Tobacco Use in Pregnancy and Preconception
Written by Sondos Kasab, Pharm.D. candidate and Regina Ginzburg, Pharm.D., CDCES, BC-ADM
Tobacco use can interfere with fertility.1,2 In people with testes, tobacco use can lead to sperm defects. In people with uteruses, tobacco smoke leads to increased testosterone and decreased estradiol and progesterone levels. This hormonal imbalance decreases the ovarian reserve and disrupts ovulation.2
Perinatal risks of tobacco use include orofacial clefts, fetal growth restriction, placenta previa, placental abruption, preterm premature rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function.3 Children of those who smoke during pregnancy are at higher risk of respiratory infections, asthma, infantile colic, bone fractures, and childhood obesity. Secondhand tobacco exposure during pregnancy is associated with similar risks and complications.
All those who are pregnant or planning a pregnancy should be informed of the significant risks associated with tobacco use.3,4 The pre-pregnancy period is an important time to assist parents-to-be to stop smoking permanently to prevent tobacco-related pregnancy and long-term health complications.
During pregnancy, the greatest benefit of smoking cessation is before 15 weeks gestation, as smoking in the third trimester has the strongest association with fetal growth restriction.3,5 However, quitting at any point in pregnancy can yield benefits. Pregnancy influences many to stop smoking and approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy.3 Effective psychosocial interventions with counseling, health education, incentives, and peer or social support are recommended by the World Health Organization.6
There is currently insufficient evidence for using nicotine replacement therapy (NRT) during pregnancy.3 In one systematic review, NRT was linked to increased rates of smoking cessation during pregnancy but not long-term cessation.7 Efficacy has been inconsistent, likely due to low adherence rates. Additionally, increased metabolism of nicotine in pregnancy can lead to lower nicotine levels. Therefore, NRT can be cautiously considered if counseling alone is ineffective and only after a comprehensive discussion with the patient about the known risks of continued smoking, the possible risks of NRT, and the need for close supervision.3,8 Possible risks associated with NRT include infantile colic and attention deficit hyperactivity disorder. However, congenital abnormalities and developmental delays have not been associated with NRT.9
Two oral tablets have been approved for smoking cessation therapy: bupropion and varenicline.10,11 Bupropion antagonizes nicotinic receptor function and can decrease withdrawal symptoms.12 Varenicl “reward” from smoking.10 The use of either medication, however, is not recommended during pregnancy.6 Although varenicline has not been shown to be teratogenic in small studies and does not increase the risk of major congenital malformations or other adverse birth outcomes, some animal studies have shown pregnancy-related adverse outcomes like decreased fetal weight.10,13 Bupropion crosses the placenta;11 while it has not been shown to increase the risk of overall congenital malformations, there is conflicting evidence regarding cardiovascular malformations.11
Currently, the recommended modality of smoking cessation in pregnancy is intensive behavioral therapy, which includes multiple individual or group counseling sessions.8 Digital modalities, such as messaging, smartphone applications, artificial intelligence-based or internet-based interventions, can also be offered. The table below exhibits some examples of online resources that can be used for assistance to quit smoking. NRT products should only be considered if behavioral therapy alone has not produced adequate smoking cessation.
| Organization | Services Offered |
|---|---|
| US Centers for Disease Control and Prevention | Telephone Text messaging Phone app (free) |
| Substance Abuse & Mental Health Services Administration | Telephone |
| QuitNow | Phone app (cost involved) |
| Kwit | Gamification phone app (cost involved) |
| Smokefree | Phone app with milestone tracking and daily goals (cost involved) |
| Max Kirsten Quit Smoking NOW | Phone app with hypnotherapy (cost involved) |
| ButtOut | Phone app with community chats & milestone maker |
RHAP Resources:
Partner Resources:
Reproductive Health Hotline (ReproHH)
A free, confidential phone service (1-844-737-7644) offering evidence-based clinical information for healthcare providers across the US who have questions related to sexual and reproductive health.
Sources:
10. Chantix (varenicline). Package insert. Pfizer Labs. 2009.
11. Zyban (bupropion). Package insert. GlaxoSmithKline. 2021.
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