7.11 Smoking cessation and pregnancy

Last updated: July 2023 Suggested citation: Jenkins, S., Hanley-Jones, S., Ford, C., & Greenhalgh, EM. 7.11 Smoking cessation and pregnancy. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-11-smoking-cessation-and-pregnancy

 

Tobacco use poses a significant threat to the health of pregnant women and their babies. Smoking is one of the most prevalent preventable causes of low birthweight, preterm birth, and perinatal death. Quitting can reduce the risk of adverse outcomes for women and for their babies; therefore it is an important and worthwhile goal. Women are more likely to quit smoking during pregnancy than at any other time of life. They also experience higher levels of social and family support for quitting and they have greater contact with the healthcare system.¹  

7.11.1 Health risks of smoking during pregnancy and the benefits of quitting

The harmful effects of smoking on the health of women and their babies are covered in Chapter 3, Sections 3.7 and 3.8, Chapter 4, Section 4.16 and 4.17, and Chapter 9, Section 9.5. The health benefits of quitting during pregnancy are outlined in Section 7.1.4.

7.11.2 Rates of smoking during pregnancy

The Australian Institute of Health and Welfare reports data on births in Australia through the National Perinatal Data Collection (NPDC). Since 1991, it has collected information concerning both the mother (including demographic profile and matters relating to the pregnancy and birth) and the baby (such as sex, birth-weight and other health indicators).

The Australian National Perinatal Data Collection reported that in 2021, 8.7% of women who gave birth smoked at some time during pregnancy, down from 9.2%  in 2020, 9.3% in 2019, 9.6% in 2018, 12.5% in 2012 and 17.4% in 2005.^2-7 Among women who gave birth in 2021, 8.3% smoked during the first 20 weeks of pregnancy and 72% of these women continuing smoking after the first 20 weeks.⁷ The NPDC reported that women who smoked during pregnancy in 2020 tended to have a later first antenatal visit, and fewer antenatal care visits during their pregnancy, on average.⁶

Mirroring smoking prevalence across the general population, rates of smoking during pregnancy also vary by state and territory. Figure 7.11.2 shows rates of smoking during pregnancy by state and territory for 2010 to 2021. Over this time period, smoking during pregnancy was highest in the Northern Territory and lowest in the Australian Capital Territory. Rates of smoking were also high in Tasmania and Queensland relative to the national average over the eleven-year period, and the decline in smoking during pregnancy was greatest for South Australia (10.2 percentage points). Large declines were also observed in Tasmania (8.6 percentage points). For most jurisdictions, the majority of the decline in smoking prevalence during pregnancy over the eleven years to 2021 occurred between 2010 and 2013. An overall decline continued for states and territories during 2021 with the exception of Queensland, which remained at 11.5%, and the Northern Territory, which increased from 20.2% in 2020 to 20.5% in 2021.⁷

 

7.11.2.1 Smoking during pregnancy and social disadvantage

Smoking during pregnancy is more common among women who: have socioeconomic disadvantages; do not have partners or who have problems in their interpersonal relationships; have higher stress and poorer adaptive functioning; have depression, anxiety, substance use disorders, or other psychiatric disorders; have less social support; have limited education; have prior children; live with other smokers or have a partner who smokes; and engage in other health risk behaviours.^8-18 Women who smoke during pregnancy are also significantly more likely to drink alcohol, compounding their risk of poor pregnancy outcomes.¹⁹ Disadvantaged women may also be more likely to take up smoking during pregnancy or in the early postpartum period,²⁰ and be less likely to quit and more likely to start smoking in their second pregnancy.²¹

There are significant variations in the prevalence of smoking during pregnancy in certain sub-populations, reflecting smoking behaviour in these groups within the wider population (see InDepth 9A). 

In 2020, notable differences in the proportions of women smoking during the first 20 weeks of pregnancy were observed for the following groups.

• Women who lived in the most disadvantaged areas were about six times more likely to smoke during pregnancy than women living in least disadvantaged areas (16.9% compared to 2.7%).
• Those living in very remote areas were about five times more likely to smoke in pregnancy than women in major cities (36% compared to 6.6%), and almost twice as likely as those in remote areas (18.5%).
• The likelihood of smoking during pregnancy decreased with maternal age. Almost one-third (32.8%) of pregnant women and girls under the age of 20 smoked during the pregnancy, compared to about 5.5% of those aged 35­—39 years, and 6.4% for 40 years and over.
• Rates of smoking also substantially differ for teenage pregnancies compared to young women aged 20­–24 years. About one-fifth (20.7%) of women aged 20–24 years smoked during pregnancy, compared to 32.8% of women and girls under the age of 20.⁶

Other research has shown that women without a partner, the less educated,²² those with lower socio-economic status^{22, 23} and women with a psychiatric disorder²⁴ are more likely to smoke during pregnancy. Data from the US shows similar patterns. Large differences in smoking during pregnancy were observed by ethnicity, highest level of educational attainment, and by state.²⁵ Not attending prenatal classes and experiencing stressful events before or during pregnancy are also associated with smoking.²⁶

About two in five (42.1%) Aboriginal and Torres Strait Islander women reported smoking during pregnancy in 2020.⁶ See Section 8.3.7 for more information on smoking prevalence among pregnant Aboriginal and Torres Strait Islander women.

7.11.3 Predictors of failure to quit during and post-pregnancy

Many women who quit smoking during pregnancy relapse within the first year of their child’s life, especially if their partner smokes or they live with other smokers.²⁷ A 2016 systematic review examined whether women who receive cessation interventions during pregnancy are able to successfully quit and maintain long-term abstinence. Results showed that among the women who were offered some sort of smoking cessation intervention, 13% were able to quit sometime during the pregnancy and remain abstinent when they delivered. The other 87% of women either tried to quit and were unsuccessful, or did not attempt to quit. Of the 13% that did quit, almost half (43%) started smoking again by six months postpartum, highlighting the need for sustained and effective cessation support after delivery.²⁸

There are a number of factors that consistently predict successful quitting among women in the perinatal period (i.e., the weeks immediately before and after birth), including  having a good understanding of the health benefits of cessation, strong concern about the effects of smoking on their child’s health, insisting on a smokefree home and environment, strong social support, developing negative attitudes about smoking, and perceiving quitting as a lifelong change.^{29, 30} Women who are more highly educated and less dependent on nicotine have higher odds of quitting during pregnancy.³¹ Breastfeeding for at least three months also seems to promote lower rates of smoking.³² A systematic review identified four factors that acted both as barriers and facilitators to a woman's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy, and appraisal of the risk of smoking.³³

Factors that predict relapse during and post pregnancy are similar to those linked to not quitting at all. These include being highly addicted, high levels of consumption prior to pregnancy, depending heavily on cigarettes to manage stress, having insufficient resources for coping with childrearing, being exposed to secondhand smoke, having easy social access to cigarettes, having low self-esteem, having a partner who smokes or living with smokers, and having smoking-related weight concerns.^{27, 30, 34-37} Research in NSW highlighted a number of demographic factors that predict lower rates of cessation during pregnancy, such as having a higher number of previous pregnancies, being an Aboriginal person, and being a teenage mother.³⁸ Qualitative research with adolescent mothers found that many no longer consider their smoking to negatively affect their infants after they give birth, even if breastfeeding.³⁹ The social networks of disadvantaged young women can undermine their smoking cessation efforts.⁴⁰ Young women in Western Australia cited fear of being left out as a barrier to smoking cessation.⁴¹ A large-scale study in the US found that women who experienced intimate partner violence had significantly higher rates of smoking before pregnancy and were less likely to quit during pregnancy than women who did not have such experiences.⁴² A sample of disadvantaged women in the US reported that being informed of smoking risks, maintaining goal-oriented thoughts, focusing on their concerns about the baby's health, and receiving positive social support from families and friends helped them to successfully cope with post-pregnancy cravings and relapses.⁴³

