Populations. Vol 186. http://tob-g.eu/wp-content/upl.... Published 2017. Accessed January 9, 2019.
 
13.
McEwen A. Smoking Cessation: A briefing for midwifery staff. 2nd ed. National Centre for Smoking Cessation and Training; 2015. http://www.ncsct.co.uk/usr/pub.... Accessed January 9, 2019.
 
14.
Mendelsohn CP, Gould GS, Oncken C. Management of smoking in pregnant women. Aust Fam Physician. 2014;43(1). https://www.racgp.org.au/downl.... Accessed January 9, 2019.
 
15.
Horak F, Fazekas T, Zacharasiewicz A, et al. Das Fetale Tabaksyndrom - Ein Statement der Österreichischen Gesellschaften für Allgemein- und Familienmedizin (ÖGAM), Gynäkologie und Geburtshilfe (ÖGGG), Hygiene, Mikrobiologie und Präventivmedizin (ÖGHMP), Kinder- und Jugendheilkunde (ÖGKJ) sowie Pneumologie (ÖGP). Wien Klin Wochenschr. 2012;124(5-6):129-145. doi:10.1007/s00508-011-0106-9.
 
16.
Britton GR, Collier R, McKitrick S, et al. CE: Original Research: The Experiences of Pregnant Smokers and Their Providers. Am J Nurs. 2017;117(6):24-34. doi:10.1097/01.NAJ.0000520228.66868.ae.
 
17.
Aulinas A, Colom C, García Patterson A, et al. Smoking affects the oral glucose tolerance test profile and the relationship between glucose and HbA1c in gestational diabetes mellitus. Diabet Med. 2016;33(9):1240-1244. doi:10.1111/dme.12966.
 
18.
Hackshaw A, Rodeck C, Boniface S. Maternal smoking in pregnancy and birth defects: A systematic review based on 173 687 malformed cases and 11.7 million controls. Hum Reprod Update. 2011;17(5):589-604. doi:10.1093/humupd/dmr022.
 
19.
Fowler PA, Bhattacharya S, Flannigan S, Drake AJ, O’Shaughnessy PJ. Maternal cigarette smoking and effects on androgen action in male offspring: Unexpected effects on second-trimester anogenital distance. J Clin Endocrinol Metab. 2011;96(9):1502-1506. doi:10.1210/jc.2011-1100.
 
20.
Button T, Thapar A, McGuffin P. Relationship Between Antisocial Behaviour, Attention-Deficit Hyperactivity Disorder and Maternal Prenatal Smoking. Br J Psychiatry. 2005;187. doi:10.1192/bjp.187.2.155.
 
21.
Ekblad M, Lehtonen L, Korkeila J, Gissler M. Maternal smoking during pregnancy and the risk of psychiatric morbidity in singleton sibling pairs. Nicotine Tob Res. 2017;19(5):597-604. doi:10.1093/ntr/ntx001.
 
22.
Action on Smoking and Health. Secondhand Smoke: the impact on children. Research Report. http://ash.org.uk/wp-content/u.... Published March, 2014. Accessed January 9, 2019.
 
23.
Ferrence R. Passive Smoking and Children. BMJ. 2010;340:c1680. doi:10.1136/bmj.c1680.
 
24.
Leonardi-Bee J, Britton J, Venn A. Secondhand Smoke and Adverse Fetal Outcomes in Nonsmoking Pregnant Women: A Meta-analysis. Pediatrics. 2011;127(4):734-741. doi:10.1542/peds.2010-3041.
 
25.
Carmines EL, Rajendran N. Evidence for carbon monoxide as the major factor contributing to lower fetal weights in rats exposed to cigarette smoke. Toxicol Sci. 2008;102(2):383-391. doi:10.1093/toxsci/kfn009.
 
26.
McCowan L, Dekker G, Chan E, et al. Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: Prospective cohort study. BMJ. 2009;338. doi:10.1136/bmj.b1558
 
27.
Griffiths SE, Parsons J, Naughton F, Fulton EA, Tombor I, Brown K. Are digital interventions for smoking cessation in pregnancy effective? A systematic review and meta-analysis. Health Psychol Rev. 2018;12(4):333-356. doi:10.1080/17437199.2018.1488602.
 
28.
Bauld L, Graham H, Sinclair L, et al. Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: Literature review and qualitative study. Health Technol Assess. 2017;21(36):v-xix, 1-158. doi:10.3310/hta21360.
 
29.
Bowker K, Lewis S, Coleman T, Cooper S. Changes in the rate of nicotine metabolism across pregnancy: A longitudinal study. Addiction. 2015;110(11):1827-1832. doi:10.1111/add.13029.
 
