7.11 Smoking cessation and pregnancy

Last updated: September 2021

Suggested citation: Greenhalgh, EM., Jenkins, S., Stillman, S., & Ford, C. 7.11 Smoking cessation and pregnancy. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. 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.3  

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

Of Australian women who gave birth in 2019, 10.2% smoked at some time during their pregnancy. Just under one in ten women (9.0%) reported smoking during the first twenty weeks of their pregnancy and 8.1% reported smoking after 20 weeks. This reduction is mostly due to women quitting during early pregnancy, with about 1 in 5 women who smoked in the first 20 weeks of pregnancy quitting after 20 weeks.4, 5 A longitudinal study in NSW found that most women who smoked during their first pregnancy continued to smoke in their second, even those who experienced poor outcomes.6

See Section 1.10.1 for more information on rates of smoking during pregnancy. 

7.11.2.1 Smoking during pregnancy and social disadvantage

See also Chapter 1 Section 1.10 and Chapter 9 Section 9.5

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.7-17 Women who smoke during pregnancy are also significantly more likely to drink alcohol, compounding their risk of poor pregnancy outcomes.18 Disadvantaged women may also be more likely to take up smoking during pregnancy or in the early postpartum period,19 and be less likely to quit and more likely to start smoking in their second pregnancy.6

 Of Australian mothers who gave birth in 2019, those living in the most disadvantaged areas were six times more likely to smoke during the first 20 weeks compared to those in the least disadvantaged areas (17.1% compared to 2.8%). Younger women were more likely to smoke during pregnancy than older women: almost one third of pregnant women under 20 (31.7%) reported smoking in the first 20 weeks of pregnancy in 2019. One-third (34.7%) of mothers living in very remote areas smoked during the first 20 weeks, compared to 19.6% in remote areas and 6.7% in major cities. About two in five (43%) Aboriginal and Torres Strait Islander women reported smoking during pregnancy in 2019.5 See Section 8.3.7 for more information on smoking prevalence among pregnant Aboriginal and Torres Strait Islander women. Not attending prenatal classes and experiencing stressful events before or during pregnancy are also associated with smoking.20

7.11.3 Factors that predict success or failure to quit during and post pregnancy

Many women who quit smoking during pregnant relapse within the first year of their child’s life, especially if their partner smokes or they live with other smokers.22 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.23

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.24, 25 Women who are more highly educated and less dependent on nicotine have higher odds of quitting during pregnancy.26 Breastfeeding for at least three months also seems to promote lower rates of smoking.27 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.28

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.22, 25, 29-32 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.33 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.34 The social networks of disadvantaged young women can undermine their smoking cessation efforts.35 Young women in Western Australia cited fear of being left out as a barrier to smoking cessation.36 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.37 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.21

Motivation to stay quit can differ between pregnancy and post-birth.38-40 For some pregnant women, quitting is a temporary suspension of habit, rather than a permanent change.41 Women who quit smoking later in pregnancy have been found to be more likely to relapse post-pregnancy. 32

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 2, 16, 42 and relapse19, 32.  Women who experience postpartum depressive symptoms43 and stress44 are also more likely to relapse, and more likely to take up smoking during and post pregnancy.19  

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.45-47 Having a partner who smokes is one of the strongest predictors of continued smoking among new mothers.48 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.7, 49

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.10, 50 There is some evidence that maternal smoking during pregnancy predicts parenting stress in infancy.51 Screening and treatment of depressive and anxiety symptoms during pregnancy and postpartum is one possible method of reducing continued smoking, relapse and uptake.19, 43, 50, 52, 53 Research suggests that pregnant women with high levels of depressive symptoms may also benefit from depression-focused treatment during pregnancy54 and from relapse prevention interventions tailored to psychosocial needs post-partum.55  

Further research is needed to develop suitable interventions for pregnant smokers with substance use disorders.14, 56 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.57 Opioid-dependent pregnant women show a particularly high prevalence of smoking, likely due to the effect of opioids on nicotine metabolism58, and are at greater risk for additional adverse health effects for themselves and their babies.59

Concern about weight gain following cessation can be a barrier to successful quitting.31, 60 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.61, 62 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,63, 64 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.65