Motivation to stay quit can differ between pregnancy and post-birth.^44-46 For some pregnant women, quitting is a temporary suspension of habit, rather than a permanent change.⁴⁷ Women who quit smoking later in pregnancy have been found to be more likely to relapse post-pregnancy. ³⁷

There are also psychological factors that can predict smoking and relapse. Depression and high levels of anxiety and psychological distress, and lower self-esteem, are associated with increased risk of smoking during pregnancy ^{17, 48, 49} and relapse.^{20, 37}  Women who experience postpartum depressive symptoms⁵⁰ and stress⁵¹ are also more likely to relapse, and more likely to take up smoking during and post pregnancy.²⁰  

7.11.4 Factors that must be addressed in reducing smoking during and post pregnancy

Understanding and addressing the factors that increase smoking relapse risk is critical for developing more effective interventions. Health professionals play an important role in identifying women at risk of relapse during pregnancy, at birth (hospital care) and in the early postpartum weeks (maternal and child healthcare) and providing tailored support. Part of this support includes encouraging partners to quit, and supporting the establishment of smokefree homes.^52-54 Having a partner who smokes is one of the strongest predictors of continued smoking among new mothers.⁵⁵ Biological, psychological, and social factors that influence a woman’s likelihood of quitting and remaining quit should be addressed as part of routine care during pregnancy and post-partum.^{8, 56}

Addressing and managing mental health factors such as maternal mood, stressful life events, and postpartum depression can be important to the success of smoking cessation during and post pregnancy.^{11, 57} There is some evidence that maternal smoking during pregnancy predicts parenting stress in infancy.⁵⁸ Screening and treatment of depressive and anxiety symptoms during pregnancy and postpartum is one possible method of reducing continued smoking, relapse and uptake.^{20, 50, 57, 59, 60} Research suggests that pregnant women with high levels of depressive symptoms may also benefit from depression-focused treatment during pregnancy⁶¹ and from relapse prevention interventions tailored to psychosocial needs post-partum.⁶²  

Further research is needed to develop suitable interventions for pregnant smokers with substance use disorders.^{15, 63} Such women often have higher rates of smoking, are heavier smokers, and are less likely to quit during pregnancy. Continued smoking is associated with depression, anxiety and lower self-worth in this group.⁶⁴ Opioid-dependent pregnant women show a particularly high prevalence of smoking, likely due to the effect of opioids on nicotine metabolism,⁶⁵ and are at greater risk for additional adverse health effects for themselves and their babies.⁶⁶

Concern about weight gain following cessation can be a barrier to successful quitting.^{36, 67} Two US studies found that women who quit smoking during pregnancy do gain a considerable amount of gestational weight; however, the health benefits of smoking cessation to both the mother and baby outweigh the disadvantage of weight gain.^{68, 69} See Section 7.1.11.3 for more information on quitting and weight gain. Common myths regarding the risks of smoking during pregnancy should be addressed and corrected. For example, the argument that nicotine withdrawal during smoking cessation is more stressful to the foetus than continued smoking is not supported by evidence,^{70, 71} or that low birthweight babies are easier to deliver. In low- and middle-income countries there is also a need for greater awareness of the harms of tobacco use during pregnancy.⁷²

7.11.5 Interventions for reducing smoking during and post pregnancy

In 2017, the sixth update of a Cochrane review was published, which assessed the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. The review found moderate-to-high quality evidence that psychosocial interventions increased the proportion of women who stopped smoking in late pregnancy, improved birthweight and reduced rate of admittance to neonatal intensive care. No adverse effects from the interventions were found.^{48, 73} The US Preventive Services Task Force (USPSTF) released a recommendation statement in 2021 that similarly concluded that for pregnant women, behavioural treatments improve smoking cessation rates and perinatal outcomes.⁷⁴

The Cochrane review found counselling, feedback and financial incentives to be effective interventions, dependent on the context of the intervention. Counselling interventions had a clear effect on stopping smoking when compared with usual care, but not when provided as part of a broader intervention. No clear effect was seen comparing one type of counselling with another.  Interventions that provided feedback had a clear effect compared with usual care and when combined with other strategies such as counselling. Financial incentive-based interventions were effective compared to alternative interventions (i.e. non-contingent incentives). Both health education and social support, alone or as part of broader interventions were not clearly effective. In single studies, exercise and dissemination of counselling did not have clear effects compared to usual care either.^{48, 73}

The interventions appeared to be equally effective for women of low socioeconomic backgrounds and a clear effect was also seen also seen with interventions among women from ethnic minority groups, but not among Indigenous women. Almost all studies were conducted in high-income countries, limiting the broader generalisability of the findings.^{48, 73}

The efficacy of financial incentives was also supported by a 2019 Cochrane review of incentives for smoking and several studies examining other aspects of incentive efficacy. The 2019 Cochrane review determined there was moderate-certainty evidence that incentive schemes conducted among pregnant smokers improve smoking cessation rates both at the end of pregnancy and post-partum.⁷⁵ A study in the UK that considered whether women might falsely report their smoking in order to obtain the incentives found that only a very small number (4%) of those enrolled lied on one or more occasions to gain vouchers.⁷⁶ Research in the US also found that financial incentives contingent on smoking status increased abstinence rates, but changing the schedule to make higher values available early in the quit attempt did not lead to different rates of quitting. The usual schedule also increased foetal growth above the control condition, while the revised schedule did not.⁷⁷ Incentives also appear to be effective for depression-prone pregnant and newly postpartum women in terms of achieving abstinence, and may also reduce the severity of postpartum depression.⁷⁸ A 2015 review concluded that incentives combined with behavioural therapy appear to show the greatest promise for promoting cessation among pregnant women,⁷⁹ and such incentives appear to be highly cost-effective.⁸⁰ Public opinion about providing financial incentives during pregnancy is mixed, but tends to be more negative among women, which may be problematic for uptake.^{81, 82}

A number of other interventions for pregnant women have also been investigated. In Australia, quitlines provide support tailored for pregnant women through a free callback service. The support is available during pregnancy and postpartum. A 2013 Cochrane review concluded that, despite some encouraging findings, there was insufficient evidence to recommend routine telephone support for women accessing maternity services. Limited benefits were found in terms of reduced depression scores, breastfeeding duration and increased overall satisfaction.⁸³ More recently, a randomised controlled trial in the US found that embedding a pregnancy-specific counselling protocol in a Quitline was effective in helping pregnant smokers quit and maintain abstinence postpartum.⁸⁴ Another US study found telephone counselling for recently quit pregnant smokers did not appear to reduce the risk of relapse.⁸⁵ Pregnant and postpartum women are less likely to use telephone support if they have to initiate the contact.⁸⁶

An approach that warrants further investigation involves applying a pre-conception counselling model, designed to reduce the risk of alcohol-exposed pregnancy, to smokers. Pharmacotherapy can be provided safely at this time.⁸⁷ There is evidence that text messaging and computer-based interventions for pregnant smokers may be effective for smoking cessation.⁸⁸ ‘Opt-out’ referral systems, whereby pregnant women who are smokers are automatically referred by healthcare professionals for cessation support, may be more effective than the traditional ‘opt-in’ method.⁸⁹ There is increasing interest in, but limited trials of, interventions focusing on partner support for pregnant women.⁹⁰