30.
Campbell KA, Fergie L, Coleman-Haynes T, et al. Improving Behavioral Support for Smoking Cessation in Pregnancy: What Are the Barriers to Stopping and Which Behavior Change Techniques Can Influence Them? Application of Theoretical Domains Framework. Int J Environ Res Public Health. 2018;15(2):1-20. doi:10.3390/ijerph15020359.
 
31.
Chamberlain C, O’Mara-Eves A, Porter J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy (Review). Cochrane Database Syst Rev. 2017;(2). doi:10.1002/14651858.CD001055.pub5.
 
32.
Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP, Goldenberg RL. Recommended cessation counselling for pregnant women who smoke: a review of the evidence. Tob Control. 2000;9:iii80-iii84. doi:10.1136/tc.9.suppl_3.iii80.
 
33.
Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, Whitlock EP. Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality (US); 2015. https://www.ncbi.nlm.nih.gov/b.... Accessed January 9, 2019.
 
34.
Smoking in Pregnancy Challenge Group. Use of electronic cigarettes in pregnancy: A guide for midwives and other healthcare professionals. http://smokefreeaction.org.uk/.... Accessed January 9, 2019.
 
35.
Lancaster T, Stead L. Individual behavioural counselling for smoking cessation (Review). Cochrane Database Syst Rev. 2017(3). doi:10.1002/14651858.CD001292.pub3.
 
36.
Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: The Guilford Press; 2012.
 
37.
Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2015;(3). doi:10.1002/14651858.CD006936.pub3.
 
38.
Kapaya M, Tong V, Ding H. Nicotine replacement therapy and other interventions for pregnant smokers: Pregnancy Risk Assessment Monitoring System, 2009-2010. Prev Med. 2015;78:92-100. doi:10.1016/j.ypmed.2015.07.008.
 
39.
Blood-Siegfried J, Rende EK. The Long-Term Effects of Perinatal Nicotine Exposure on Neurologic Development. J Midwifery Womens Health. 2010;55(2):143-152. doi:10.1016/j.jmwh.2009.05.006.
 
40.
Hickson C, Lewis S, Campbell KA, et al. Comparison of nicotine exposure during pregnancy when smoking and abstinent with nicotine replacement therapy: systematic review and meta-analysis. Addiction. 2018. doi:10.1111/add.14473.
 
41.
Bowker KA, Lewis S, Coleman T, Vaz LR, Cooper S. Comparison of cotinine levels in pregnant women while smoking and when using nicotine replacement therapy. Nicotine Tob Res. 2014;16(6):895-898. doi:10.1093/ntr/ntu029.
 
42.
Hartmann-Boyce J, Chepkin SC, Ye W, Bullen C, Lancaster T. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018. doi:10.1002/14651858.CD000146.pub5.
 
43.
Bowker K, Campbell KA, Coleman T, Lewis S, Naughton F, Cooper S. Understanding pregnant smokers’ adherence to nicotine replacement therapy during a quit attempt: A qualitative study. Nicotine Tob Res. 2016;18(5):906-912. doi:10.1093/ntr/ntv205.
 
44.
Dhalwani NN, Szatkowski L, Coleman T, Fiaschi L, Tata LJ. Prescribing of nicotine replacement therapy in and around pregnancy: a population-based study using primary care data. Br J Gen Pract. 2014;64(626):e554-e560. doi:10.3399/bjgp14X681361.
 
45.
Van Schayck OC, Pinnock H, Ostrem A, et al. IPCRG Consensus statement: Tackling the smoking epidemic - Practical guidance for primary care. Prim Care Respir J. 2008;17(3):185-193. doi:10.3132/pcrj.2008.00060.
 
46.
National Institute for Health and Care Excellence. Stopping smoking in pregnancy and after childbirth. https://pathways.nice.org.uk/p.... Published 2019. Accessed January 9, 2019.
 
47.
Kurti AN, Redner R, Lopez AA, et al. Tobacco and nicotine delivery product use in a national sample of pregnant women. Prev Med. 2017;104:50-56. doi:10.1016/j.ypmed.2017.07.030.
 
48.
Solomon LJ, Quinn VP. Spontaneous quitting: Self-initiated smoking cessation in early pregnancy. Nicotine Tob Res. 2004;6. doi:10.1080/14622200410001669132.
 
49.
Forman J, Harris JM, Lorencatto F, McEwen A, Duaso MJ. National Survey of Smoking and Smoking Cessation Education Within UK Midwifery School Curricula. Nicotine Tob Res. 2017;19(5):591-596. doi:10.1093/ntr/ntw230.
 
50.
Wickstrom R. Effects of Nicotine During Pregnancy: Human and Experimental Evidence. Curr Neuropharmacol. 2007;5(3):213-222. doi:10.2174/157015907781695955.
 
51.
Miyazaki Y, Hayashi K, Imazeki S. Smoking cessation in pregnancy: Psychosocial interventions and patient-focused perspectives. Int J Womens Health. 2015;415-427. doi:10.2147/IJWH.S54599.
 
