Clinical Practice Guidelines Antenatal care - Module I

10.1 Tobacco smoking

Page last updated: 02 April 2013

Health professionals have an important role in advising women of the risks associated with smoking in pregnancy, assessing smoking status on first contact with a woman and supporting efforts to stop or reduce smoking at subsequent contacts.

The effects of tobacco smoking on an individual’s health are well documented. Tobacco smoking in pregnancy is a risk factor for complications, and is associated with low birth weight, preterm birth, small-for-gestational-age babies and perinatal death (Laws et al 2006). While the prevalence of smoking in pregnancy has declined in high-income countries over the last decade, this decline has not been consistent across all sectors of society.

Women who continue to smoke in pregnancy generally have a low income, have a high number of previous births, are without a partner, have low levels of social support, receive publicly funded maternity care, have limited education and are more likely to feel criticised by society (Graham 1977; Frost et al 1994; Graham 1996; Tappin et al 1996; US DHHS 2004; Ebert & Fahy 2007). Globally, there is a significantly higher prevalence of smoking in pregnancy in several Indigenous and ethnic minority groups, including Aboriginal and Torres Strait Islander women, which is in accord with their social and material dispossession (Wiemann et al 1994; Kaplan et al 1997; Chan et al 2001; Hunt 2003; US DHHS 2004).

10.1.1 Background

Smoking during pregnancy among Australian women
  • General population — A considerable number of Australian women (around 16% in 2008) smoke during pregnancy (Laws et al 2010). The rate varies between jurisdictions (eg almost 13% in NSW and the ACT compared to around 28% in NT and Tasmania).
  • Adolescent women — A high proportion of adolescent women (39%) smoked during pregnancy in 2008 (Laws et al 2010).
  • Aboriginal and Torres Strait Islander women — Around half of Aboriginal and Torres Strait women (50.9%) smoked during pregnancy in 2008 (Laws et al 2010). Aboriginal and Torres Strait Islander women are considerably more likely to become pregnant before the age of 20 (21% versus 4% in the general population in 2009)(AIHW 2011) and these young women are more likely to smoke during pregnancy than non-Indigenous adolescents (Lewis et al 2009).
  • Women with serious mental health disorders — Prevalence of smoking during pregnancy is higher among women with serious mental disorders than among women in general (eg 51% vs 24% for women with schizophrenia [Nilsson et al 2002]). A considerable proportion of adverse pregnancy outcomes among women with serious mental health disorders is attributable to smoking (Hauck et al 2008; King-Hele et al 2009; Matevosyan 2011).

Risks associated with smoking during pregnancy

High-level evidence identified in the NICE guidelines indicates a significant association between smoking in pregnancy and adverse outcomes. These include:
  • birth defects including cleft lip and palate (Wyszynski et al 1997);
  • effects on the pregnancy including perinatal mortality (DiFranza & Lew 1995), placental abruption (Ananth et al 1999; Castles et al 1999), preterm premature rupture of membranes (Castles et al 1999), ectopic pregnancy (Castles et al 1999), placenta praevia (Castles et al 1999), preterm birth (Shah & Bracken 2000), and miscarriage (DiFranza & Lew 1995);
  • effects on the baby, in particular reduced birth weight (with babies born to smokers being a consistent 175–200 g smaller than those born to similar non-smokers) (Lumley 1987), small-for-gestational-age baby (Clausson et al 1998), stillbirth (Raymond et al 1994), fetal and infant mortality (Kleinman et al 1988) and sudden infant death syndrome (DiFranza & Lew 1995); and
  • although studies into long-term effects report conflicting results (Faden & Graubard 2000; MacArthur et al 2001; von Kries et al 2002), there is evidence of an association between low birth weight and coronary heart disease, type 2 diabetes and adiposity in adulthood (Gluckman et al 2008).
Passive smoking (exposure to second-hand or environmental tobacco smoke) during pregnancy may also be associated with increased risk of low birth weight or preterm birth (Khader et al 2010).
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10.1.2 Assessing smoking status

While many women who smoke quit spontaneously before their first antenatal visit, a significant proportion will relapse during or after pregnancy (Panjari et al 1997). Other women may not be aware of the risks associated with smoking in pregnancy or find it difficult to quit. It is important that women are asked early in pregnancy about their smoking status and whether others in the household smoke.