Along with individual-level strategies, government tobacco control policies can also prompt cessation among pregnant women. Research in the US found that low-educated pregnant women had the highest rates of smoking and were the most responsive to cigarette tax increases; therefore such taxes may be an effective population-level intervention to decrease disparities in smoking during pregnancy. Smoke-free legislation, however, appeared to have a limited effect on smoking cessation among pregnant women and birth outcomes.⁹¹  

Relapse prevention interventions during pregnancy and in the postpartum period are extremely important for the continued protection of maternal and child health. A 2020 review found evidence that counselling, but not cognitive behavioural therapy, prevented post-partum relapse, and that financial incentives may also be effective.⁹² Though cognitive behavioural strategies, such as positive ‘self-talk’ and avoiding being around other smokers, may be helpful in preventing lapses.⁹³ One study found that in neonatal intensive care settings, interventions that support mother-infant bonding during a newborn’s hospitalisation are associated with reduced rates of smoking relapse and prolonged duration of breastfeeding during the first eight weeks postpartum.⁹⁴ As discussed previously, smokefree homes are important in supporting cessation.^{54, 95} There is a short-term increase in the proportion of smokefree homes following birth⁹⁶ but such changes may be temporary. There is limited evidence on interventions that increase smokefree homes among new families. A systematic review concluded that comprehensive interventions that emphasise the effects of secondhand smoke on the family and encourage smokefree home environments, and that increase the motivation and confidence of family members to stay quit, could reduce relapse rates.³⁴ Another review concluded that there is limited evidence regarding the success of interventions to reduce environmental tobacco smoke, and called for further research.⁹⁷

Although pregnant women are advised to abruptly quit smoking to minimise health risks, cutting down on cigarette consumption is a commonly reported practice.⁹⁸ Australian research found that more than two-thirds of women smokers in maternity hospitals preferred to stop smoking gradually.⁹⁹ Women who are pregnant often receive mixed messages from health professionals about the benefits of cutting down as opposed to quitting smoking altogether.¹⁰⁰ There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight¹⁰¹ and reduce preterm birth.¹⁰² Qualitative research in the UK explored the perspectives of women who chose to cut down during pregnancy. Reducing consumption was used as both a method of quitting and, for persistent smokers, a method of harm reduction. The women perceived cutting down as a positive behaviour change in often-difficult circumstances, and felt that health professionals condoned it. The authors suggest that cutting down in pregnancy, as an aid and an alternative to quitting, should receive greater recognition if healthcare and tobacco control policies are to be sensitive to the perspectives and circumstances of pregnant smokers.⁹⁸ However, Australian¹⁰³ and UK¹⁰⁰ guidelines state that health professionals should be recommending complete abstinence to pregnant women in order to maximise health benefits. See also Section 3.36.5 for a discussion of smoking reduction.

7.11.5.1 Role of pharmacotherapies

Research in Australian maternity hospitals found that almost half of women smokers cited medications, particularly nicotine replacement therapy (NRT) as their preferred method of quitting.⁹⁹ NRT can be used by pregnant and breastfeeding mothers, however the risks and benefits should be explained by those providing the product and the clinician supervising the pregnancy should be consulted.^104-106 Behavioural interventions among pregnant women benefit cessation and perinatal health, and are recommended as first-line treatments.¹⁰⁷ NRT may be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking. If NRT use is recommended, intermittent-use forms (such as gum or spray) are preferred over continuous-delivery nicotine (patches) for pregnant or breastfeeding women, as outlined in the official ‘product information’ approved by the TGA.^{52, 108} This helps to avoid high levels of nicotine in the foetal circulation.⁷⁹

A 2020 Cochrane review investigated the effectiveness of pharmacological interventions for smoking cessation during pregnancy. The authors concluded that there is weak evidence to suggest that using NRT with behavioural support for smoking cessation in late pregnancy is effective; however, the authors note that findings should be interpreted with caution, due to the risk of bias in some of the studies. The review also concluded that there is no evidence that NRT has either a positive or negative impact on health outcomes for the mother or child.¹⁰⁹

One study has suggested that NRT patches deliver an inadequate dose of nicotine to aid smoking cessation during pregnancy.¹¹⁰ A large randomised controlled trial in France found that use of nicotine patches did not increase either smoking cessation rates or birth weights, even when the doses of nicotine were adjusted to match levels attained when smoking, and when higher than usual doses were used.¹¹¹  Further research is also needed as to whether the use of NRT during pregnancy is a cost effective strategy.¹¹²

There is evidence that pregnant women are reluctant to use NRT¹¹³ and healthcare providers may also be reluctant to provide NRT to pregnant women due to safety concerns, despite known harms of continued smoking during pregnancy.^{114, 115} A 2020 Cochrane review found women’s confidence to use NRT is affected by the advice of health professionals and women’s past experiences with NRT can also affect their willingness to use it again during pregnancy.¹¹⁶

The 2020 Cochrane review concluded that there was insufficient evidence regarding the use of bupropion, varenicline, or e-cigarettes to recommend their use during pregnancy.^{109, 117} Since the 2020 Cochrane review, an observation study conducted in Australia found evidence that varenicline, bupropion and NRT are not associated with increased risk of adverse birth outcomes.¹¹⁸ Another Australian study observed higher rates of cessation among women who used varenicline during pregnancy compared to those who used NRT.¹¹⁹ A clinical trial of nicotine inhalators for cessation during pregnancy found lower rates of preterm delivery but poor efficacy for smoking cessation.¹²⁰ US research found that few women filled any prescription for a smoking-cessation pharmacotherapy during pregnancy or postpartum, but this increased with pregnancy complications and substance use.¹²¹

Some women report using e-cigarettes for smoking cessation during pregnancy, however there is insufficient evidence for their effectiveness in this context.¹²² See Section 18.6.1 for an overview of the health effects of e-cigarette use during pregnancy.

7.11.5.2 Role of treating health professionals

Health professionals and healthcare settings are in an excellent position to promote cessation among pregnant women, who are often highly motivated to quit. A Cochrane review of interventions for promoting smoking cessation during pregnancy states that ‘attention to smoking behaviour together with support for smoking cessation and relapse prevention needs to be as routine a part of antenatal care as the measurement of blood pressure’.¹⁰ This continues to be a key recommendation of guidelines for treating tobacco use and dependence among pregnant women.^{52, 123} If possible, cessation interventions should be also be integrated into existing services that deal with sexual, reproductive, and child health.⁵²

Early pregnancy represents an important time for first promoting cessation, as many women begin their contact with a variety of health professionals who will monitor their health during the perinatal period. However, pregnant smokers with high levels of social disadvantage can often be late to access antenatal care. Health professionals involved with pregnant women and their families at any stage of pregnancy and postpartum should ask about tobacco use, provide education about the risks of smoking and secondhand smoke, and encourage and support their efforts to stop smoking.