52.
Hendrick V, Suri R, Gitlin MJ, Ortiz-Portillo E. Bupropion Use During Pregnancy: A Systematic Review. Prim Care Companion CNS Disord. 2017;19(5). doi:10.4088/PCC.17r02160.
 
53.
Stotts AL, Northrup TF, Cinciripini PM, et al. Randomized, controlled pilot trial of bupropion for pregnant smokers: challenges and future directions. 2015;32(4):351-356. doi:10.1055/s-0034-1386635.
 
54.
Richardson JL, Stephens S, Yates LM, et al. Pregnancy outcomes after maternal varenicline use; analysis of surveillance data collected by the European Network of Teratology Information Services. Reprod Toxicol. 2017;67:26-34. doi:10.1016/j.reprotox.2016.11.010.
 
55.
Turner E, Jones M, Vaz LR, Coleman T. Systematic Review and Meta-Analysis to Assess the Safety of Bupropion and Varenicline in Pregnancy. Nicotine Tob Res. 2018:1-10. doi:10.1093/ntr/nty055.
 
56.
Herbec A, Beard E, Brown J, Gardner B, Tombor I, West R. The needs and preferences of pregnant smokers regarding tailored internet-based smoking cessation interventions: A qualitative interview study. BMC Public Health. 2014;14(1). doi:10.1186/1471-2458-14-1070.
 
57.
Shipton D, Tappin DM, Vadiveloo T, Crossley JA, Aitken DA, Chalmers J. Reliability of self reported smoking status by pregnant women for estimating smoking prevalence: A retrospective, cross sectional study. BMJ. 2009;339. doi:10.1136/bmj.b4347.
 
58.
Whittington JR, Simmons PM, Phillips AM, et al. The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature. Obstet Gynecol Surv. 2018;73(9):544-549. doi:10.1097/OGX.0000000000000595.
 
59.
McEwen A, McRobbie H. Electronic_cigarettes: A Briefing for Stop Smoking Services. National Centre for Smoking Cessation and Training; 2016. http://www.ncsct.co.uk/usr/pub.... Accessed January 9, 2019.
 
60.
Bals R, Boyd J, Esposito S, et al. Electronic cigarettes: a task force report from the European Respiratory Society. Eur Respir J. 2018;53. doi:10.1183/13993003.01151-2018.
 
61.
Bahl V, Lin S, Xu N, Davis B, Wang YH, Talbot P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol. 2012;34(4):529-537. doi:10.1016/j.reprotox.2012.08.001.
 
62.
Shahab L, West R, McNeill A. A randomised controlled trial of adding expired carbon-monoxide feedback to brief stop smoking advice: evaluation of cognitive and behavioural effects. Health Psychol. 2011;30(1). doi:10.1037/a0021821.
 
63.
Flemming K, Graham H, McCaughan D, Angus K, Bauld L. The barriers and facilitators to smoking cessation experienced by women’s partners during pregnancy and the post-partum period: A systematic review of qualitative research. BMC Public Health. 2015;15(1):1-10. doi:10.1186/s12889-015-2163-x.
 
64.
Quinn G, Ellison BB, Meade C, et al. Adapting smoking relapse-prevention materials for pregnant and postpartum women: Formative research. Matern Child Health J. 2006;10(3). doi:10.1007/s10995-005-0046-y.
 
65.
Cooper S, Orton S, Leonardi-Bee J, et al. Smoking and quit attempts during pregnancy and postpartum: A longitudinal UK cohort. BMJ Open. 2017;7. doi:10.1136/bmjopen-2017-018746.
 
66.
Ashford KB, Hahn E, Hall L, Rayens MK, Noland M. Postpartum smoking relapse and secondhand smoke. Public Health Rep. 2009;124(4):515-526. doi:10.1177/003335490912400408.
 
67.
Liu J, Rosenberg KD, Sandoval AP. Breastfeeding duration and perinatal cigarette smoking in a population-based cohort. Am J Public Health. 2006;96(2):309-314. doi:10.2105/AJPH.2004.060798.
 
68.
Aveyard P, Lawrence T, Croghan E, Evans O, Cheng KK. Is advice to stop smoking from a midwife stressful for pregnant women who smoke? Data from a randomized controlled trial. Prev Med. 2005;40(5):575-582. doi:10.1016/j.ypmed.2004.07.012.
 
69.
Naughton F, Hopewell S, Sinclair L, McCaughan D, McKell J, Bauld L. Barriers and facilitators to smoking cessation in pregnancy and in the post-partum period: The health care professionals’ perspective. Br J Health Psychol. 2018;23(3):741-757. doi:10.1111/bjhp.12314.
 
eISSN:1617-9625