Women may feel guilty or stigmatised if they smoke during pregnancy, and as a result may deny or underreport their smoking (Walsh et al 1996; Windsor et al 1998; Gilligan et al 2009 a). Questions about smoking should be phrased in a non-judgmental way, or collected using a written questionnaire rather than verbally, for example using a multiple-choice question as outlined below.
‘Which of the following statements best describes your cigarette smoking?
  • I smoke daily now, about the same as before finding out I was pregnant
  • I smoke daily now, but I’ve cut down since I found out I has pregnant
  • I smoke every once in a while
  • I quit smoking since finding out I was pregnant
  • I wasn’t smoking around the time I found out I was pregnant and I don’t currently smoke.’
Specific resources to assist with assessing smoking status are available (see Section 10.3.6).

Recommendation - Grade A

23. At the first antenatal visit:
  • assess the woman’s smoking status and exposure to passive smoking;
  • give the woman and her partner information about the risks to the unborn baby associated with maternal and passive smoking; and
  • if the woman smokes, emphasise the benefits of quitting as early as possible in the pregnancy and discuss any concerns she or her family may have about stopping smoking.

10.1.3 Interventions to assist women to stop smoking

Pregnancy is a time when women who smoke may be more receptive to quitting (McDermott et al 2004) and there are many opportunities for supporting women to quit at this time. This section summarises the available evidence on smoking cessation interventions in pregnancy. Discussion of ways to support people to quit smoking is included in specific smoking cessation guidelines (see Section 10.1.6).

Summary of the evidence

There is high-level evidence, based on systematic reviews and RCTs, that smoking cessation interventions reduce smoking rates in pregnant women. A Cochrane review (Lumley et al 2009), which is the largest study on this topic to date, found that interventions:
  • improved smoking cessation rates by 6% (RR 0.94; 95% CI 0.93–0.96); and
  • reduced rates of low birth weight (RR 0.83; 95% CI 0.73–0.95) and preterm birth (RR 0.86; 95% CI 0.74–0.98) and there was a 53.91g increase in mean birth weight (95% CI 10.44–95.38g).
Of the interventions studied, cognitive behavioural interventions (including educational strategies and motivational interviewing; see Glossary) (RR 0.95; 95% CI 0.93–0.97) were similar in effect to interventions in general. Incentives (eg vouchers) increased the effectiveness of interventions (RR 0.76; 95% CI 0.71– 0.81), while using the ‘stages of change’ theory (RR 0.99; 95% CI 0.97–1.00) or providing feedback to the mother (eg fetal health status) (RR 0.92; 95% CI 0.84–1.02) did not. While nicotine replacement therapy (NRT) was as effective as cognitive behaviour therapy (CBT) (RR 0.95; 95% CI 0.92–0.98), there is no clear evidence on its safety during pregnancy.

Other recent studies are consistent with the Cochrane review. Additional findings include that:
  • telephone-based support combined with face-to-face sessions is beneficial (Dennis & Kingston 2008);
  • providing information (eg at ultrasound appointments) has a significant effect (Stotts et al 2009); and
  • smoking cessation may be influenced by concern about weight gain (Berg et al 2008).
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Cost-effectiveness of interventions

An economic analysis conducted to inform the development of these Guidelines (see Appendix E) found that smoking cessation interventions for both pregnant women and the wider population may be costeffective from both a health system and societal perspective.

CBT and NRT have the same effect on life-years saved but the cost to the health system for NRT is lower. However, NRT is not an appropriate option for women who smoke less than 10 or 15 cigarettes a day (Hotham et al 2006) and CBT is likely to be more successful in these women. Also, a woman’s out-of-pocket costs are higher for NRT. If the health system were to cover the total costs of treatment, CBT would be the more cost-effective option.