However, opportunities to intervene with pregnant women are often underutilised. Although most pregnant women are asked about their smoking, appropriate advice, intervention, and follow-up can be lacking.⁹⁷ Research in 2009 suggested that the proportion of pregnant women being advised of the risks of smoking and given advice to stop by antenatal health professionals ranges from 40–60%.¹²⁴ Less than half of smokers in two large Australian maternity hospitals reported that their health professionals discouraged smoking during pregnancy.⁹⁹ Similarly, surveys carried out before and after the implementation of cessation guidelines in Australia found that, despite an increase over time, half of smokers still failed to receive the full complement of advice and support.¹²⁵ A meta-analysis of studies from 10 countries found health providers deliver the ‘Ask’, ‘Advise’ and ‘Assess’ components of 5A cessation guidelines to most pregnant women but had lower adherence to the ‘Assist’, ‘Arrange’ and NRT prescription components.¹²⁶ A large survey in the US in 2012 found that, compared with 1998, ob-gyns were less likely to adhere to the 5A guidelines.¹²⁷ Midwives tend to deliver interventions at a higher rate than doctors,¹²⁸ and training midwives to deliver the 5As can promote higher reduction and cessation rates among pregnant women.¹²⁹

While asking about smoking status during consultations and encouraging and supporting quitting is part of national guidelines in a number of countries, including Australia,⁵² some health professionals continue to find discussion of smoking behaviour with pregnant women difficult.⁹⁷ Pregnant women are often not routinely asked about their smoking by each of their health professionals, due to concerns about damaging the relationship, time constraints, and differences between professional groups.⁹⁷ Some Australian GPs also report focusing on harms of smoking to pregnancy and providing treatment options only to patients motivated to quit. ¹¹⁵ A study in the US found that time constraints and documentation issues were major barriers to implementing the 5As with pregnant and post-partum women.¹³⁰ Implementing clinic systems designed to increase the assessment and documentation of tobacco use almost doubles the rate at which clinicians intervene with their patients who smoke and results in higher rates of smoking cessation.¹³¹ Other barriers can include self-perceptions of limited skills and knowledge about smoking cessation, difficulty addressing patient’s psychological stress, lack of staffing, educational materials and familiarity with Quitline services (particularly for Aboriginal and Torres Strait Islander pregnant smokers); pessimism about the effectiveness of what they do provide; uncertainty regarding role; and concern about the cost and safety of NRT (see 7.11.5.1).^{97, 115, 132} Health professionals also cite the association between maternal smoking and social disadvantage as a considerable barrier to addressing and supporting cessation.¹³³

Pregnant women report some dissatisfaction with the content and clarity of the advice provided to them. The advice and recommendations given by health professionals often varies regarding the provision of cessation counselling, self-help materials, information about NRT, and referral to other specialist services. Some advice is contradictory, particularly regarding the recommendation of quitting smoking versus cutting down (see Section 7.11.5). 

The manner in which information is provided is important and may affect a woman’s willingness to consider stopping smoking.⁹⁷ Interviews with a small number of socially disadvantaged pregnant women in Australia revealed that they often felt that advice and support to quit from health professionals was overly didactic and superficial.¹³⁴ New Zealand research found that compared with informational approaches, cessation messages that evoke strong affective responses (e.g., that depict unwell or distressed children) capitalise on the dissonance many women feel when smoking while pregnant and stimulate stronger consideration of quitting.¹³⁵ Though another study found smoking women considered gain-framed messages more effective than loss-framed messages.¹³⁶

Given the time and resource constraints on most health professionals and antenatal services, the brief intervention ‘5As’ approach discussed in Section 7.10

is a workable, minimal approach for these settings.⁵² This approach has been implemented in a number of antenatal services across Australia.^137-141 It includes integrating a record of 5As interventions into medical records of pregnancy as part of routine practice, training health workers, raising the issues in early consultations, providing printed information on smoking and pregnancy, reviewing quitting intentions, and discussing action at each subsequent consultation.^{138, 140, 141} In the antenatal setting, there is opportunity for following up with women who were initially unsure about quitting or not ready. Ongoing follow-up can also help to identify women who may have previously concealed their smoking.¹⁴²

Intervention should provide positive, non-judgemental encouragement to quit that addresses women’s concerns about stopping smoking, and include referral to the Quitline or other services able to provide tailored support for pregnant women.^{10, 138, 140}  Referral to services that address common predictors of relapse (such as treatment for depression, relationship counselling, etc.) may also be warranted. Support and interventions with smoking partners should also form part of routine care.¹⁴³ A 2019 meta-analysis also indicated that that audits, feedback and the use of behaviour change theories within intervention design may increase effectiveness of cessation care during pregnancy.¹⁴⁴

7.11.5.3 Specialist smoking cessation services for pregnant women

There is limited research on the use of specialist smoking cessation services and courses (apart from quitline services) for pregnant women. A specialised service or course may be more likely to understand the needs of pregnant women who continue to smoke, but referral to such services from antenatal health professionals can be lacking. Major barriers to pregnant women accessing such services and courses can include problems with transport and childcare for other children, lack of time, and a disbelief that they would help.⁹⁷ Offering flexible home visits and providing intensive multisession treatment delivered by well-trained staff may help to overcome these barriers and promote greater rates of cessation.¹⁴⁵

 

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated September 2023)

 

References

1. Orleans CT, Barker DC, Kaufman NJ, and Marx JF. Helping pregnant smokers quit: Meeting the challenge in the next decade. Tobacco Control, 2000; 9(suppl. 3):iii6–11. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/9/suppl_3/iii6

2. Hilder L, Zhichao Z, Parker M, Jahan S, and Chambers GM. Australia’s mothers and babies 2012. Perinatal statistics series no. 30. Cat. no. PER 69, Canberra: AIHW, 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550033.

3. Laws P, Abeywardana S, Walker J, and Sullivan E. Australia’s mothers and babies 2005.  Perinatal statistics series no. 20.  Cat. No. Per 40. Sydney: AIHW National Perinatal Statistics Unit., 2007. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-2005/contents/table-of-contents.

4. Australian Institute of Health and Welfare. Australia’s mothers and babies 2018—in brief. Cat. no. PER 108, Canberra: AIHW 2020. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-and-babies-2018-in-brief/summary.

5. Australian Institute of Health and Welfare. Australia's mothers and babies. Canberra: AIHW, 2021. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies.

6. Australian Institute of Health and Welfare. National Perinatal Data Collection annual update 2020—data tables. Canberra: Australian Institute of Health and Welfare, 2022. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/data.

7. Australian Institute of Health and Welfare. National Perinatal Data Collection annual update 2021— data tables. Canberra: AIHW, 2023. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/data.

8. Miyazaki Y, Hayashi K, and Imazeki S. Smoking cessation in pregnancy: Psychosocial interventions and patient-focused perspectives. Int J Womens Health, 2015; 7:415–27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25960677

9. Smedberg J, Lupattelli A, Mardby AC, and Nordeng H. Characteristics of women who continue smoking during pregnancy: A cross-sectional study of pregnant women and new mothers in 15 European countries. BMC Pregnancy Childbirth, 2014; 14:213. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24964728

10. Lumley J, Oliver SS, Chamberlain C, and Oakley L Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2004. Available from: http://dx.doi.org/10.1002/14651858.CD001055.pub2

11. Page R, Padilla Y, and Hamilton E. Psychosocial factors associated with patterns of smoking surrounding pregnancy in fragile families. Maternal and Child Health Journal, 2012; 16(1):249–57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21197563

12. Hilder L, Zhichao Z, Parker M, Jahan S, and Chambers GM. Australia’s mothers and babies 2012. Perinatal statistics series no. 30, Cat. no. PER 69. Canberra: AIHW, 2014. Available from: http://www.aihw.gov.au/publication-detail/?id=60129550033.

