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    TOBACCO AND PREGNANCY

     

     

    Prevalence

     
    • During 2009-2011, 19% of women reported smoking during the three months prior to pregnancy.  Approximately 58% of those women were able to stop smoking by the last three months of pregnancy.  However, only about 32% were able to maintain smoking cessation in the postpartum period.1
    • Smoking during the last three months of pregnancy was highest among White, non-Hispanic women (12%) and those 1

     

     

     

    Health Impact

    Smoking cessation prior to 15 weeks gestation produces the greatest maternal and fetal benefits.  However, quitting smoking at any point yields substantial health benefits.2
     

    Effects of Smoking

    • Ectopic Pregnancy2,3
      •   The fertilized ovum implants outside of the uterus, most commonly in the fallopian tubes.3
    • Spontaneous Abortion (Miscarriage)3
      • The involuntary loss of an intrauterine pregnancy prior to 20 weeks of gestation.3
    • Placenta Previa2,3
      • he placenta partially or completely obstructs the cervical os, which frequently prompts delivery by Caesarean section.he placenta partially or completely obstructs the cervical os, which frequently prompts delivery by Caesarean section.3
      • If smoking during pregnancy were eliminated, an estimated 10% of abnormal placentation cases could be avoided.3
    • Placental Abruption2,3
      • he placenta detaches from the wall of the uterus before delivery and can lead to preterm birth, stillbirth, or infant death.he placenta detaches from the wall of the uterus before delivery and can lead to preterm birth, stillbirth, or infant death.3
      • Compared to nonsmokers, the risk of placental abruption is an estimated 1.4 to 2.4 times higher among smokers.3
    • Prreterm Premature Rupture of Membranes (PPROM)reterm Premature Rupture of Membranes (PPROM)2,3
      • The rupture of the amniotic sac prior to the onset of labor is called premature rupture of membranes (PROM).he rupture of the amniotic sac prior to the onset of labor is called premature rupture of membranes (PROM).  When this occurs before 37 weeks gestation, it is known as preterm PROM (PPROM).3
    • Preterm Delivery2,3
      • Delivery before 37 weeks gestation is considered preterm.3
      • An estimated 5-8% of preterm deliveries and 5-7% of preterm-related infant deaths can be attributed to prenatal maternal smoking.2
    • Intrauterine Growth Restriction (IUGR)2,3
      • IUGR is reduced fetal growth during gestation, specifically the lowest 10% of birth weights for any gestational age.3
      • If all women were nonsmokers during pregnancy, the occurrence of IUGR could be reduced by an estimated 30%.3
    • Low Birth Weight (LBW)2,3
      • LBW is defined as less than 2,500g at birth and is the leading cause of infant death.3
      • If all women were nonsmokers during pregnancy, the occurrence of LBW could be reduced by an estimated 20%.3
    • Infant Mortality and Stillbirths2,3
      • Stillbirth is fetal death occurring after 28 weeks gestation.  Infant mortality is defined as death within the first year of life.3
      • Smoking during pregnancy is linked to approximately 1,000 infant deaths annually.4
    • Sudden Infant Death Syndrome (SIDS)2
      • An estimated 23-24% of cases of SIDS can be attributed to prenatal maternal smoking.2
    • Impact on Child’s Health:
      • Asthma2
      • Infantile colic2
      • Childhood obesity2

     

    Effects of Secondhand Smoke

    • Like primary tobacco exposure, secondhand smoke also increases the risk for adverse obstetric and pediatric outcomes and should be avoided.2
    • Exposure to secondhand smoke during pregnancy increases the risk of:
      • Spontaneous abortion (miscarriage)5
      • Preterm birth5
      • Low birth weight5
      • Sudden infant death syndrome (SIDS)5
    • Children that breathe in secondhand smoke experience more:
      • Ear infections5
      • Coughs and colds5
      • Respiratory infections like bronchitis and pneumonia5
      • More frequent and severe asthma attacks5
      • Tooth decay5

     

    Screening

    “The USPSTF [U.S. Preventive Services Task Force] recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.” Level A recommendation4
    • Physicians should screen all pregnant patients at the first prenatal visit as well as throughout the course of the pregnancy.2
    • Incorporate the impacts of tobacco on pregnancy and infant health, as detailed above, in the counseling of pregnant patients.2
     

    What If Screening Is Positive?

    All patients identified as smokers should be given resources to assist with quitting, e.g. 1-800-QUIT-NOW.2  More Resources
     

    Pharmacotherapy

    In Pregnancy

    • The U.S. Preventive Services Task Force (USPSTF) concluded that there is inadequate evidence to evaluate the safety or efficacy of pharmaceuticals for smoking cessation [including nicotine replacement therapies (nicotine gum, patch, lozenge, inhaler, or nasal spray), Varenicline (Chantix®), and Bupropion (Zyban®)] during pregnancy.2,4
      • Clinical trials studying the use of nicotine replacement therapy in pregnancy have been attempted, but in the United States, they have all been ended prematurely due to adverse pregnancy effects or failure to demonstrate effectiveness.2
    • The American College of Obstetricians and Gynecologists (ACOG) states that nicotine replacement therapy in pregnancy should only be used in a patient highly motivated to quit, after careful discussion about the risks of smoking and that of nicotine replacement therapy, and under close supervision.2
      • ACOG also states that in pregnancy Varenicline and Bupropion should only be used with caution and in consultation with experienced prescribers due to the risk of depression and suicidality with their use.2

     

    In Breastfeeding

    • The USPSTF concluded that there is insufficient evidence to assess the safety or efficacy of medications for smoking cessation during lactation.2
    • ACOG advises that nicotine replacement therapy during lactation only be used in patients clearly determined to quit, after thorough discussion about the risks of smoking and that of nicotine replacement therapy, and under careful supervision.2
    • ACOG also states that in lactation Varenicline and Bupropion should only be used with vigilance and in consultation with experienced providers due to the risk of depression and suicidality with their use.2
     

     
    Resources
     
    1. Maryland PRAMS Report 2009-2011 Births. Available Online: http://phpa.dhmh.maryland.gov/mch/Documents/PRAMS_Phase_6_Report_Web_040213.pdf.
    2. American College of Obstetricians and Gynecologist. (2010). ACOG Committee Opinion 471: Smoking Cessation During Pregnancy. Washington, DC: American College of Obstetricians and Gynecologist.  Available Online: http://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/co471.pdf?dmc=1&ts=20141016T2151542849 
    3. 2004 Surgeon General’s Report – The Health Consequences of Smoking. Retrieved October 6, 2014 from Centers for Disease Control and Prevention Website: http://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/index.htm.
    4. Final Recommendation Statement: Tobacco Use in Adults and Pregnant Women: Counseling and Interventions. Retrieved October 7, 2014 from U.S. Preventive Services Task Force Website:  http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions.
    5. The Dangers of Secondhand Smoke. Retrieved October 7, 2014 from healthychildren.org Website: http://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx.
     
     
     
    October 2014