Management of tobacco smoking during pregnancy

Pregnancy is often the time of highest motivation for a person to make changes to tobacco use. It can also be an opportunity for a clinician to provide prospective parents (and others who will be involved with a newborn) with help in managing smoking.

Smoking during pregnancy exposes the fetus to nicotine and other harmful chemicals that increase the risks of spontaneous abortion, premature delivery, intrauterine growth restriction, sudden infant death syndrome and neonatal nicotine withdrawal syndrome. Neurocognitive and neurobehavioural deficits in older children are also associated with fetal exposure to smoking.

Behavioural interventions in pregnancy are safe and effective. These are first-line treatment in pregnancy. Nicotine replacement therapy (NRT) exposes the fetus to less nicotine than would heavy smoking; NRT also removes the risks from other chemicals in tobacco. Intermittent use of medium- and fast-acting NRT (eg gum, lozenges, inhalators) is preferable to using patches, which result in continuous nicotine replacement. If intermittent NRT is unsuccessful, the 16-hour NRT patch can be added; the patch should be removed before bed,Bar-Zeev, 2018 with the goal of reducing total daily exposure of the fetus to nicotine and maximising placental blood flow overnight.

The use of varenicline or bupropion in pregnancy requires consideration of the individual balance of harms and benefits. The uncertainty of the effects of these medications in pregnancy and on long-term development needs to be balanced against the well-known risks of tobacco smokingTran, 2020. Use of varenicline or bupropion is only considered if NRT is ineffective or not tolerated (eg because of marked nausea in pregnancy).