13. Flick L, Cook C, Homan S, McSweeney M, Campbell C, et al. Persistent tobacco use during pregnancy and the likelihood of psychiatric disorders American Journal of Public Health 2006; 96(10):1799−807. Available from: http://www.ajph.org/cgi/content/abstract/96/10/1799

14. Lu Y, Tong S, and Oldenburg B. Determinants of smoking and cessation during and after pregnancy. Health Promotion International, 2001; 16(4):355–65. Available from: www.ncbi.nlm.nih.gov/pubmed/11733454

15. Burns L, Mattick RP, and Wallace C. Smoking patterns and outcomes in a population of pregnant women with other substance use disorders. Nicotine and Tobacco Research, 2008; 10(6):969 – 74. Available from: www.ncbi.nlm.nih.gov/pubmed/18584460

16. Wakschlag LS, Pickett KE, Middlecamp MK, Waltona LL, Tenzere P, et al. Pregnant smokers who quit, pregnant smokers who don’t: Does history of problem behavior make a difference? . Social Science & Medicine 2003; 56(12):2449–60. Available from: www.ncbi.nlm.nih.gov/pubmed/12742608

17. Tojal C and Costa R. Anxiety and depression symptoms among pregnant women with different smoking habits. Psychology, Health and Medicine, 2019:1-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31232092

18. Kendler KS, Ohlsson H, Fagan AA, Lichtenstein P, Sundquist J, et al. Evidence for a causal relationship between academic achievement and cigarette smoking. Nicotine and Tobacco Research, 2020. Available from: https://doi.org/10.1093/ntr/ntaa161

19. O'Keeffe LM, Kearney PM, McCarthy FP, Khashan AS, Greene RA, et al. Prevalence and predictors of alcohol use during pregnancy: Findings from international multicentre cohort studies. BMJ Open, 2015; 5(7). Available from: http://bmjopen.bmj.com/content/5/7/e006323.abstract

20. Webb D, Culhane J, Mathew L, Bloch J, and Goldenberg R. Incident smoking during pregnancy and the postpartum period in a low-income urban population. Public Health Reports, 2011; 126(1):50–9. Available from: http://www.publichealthreports.org/archives/issuecontents.cfm?Volume=126&Issue=1

21. Tran D, Roberts C, Jorm L, Seeho S, and Havard A. Change in smoking status during two consecutive pregnancies: A population-based cohort study. BJOG, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24735217

22. Lu Y, Tong S, and Oldenburg B. Determinants of smoking and cessation during and after pregnancy. Health Promot Int, 2001; 16(4):355–65. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11733454

23. Mohsin M and Bauman A. Socio-demographic factors associated with smoking and smoking cessation among 426,344 pregnant women in new south wales, Australia. BMC Public Health, 2005; 5:138. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-5-138.pdf

24. Flick L, Cook C, Homan S, McSweeney M, Campbell C, et al. Persistent tobacco use during pregnancy and the likelihood of psychiatric disorders.Flick lh, cook ca, homan sm, mcsweeney m, campbell c, parnell l. American Journal of Public Health, 2006; 96:1799–807.

25. Drake P, Driscoll AK, and Mathews TJ. Cigarette smoking during pregnancy: United States, 2016. Centers for Disease Control and Prevention,  2018. Available from: https://www.cdc.gov/nchs/products/databriefs/db305.htm.

26. Al-Sahab B, Saqib M, Hauser G, and Tamim H. Prevalence of smoking during pregnancy and associated risk factors among canadian women: A national survey. BMC Pregnancy Childbirth, 2010; 10:24. Available from: http://www.biomedcentral.com/1471-2393/10/24

27. McDermott L, Russell A, and Dobson A. Cigarette smoking among women in Australia. Canberra: Commonwealth Department of Health and Ageing, 2002.

28. Jones M, Lewis S, Parrott S, Wormall S, and Coleman T. Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: A systematic review. Addiction, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26990248

29. Ashford K, Hahn E, Hall L, Peden A, and Rayens M. Postpartum smoking abstinence and smoke-free environments. Health Promotion Practice, 2010; 12(1):126–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20720096

30. Ripley-Moffitt CE, Goldstein AO, Fang WL, Butzen AY, Walker S, et al. Safe babies: A qualitative analysis of the determinants of postpartum smoke-free and relapse states. Nicotine and Tobacco Research, 2008; 10(8):1355–64. Available from: http://www.informaworld.com/smpp/content~content=a901415349~db=all~order=page

31. Vaz LR, Leonardi-Bee J, Aveyard P, Cooper S, Grainge M, et al. Factors associated with smoking cessation in early and late pregnancy in the smoking, nicotine, and pregnancy trial: A trial of nicotine replacement therapy. Nicotine and Tobacco Research, 2014; 16(4):381–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24127265

32. Shisler S, Homish GG, Molnar DS, Schuetze P, Colder CR, et al. Predictors of changes in smoking from 3rd trimester to 9 months postpartum. Nicotine and Tobacco Research, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25744971

33. Flemming K, McCaughan D, Angus K, and Graham H. Qualitative systematic review: Barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth. Journal of Advanced Nursing, 2015; 71(6):1210–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25430626

34. Ashford K, Hahn E, Hall L, Rayens M, and Noland M. Postpartum smoking relapse and secondhand smoke. Public Health Reports, 2009; 124(4):515–26. Available from: www.ncbi.nlm.nih.gov/pubmed/19618788

35. Gadomski A. Smoking and smoking cessation during pregnancy and postpartum Current Cardiovascular Risk Reports 2010; 4(6):405–12. Available from: http://www.springerlink.com/content/9425273j7xk175k6/fulltext.html

36. Levine M, Marcus M, Kalarchian M, Houck P, and Cheng Y. Weight concerns, mood, and postpartum smoking relapse. American Journal of Preventive Medicine, 2010; 39(4):345–51. Available from: www.ncbi.nlm.nih.gov/pubmed/20837285

37. Miguez MC and Pereira B. Factors associated with smoking relapse in the early postpartum period: A prospective longitudinal study in spain. Maternal and Child Health Journal, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33206303

38. Passmore E, McGuire R, Correll P, and Bentley J. Demographic factors associated with smoking cessation during pregnancy in new south wales, Australia, 2000-2011. BMC Public Health, 2015; 15:398. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25928643

39. Constantine NA, Slater JK, Carroll JA, and Antin TM. Smoking cessation, maintenance, and relapse experiences among pregnant and postpartum adolescents: A qualitative analysis. Journal of Adolescent Health, 2014; 55(2):216–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24566100

40. Derksen ME, Kunst AE, Murugesu L, Jaspers MWM, and Fransen MP. Smoking cessation among disadvantaged young women during and after pregnancy: Exploring the role of social networks. Midwifery, 2021; 98:102985. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33761432

41. Hauck Y, Ronchi F, Lourey B, and Lewis L. Challenges and enablers to smoking cessation for young pregnant Australian women: A qualitative study. Birth, 2013; 40(3):202–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24635505

42. Cheng D, Salimi S, Terplan M, and Chisolm MS. Intimate partner violence and maternal cigarette smoking before and during pregnancy. Obstetrics and Gynecology, 2015; 125(2):356–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25568990

43. Wen KY, Miller SM, Roussi P, Belton TD, Baman J, et al. A content analysis of self-reported barriers and facilitators to preventing postpartum smoking relapse among a sample of current and former smokers in an underserved population. Health Education Research, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25099776

44. Lopez E, Simmons V, Quinn G, Meade C, Chirikos T, et al. Clinical trials and tribulations: Lessons learned from recruiting pregnant ex-smokers for relapse prevention. Nicotine and Tobacco Research, 2008; 10(1):87–96. Available from: www.ncbi.nlm.nih.gov/pubmed/18188749

45. Nichter M, Nichter M, Adrian S, Goldade K, Tesler L, et al. Smoking and harm-reduction efforts among postpartum women. Qualitative Health Research, 2008; 18(9):1184–94. Available from: http://qhr.sagepub.com/cgi/reprint/18/9/1184