 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.2, 66 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.67

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.2, 66

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.2, 66

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.69 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.71 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.72 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.74 A 2015 review concluded that incentives combined with behavioural therapy appear to show the greatest promise for promoting cessation among pregnant women,75 and such incentives appear to be highly cost-effective.76 Public opinion about providing financial incentives during pregnancy is mixed, but tends to be more negative among women, which may be problematic for uptake.77, 78

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.79 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.80 Another US study found telephone counselling for recently quit pregnant smokers did not appear to reduce the risk of relapse.81 Pregnant and postpartum women are less likely to use telephone support if they have to initiate the contact.82

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.83 There is evidence that text messaging and computer-based interventions for pregnant smokers may be effective for smoking cessation.87 ‘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.92  

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.94 Though cognitive behavioural strategies, such as positive ‘self-talk’ and avoiding being around other smokers, may be helpful in preventing lapses.95 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.96 As discussed previously, smokefree homes are important in supporting cessation.47, 97 There is a short-term increase in the proportion of smokefree homes following birth98 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.29 Another review concluded that there is limited evidence regarding the success of interventions to reduce environmental tobacco smoke, and called for further research.99

Although pregnant women are advised to abruptly quit smoking to minimise health risks, cutting down on cigarette consumption is a commonly reported practice.101 Australian research found that more than two-thirds of women smokers in maternity hospitals preferred to stop smoking gradually.102 Women who are pregnant often receive mixed messages from health professionals about the benefits of cutting down as opposed to quitting smoking altogether.103 There is some evidence that reducing consumption to fewer than eight cigarettes per day can improve birthweight104 and reduce preterm birth.105 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, andfelt 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.101 However, Australian106 and UK103 guidelines state that health professionals should be recommending complete abstinence to pregnant women in order to maximise health benefits. See also Section 18.3 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.102 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.107-109 Behavioural interventions among pregnant women benefit cessation and perinatal health, and are recommended as first-line treatments.110 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.45, 111 This helps to avoid high levels of nicotine in the foetal circulation.75

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.112

One study has suggested that NRT patches deliver an inadequate dose of nicotine to aid smoking cessation during pregnancy.113 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.114  Further research is also needed as to whether the use of NRT during pregnancy is a cost effective strategy.115

There is evidence that pregnant women are reluctant to use NRT1 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.117, 118 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.119

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.112, 121 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.122 Another Australian study observed higher rates of cessation among women who used varenicline during pregnancy compared to those who used NRT.123 A clinical trial of nicotine inhalators for cessation during pregnancy found lower rates of preterm delivery but poor efficacy for smoking cessation.124 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.125

Some women report using e-cigarettes for smoking cessation during pregnancy, however there is insufficient evidence for their effectiveness in this context.126 See Section 18B.5.1 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’.9 This continues to be a key recommendation of guidelines for treating tobacco use and dependence among pregnant women.45, 127 If possible, cessation interventions should be also be integrated into existing services that deal with sexual, reproductive, and child health.45

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.99 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%.128 Less than half of smokers in two large Australian maternity hospitals reported that their health professionals discouraged smoking during pregnancy.102 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.129 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.130 A large survey in the US in 2012 found that, compared with 1998, ob-gyns were less likely to adhere to the 5A guidelines.131 Midwives tend to deliver interventions at a higher rate than doctors,132 and training midwives to deliver the 5As can promote higher reduction and cessation rates among pregnant women.133

While asking about smoking status during consultations and encouraging and supporting quitting is part of national guidelines in a number of countries, including Australia,45 some health professionals continue to find discussion of smoking behaviour with pregnant women difficult.99 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.99 Some Australian GPs also report focusing on harms of smoking to pregnancy and providing treatment options only to patients motivated to quit. 118 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.134 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.135 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).99, 118, 136 Health professionals also cite the association between maternal smoking and social disadvantage as a considerable barrier to addressing and supporting cessation.137

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.99 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.138 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.139 Though another study found smoking women considered gain-framed messages more effective than loss-framed messages.140

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.45 This approach has been implemented in a number of antenatal services across Australia.141-145 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.142, 144, 145 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.146

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.9, 142, 144  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.147 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.148

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.99 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.149

 

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References

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