46. Germeroth LJ, Wang Z, Emery RL, Cheng Y, and Levine MD. The role of self-efficacy and motivation in postpartum sustained smoking abstinence. Women's Health Issues, 2019; 29(3):259-66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31072756

47. Gaffney K, Henry L, Douglas C, and Goldberg P. Tobacco use triggers for mothers of infants: Implications for pediatric nursing practice. Pediatric Nursing, 2008; 34(3):253–8. Available from: www.ncbi.nlm.nih.gov/pubmed/18649816

48. Chamberlain C, O'Mara-Eves A, Porter J, Coleman T, Perlen SM, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews, 2017; 2:CD001055. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28196405

49. Varescon I, Leignel S, Gerard C, Aubourg F, and Detilleux M. Self-esteem, psychological distress, and coping styles in pregnant smokers and non-smokers. Psychological Reports, 2013; 113(3):935–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24693823

50. Allen A, Prince C, and Dietz P. Postpartum depressive symptoms and smoking relapse American Journal of Preventive Medicine, 2009; 36(1):9–12. Available from: www.ncbi.nlm.nih.gov/pubmed/19095161

51. Correa JB, Simmons VN, Sutton SK, Meltzer LR, and Brandon TH. A content analysis of attributions for resuming smoking or maintaining abstinence in the post-partum period. Maternal and Child Health Journal, 2015; 19(3):664–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24996953

52. Health NDo. National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn 2006. 2006. Available from: www.health.nsw.gov.au/pubs/2006/pdf/ncg_druguse.pdfSimilar

53. Collins BN, Nair US, Davis SM, and Rodriguez D. Increasing home smoking restrictions boosts underserved moms' bioverified quit success. American Journal of Health Behavior, 2019; 43(1):50-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30522566

54. Nabi-Burza E, Wasserman R, Drehmer JE, Walters BH, Luo M, et al. Spontaneous smoking cessation in parents. J Smok Cessat, 2021; 2021:5526715. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34306222

55. Simmons VN, Sutton SK, Quinn GP, Meade CD, and Brandon TH. Prepartum and postpartum predictors of smoking. Nicotine and Tobacco Research, 2014; 16(4):461–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24203933

56. Meernik C and Goldstein AO. A critical review of smoking, cessation, relapse and emerging research in pregnancy and post-partum. British Medical Bulletin, 2015; 114(1):135–46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25926615

57. Gyllstrom M, Hellerstedt W, and Hennrikus D. The association of maternal mental health with prenatal smoking cessation and postpartum relapse in a population-based sample. Maternal and Child Health Journal, 2012; 16(3):685–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21369723

58. Lynch M, Johnson K, Kable J, Carroll J, and Coles C. Smoking in pregnancy and parenting stress: Maternal psychological symptoms and socioeconomic status as potential mediating variables. Nicotine and Tobacco Research, 2011; 13(7):532–9. Available from: www.ncbi.nlm.nih.gov/pubmed/21436299

59. Bottomley K and Lancaster S. The association between depressive symptoms and smoking in pregnant adolescents. Psychology, Health and Medicine, 2008; 13(5):574–82. Available from: www.ncbi.nlm.nih.gov/pubmed/18942010

60. Miguez MC, Pereira B, Pinto TM, and Figueiredo B. Continued tobacco consumption during pregnancy and women's depression and anxiety symptoms. International Journal of Public Health, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31628523

61. Cinciripini P, Blalock J, Minnix J, Robinson J, Brown V, et al. Effects of an intensive depression-focused intervention for smoking cessation in pregnancy. Journal of Consulting and Clinical Psychology, 2010; 78(1):44–54. Available from: www.ncbi.nlm.nih.gov/pubmed/20099949

62. Levine MD, Emery RL, Kolko Conlon RP, Marcus MD, Germeroth LJ, et al. Depressive symptoms assessed near the end of pregnancy predict differential response to postpartum smoking relapse prevention intervention. Annals of Behavioral Medicine, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31219152

63. Burstyn I, Kapur N, and Cherry N. Substance use of pregnant women and early neonatal morbidity: Where to focus intervention? Canadian Journal of Public Health, 2010; 101(2):149–53. Available from: www.ncbi.nlm.nih.gov/pubmed/20524381

64. Massey S, Lieberman D, Reiss D, Leve L, Shaw D, et al. Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy. The American Journal on Addictions, 2011; 20(2):143–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21314757

65. Oncken C, Mead EL, Dornelas EA, Kuo CL, Sankey HZ, et al. Opioid use and rate of nicotine metabolism among pregnant smokers. Nicotine and Tobacco Research, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31063550

66. Winklbaur B, Baewert A, Jagsch R, Rohrmeister K, Metz V, et al. Association between prenatal tobacco exposure and outcome of neonates born to opioid-maintained mothers. Implications for treatment. European Addiction Research, 2009; 15(3):150–6. Available from: www.ncbi.nlm.nih.gov/pubmed/19420947

67. Berg CJ, Park ER, Chang Y, and Rigotti NA. Is concern about post-cessation weight gain a barrier to smoking cessation among pregnant women? Nicotine and Tobacco Research, 2008; 10(7):1159–63. Available from: www.ncbi.nlm.nih.gov/pubmed/18629725

68. Levine MD, Cheng Y, Marcus MD, and Emery RL. Psychiatric disorders and gestational weight gain among women who quit smoking during pregnancy. Journal of Psychosomatic Research, 2015; 78(5):504–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25433975

69. Rockhill KM, England LJ, Tong VT, and Sharma AJ. Biochemically confirmed smoking cessation and gestational weight gain. Birth, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30633363

70. US Department of Health and Human Services. Women and smoking. A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm.

71. US Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm.

72. Shukla R, Kanaan M, and Siddiqi K. Tobacco use among 1 310 716 women of reproductive age (15-49 years) in 42 low- and middle-income countries: Secondary data analysis from the 2010-2016 demographic and health surveys. Nicotine and Tobacco Research, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34291296

73. Chamberlain C, O'Mara-Eves A, Oliver S, Caird JR, Perlen SM, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews, 2013; 10:CD001055. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24154953

74. Patnode CD, Henderson JT, Coppola EL, Melnikow J, Durbin S, et al. Interventions for Tobacco cessation in adults, including pregnant persons: Updated evidence report and systematic review for the US preventive services task force. JAMA, 2021; 325(3):280-98. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33464342

75. Notley C, Gentry S, Livingstone-Banks J, Bauld L, Perera R, et al. Incentives for smoking cessation. Cochrane Database of Systematic Reviews, 2019; 7:CD004307. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31313293

76. Ierfino D, Mantzari E, Hirst J, Jones T, Aveyard P, et al. Financial incentives for smoking cessation in pregnancy: A single-arm intervention study assessing cessation and gaming. Addiction, 2015; 110(4):680–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25727238

77. Higgins ST, Washio Y, Lopez AA, Heil SH, Solomon LJ, et al. Examining two different schedules of financial incentives for smoking cessation among pregnant women. Preventive Medicine, 2014; 68:51–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24704135

78. Lopez AA, Skelly JM, and Higgins ST. Financial incentives for smoking cessation among depression-prone pregnant and newly postpartum women: Effects on smoking abstinence and depression ratings. Nicotine and Tobacco Research, 2015; 17(4):455–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25762756

79. Leung LW and Davies GA. Smoking cessation strategies in pregnancy. Journal of Obstetrics and Gynaecology Canada, 2015; 37(9):791–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26605448

80. Boyd KA, Briggs AH, Bauld L, Sinclair L, and Tappin D. Are financial incentives cost-effective to support smoking cessation during pregnancy? Addiction, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26370095

81. Hoddinott P, Morgan H, MacLennan G, Sewel K, Thomson G, et al. Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: A survey of the British public. BMJ Open, 2014; 4(7):e005524. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25037645

82. Lynagh M, Bonevski B, Symonds I, and Sanson-Fisher RW. Paying women to quit smoking during pregnancy? Acceptability among pregnant women. Nicotine and Tobacco Research, 2011; 13(11):1029–36. Available from: http://ntr.oxfordjournals.org/content/13/11/1029.abstract

83. Lavender T, Richens Y, Milan SJ, Smyth R, and Dowswell T. Telephone support for women during pregnancy and the first six weeks postpartum. The Cochrane Library, 2013. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23881662

84. Cummins SE, Tedeschi GJ, Anderson CM, and Zhu SH. Telephone intervention for pregnant smokers: A randomized controlled trial. American Journal of Preventive Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27056131

85. Murphy CM, Micalizzi L, Sokolovsky AW, Borrelli B, Jennings EG, et al. Motivational interviewing telephone counseling to increase postpartum maintenance of abstinence from tobacco. Journal of Substance Abuse Treatment, 2021; 132:108419. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34098201

86. Dennis C and Kingston D. A systematic review of telephone support for women during pregnancy and the early postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 2008; 37(3):301–14. Available from: www.ncbi.nlm.nih.gov/pubmed/18507601

87. Parrish D, von Sternberg K, Velasquez M, Cochran J, Sampson M, et al. Characteristics and factors associated with the risk of a nicotine exposed pregnancy: Expanding the choices preconception counseling model to tobacco. Maternal and Child Health Journal, 2012; 16(6):1224–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21735139

88. Griffiths SE, Parsons J, Naughton F, Fulton EA, Tombor I, et al. Are digital interventions for smoking cessation in pregnancy effective? A systematic review and meta-analysis. Health Psychol Rev, 2018; 12(4):333-56.

89. Campbell KA, Cooper S, Fahy SJ, Bowker K, Leonardi-Bee J, et al. 'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: Impact on engagement with smoking cessation support. Tobacco Control, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27225017

90. Faseru B, Richter KP, Scheuermann TS, and Park EW. Enhancing partner support to improve smoking cessation. Cochrane Database of Systematic Reviews, 2018; 8:CD002928. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30101972

91. Hawkins SS and Baum CF. The downstream effects of state tobacco control policies on maternal smoking during pregnancy and birth outcomes. Drug and Alcohol Dependence, 2019; 205:107634. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31669802

92. Grange G, Berlin I, Bretelle F, Bertholdt C, Berveiller P, et al. Smoking and smoking cessation in pregnancy. Synthesis of a systematic review. J Gynecol Obstet Hum Reprod, 2020:101847. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32619725

93. Naughton F, McEwen A, and Sutton S. Use and effectiveness of lapse prevention strategies among pregnant smokers. J Health Psychol, 2015; 20(11):1427–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24296735

94. Phillips R, Merritt T, Goldstein M, Deming D, Slater L, et al. Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. Journal of Perinatology, 2012; 32(5):374–80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21836549

95. Wen L, Rissel C, and Lee E. Smoke-free home status and parents' smoking status among first-time mothers. Australian and New Zealand Journal of Public Health, 2010; 34(5):532–3. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1753-6405.2010.00604.x/full

96. Borland R, Yong HH, Cummings K, Hyland A, Anderson S, et al. Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (itc) four country survey. Tobacco Control, 2006; 15(Suppl 3):iii 42–50. Available from: http://tobaccocontrol.bmj.com/content/15/suppl_3/iii42.abstract

97. Baxter S, Blank L, Guillaume L, Messina J, Everson-Hock E, et al. Systematic review of how to stop smoking in pregnancy and following childbirth. School of Health and Related Research (ScHARR), 2009; August 2009. Available from: https://www.nice.org.uk/guidance/ph26/documents/quitting-smoking-in-pregnancy-and-following-childbirth-evidence-review-full-report2

98. Graham H, Flemming K, Fox D, Heirs M, and Sowden A. Cutting down: Insights from qualitative studies of smoking in pregnancy. Health and Social Care in the Community, 2014; 22(3):259–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24224830

99. Hoekzema L, Werumeus Buning A, Bonevski B, Wolke L, Wong S, et al. Smoking rates and smoking cessation preferences of pregnant women attending antenatal clinics of two large Australian maternity hospitals. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2014; 54(1):53–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24471847

100. National Institute for Health and Care Excellence. Smoking: Stopping in pregnancy and after childbirth. 2010. Available from: http://www.nice.org.uk/guidance/ph26

101. England LJ, Kendrick JS, Wilson HG, Merritt RK, Gargiullo PM, et al. Effects of smoking reduction during pregnancy on the birth weight of term infants. American Journal of Epidemiology, 2001; 154(8):694-701. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11590081

102. Seybold DJ, Broce M, Siegel E, Findley J, and Calhoun BC. Smoking in pregnancy in West virginia: Does cessation/reduction improve perinatal outcomes? Maternal and Child Health Journal, 2012; 16(1):133-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21258963

103. The Royal Australian College of General Practitioners, Supporting smoking cessation: A guide for health professionals.  Melbourne: RACGP; 2014. Available from: http://www.racgp.org.au/your-practice/guidelines/smoking-cessation/.

104. Action on Smoking and Health Australia. Nicotine replacement therapy.  Guidelines for healthcare professionals on using nicotine replacement therapy for smokers not yet ready to stop smoking. February.Sydney, NSW: Action on Smoking and Health Australia (ASH), 2007. Available from: www.ashaust.org.au/pdfs/NRTguide0702.pdf.

105. Zwar N, Richmond R, Borland R, Peters M, Stillman S, et al. Smoking cessation pharmacotherapy: An update for health professionals. Melbourne: Royal Australian College of General Practitioners, 2007. Available from: http://www.treatobacco.net/en/uploads/documents/Treatment%20Guidelines/Australia%20treatment%20guidelines%20-%20pharmacotherapy%20in%20English%202007.pdf.

106. Coleman T. Recommendations for the use of pharmacological smoking cessation strategies in pregnant women. CNS Drugs, 2007; 21(12):983–93. Available from: www.ncbi.nlm.nih.gov/pubmed/18020479

107. Patnode CD, Henderson JT, Thompson JH, Senger CA, Fortmann SP, et al. 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. Annals of Internal Medicine, 2015; 163(8):608-21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26389650

108. Johnson & Johnson Pacific. Product information: Nicorette® 16hr invisipatch® patch. 2016. Available from: http://www.medicines.org.au/files/pcpinvis.pdf

109. Claire R, Chamberlain C, Davey MA, Cooper SE, Berlin I, et al. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, 2020; 3:CD010078. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32129504

110. Bowker KA, Lewis S, Coleman T, Vaz LR, and Cooper S. Comparison of cotinine levels in pregnant women while smoking and when using nicotine replacement therapy. Nicotine and Tobacco Research, 2014; 16(6):895–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24634462

111. Berlin I, Grange G, Jacob N, and Tanguy ML. Nicotine patches in pregnant smokers: Randomised, placebo controlled, multicentre trial of efficacy. BMJ, 2014; 348:g1622. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24627552

112. Essex HN, Parrott S, Wu Q, Li J, Cooper S, et al. Cost-effectiveness of nicotine patches for smoking cessation in pregnancy: A placebo randomized controlled trial (snap). Nicotine and Tobacco Research, 2014. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25481916

113. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, 2009; (3):CD001055. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19588322

114. Kapaya M, Tong V, and Ding H. Nicotine replacement therapy and other interventions for pregnant smokers: Pregnancy risk assessment monitoring system, 2009-2010. Preventive Medicine, 2015; 78:92–100. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26190366

115. Bar-Zeev Y, Skelton E, Bonevski B, Gruppetta M, and Gould GS. Overcoming challenges to treating Tobacco use during pregnancy - a qualitative study of Australian general practitioners barriers. BMC Pregnancy Childbirth, 2019; 19(1):61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30732568

116. Campbell K, Coleman-Haynes T, Bowker K, Cooper SE, Connelly S, et al. Factors influencing the uptake and use of nicotine replacement therapy and e-cigarettes in pregnant women who smoke: A qualitative evidence synthesis. Cochrane Database of Systematic Reviews, 2020; 5:CD013629. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32441810

117. Coleman T, Chamberlain C, Davey MA, Cooper SE, and Leonardi-Bee J. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, 2015; 12:CD010078. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26690977

118. Tran DT, Preen DB, Einarsdottir K, Kemp-Casey A, Randall D, et al. Use of smoking cessation pharmacotherapies during pregnancy is not associated with increased risk of adverse pregnancy outcomes: A population-based cohort study. BMC Medicine 2020; 18(1):15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32019533

119. Choi SKY, Tran DT, Kemp-Casey A, Preen DB, Randall D, et al. The comparative effectiveness of varenicline and nicotine patches for smoking abstinence during pregnancy: Evidence from a population-based cohort study. Nicotine and Tobacco Research, 2021; 23(10):1664-72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34398235

120. Oncken C, Dornelas EA, Kuo CL, Sankey HZ, Kranzler HR, et al. Randomized trial of nicotine inhaler for pregnant smokers. Am J Obstet Gynecol MFM, 2019; 1(1):10-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31380506

121. Jarlenski MP, Chisolm MS, Kachur S, Neale DM, and Bennett WL. Use of pharmacotherapies for smoking cessation: Analysis of pregnant and postpartum medicaid enrollees. American Journal of Preventive Medicine, 2015; 48(5):528–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25891051

122. Calder R, Gant E, Bauld L, McNeill A, Robson D, et al. Vaping in pregnancy: A systematic review. Nicotine and Tobacco Research, 2021; 23(9):1451-8. Available from: https://doi.org/10.1093/ntr/ntab017

123. Caponnetto P, Polosa R, and Best D. Tobacco use cessation counseling of parents. Current Opinion in Pediatrics, 2008; 20(6):729–33. Available from: https://pubmed.ncbi.nlm.nih.gov/19023920/

124. Campbell R and Murphy D. Smoking in pregnancy. British Medical Journal (Clinical Research Edition), 2009; 338:b2188. Available from: www.ncbi.nlm.nih.gov/pubmed/19546134

125. Perlen S, Brown SJ, and Yelland J. Have guidelines about smoking cessation support in pregnancy changed practice in victoria, Australia? Birth, 2013; 40(2):81–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24635461

126. Gould GS, Twyman L, Stevenson L, Gribbin GR, Bonevski B, et al. What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis. BMJ Open, 2019; 9(8):e026037. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31427313

127. Coleman-Cowger VH, Anderson BL, Mahoney J, and Schulkin J. Smoking cessation during pregnancy and postpartum: Practice patterns among obstetrician-gynecologists. J Addict Med, 2014; 8(1):14–24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24317354

128. Walsh RA, Lowe JB, and Hopkins PJ. Quitting smoking in pregnancy. Medical Journal of Australia, 2001; 175(6):320–3. Available from: http://www.mja.com.au/public/issues/175_06_170901/walsh/walsh.html

129. Chertok IR and Archer SH. Evaluation of a midwife- and nurse-delivered 5 a's prenatal smoking cessation program. Journal of Midwifery and Women's Health, 2015; 60(2):175–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25782851

130. Agaku IT, Olaiya O, Quinn C, Tong VT, Kuiper NM, et al. A mixed-methods assessment of a brief smoking cessation intervention implemented in ohio public health clinics, 2013. Maternal and Child Health Journal, 2015; 19(12):2654–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26179721

131. Miller M and Wood L. Review of evidence and implications for best practice in health care settings. Final report august 2001. Canberra: Commonwealth Department of Health and Ageing, 2002. Available from: http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-pubhlth-publicat-document-smoking_ces-cnt.htm/$FILE/smoking_ces.pdf.

132. Kumar R, Stevenson L, Jobling J, Bar-Zeev Y, Eftekhari P, et al. Health providers' and pregnant women's perspectives about smoking cessation support: A com-b analysis of a global systematic review of qualitative studies. BMC Pregnancy Childbirth, 2021; 21(1):550. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34384387

133. Flemming K, Graham H, McCaughan D, Angus K, Sinclair L, et al. Health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period: A systematic review of qualitative research. BMC Public Health, 2016; 16(1):290. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27030251

134. Gamble J, Grant J, and Tsourtos G. Missed opportunities: A qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women. Women Birth, 2015; 28(1):8–15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25438715

135. Hoek J, Gifford H, Maubach N, and Newcombe R. A qualitative analysis of messages to promote smoking cessation among pregnant women. BMJ Open, 2014; 4(11):e006716. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25431224

136. Klein EG, Macisco J, Lazard A, Busho A, Oslock A, et al. Framing pregnancy-related smoking cessation messages for women of reproductive age. Addict Behav Rep, 2020; 12:100290. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32637566

137. Trotter L and Montague M. Promoting smoking cessation among pregnant wormen: Routine antenatal care guidelines. Health Promotion Journal of Australia, 2003; 14(2):90–5.

138. Centre for Clinical Studies. Clinical practice guideline for smoking cessation in pregnancy. Brisbane: Mater Health Services, 2005.

139. Hickling JA and Hoey M. Evaluation of the South Australian “smoke-free pregnancy project”. Adelaide: Tobacco Control Research & Evaluation Program, 2006. Available from: http://www.quitnow.info.au/internet/quitnow/publishing.nsf/Content/evaluation-reports.

140. Fiore MC, Jaén M, Carlos Roberto, Baker TB, Bailey WC, Benowitz NL, et al. Treating tobacco use and dependence. Clinical practice guidelines. Rockville, MD: US Department of Health and Human Services, 2008. Available from: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.

141. Oag D Quit South Australia. National smoke-free pregnancy project : Workplan. June.Canberra, ACT: Australian Government Department of Health and Ageing, 2007.

142. Bailey B and Wright H. Assessment of pregnancy cigarette smoking and factors that predict denial. American Journal of Health Behavior, 2010; 34(2):166–76. Available from: www.ncbi.nlm.nih.gov/pubmed/19814596

143. Stanton W, Lowe J, Moffat J, and Del Mar C. Randomised control trial of a smoking cessation intervention directed at men whose partners are pregnant. Preventive Medicine, 2004; 38(1):6–9. Available from: www.ncbi.nlm.nih.gov/pubmed/14672636

144. Bar-Zeev Y, Bonevski B, Lim LL, Twyman L, Skelton E, et al. Improving health providers smoking cessation care in pregnancy: A systematic review and meta-analysis. Addictive Behaviours, 2019; 93:29-38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30684819

145. Lee PN. Maternal smoking during pregnancy and offspring iq. International Journal of Epidemiology, 2006; 35(2):491; author reply –2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16434433