Recommendation - Grade A

24. Offer women who smoke referral for smoking cessation interventions such as cognitive behavioural therapy.

Supporting smoking cessation

Antenatal care is an opportunity to provide women with information about interventions that have been identified as effective (see above), are available locally or through the phone or internet, and are suitable to the individual woman’s age, education level, intellectual capacity, language and/or cultural factors and motivation. Providing written or other form of information can reinforce this advice.

Practice point

y. At each antenatal visit, offer women who smoke personalised advice on how to stop smoking and provide information about available services to support quitting, including details on when, where and how to access them.

Pharmacological therapy

While the safety or otherwise of single-agent NRT in pregnancy has not been established (Lumley et al 2009), a large cohort study (Lassen et al 2010) found no serious effect on birth weight unless more than one type of NRT product was used.
NRT appears to be effective in reducing smoking among pregnant women with nicotine dependence (Smith et al 2006; Oncken et al 2008). Prescribing NRT or other pharmacological therapy requires consideration of the risks from the treatment versus the benefits of the woman not smoking. If NRT is prescribed, women should be advised that smoking while using NRT leads to high nicotine levels.

Recommendation - Grade B

25. If, after options have been explored, a woman expresses a clear wish to use nicotine replacement therapy, discuss the risks and benefits with her.

Practice point

z. If nicotine replacement therapy is used during pregnancy, intermittent–use formulations (gum, lozenge, inhaler and tablet) are preferred to continuous-use formulations (nicotine patches).

Reducing smoking if quitting is not possible

Women who are unable to quit during pregnancy often reduce the number of cigarettes that they smoke. This can reduce nicotine concentrations and offer some measure of protection for the fetus, with a 50% reduction being associated with a 92g increase in birth weight (Li et al 1993; Windsor et al 1999). However, the greatest health benefits for the woman and baby are from quitting completely.

Monitoring and relapse prevention

Even where women are motivated to quit smoking in pregnancy, they may relapse either later in the pregnancy or after the birth. Health professionals should reinforce quitting behaviours and continue to monitor all women who have recently quit about their willingness to stay smoke free. Partner smoking is highly correlated to relapse so it may be beneficial to extend the offer of smoking cessation support strategies to the woman’s partner.

At each visit, congratulate the woman for having quit, review and reinforce the reasons for quitting, and encourage the non-smoker image. Discuss some high-risk times for relapse, such as late pregnancy, post-partum and after breastfeeding has stopped. Remind the woman about useful resources and sources of support (RACGP 2007). Continue to advise women who are trying to reduce their exposure to passive smoking.
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Practice point

aa. Smoking status should be monitored and smoking cessation advice, encouragement and support offered throughout pregnancy.

10.1.4 Considerations among specific population groups

As discussed in Section 10.1.1, the prevalence of smoking among Aboriginal and Torres Strait Islander women is high, with around half of women smoking in pregnancy. The recommendations given in the preceding sections apply to all women in the antenatal period. This section outlines additional considerations and approaches that may assist in supporting Aboriginal and Torres Strait Islander women and adolescent women to quit smoking. Having an understanding of community attitudes to smoking and language used when referring to tobacco products will support both assessment and intervention.

Aboriginal and Torres Strait Islander women

A range of factors has contributed to the relatively high proportion of Aboriginal and Torres Strait Islander women who smoke and continue to smoke in pregnancy. These include:
  • the ‘normalisation’ of tobacco use within many Aboriginal and Torres Strait Islander communities in which smoking continues to play a key role in social interaction and relationship building (Harvey et al 2002; Briggs et al 2003; Power et al 2009);
  • continuing socioeconomic disadvantage (Power et al 2009); and
  • the potential for children and non-smoking adults to be exposed to tobacco smoke in larger households (Cunningham 1994; Briggs et al 2003; ABS 2006).
At the individual level, knowledge and attitudes influence smoking behaviour. Qualitative research into the context surrounding smoking among Aboriginal and Torres Strait Islander women has identified some factors that may affect motivation or ability to quit (Heath et al 2006; Wood et al 2008; Gilligan et al 2009b):
  • smoking provides an opportunity for ‘time out’ from social pressures and for ‘sharing with others’;
  • smoking is perceived as reducing stress, easing social interaction, relieving boredom and controlling weight;
  • smoking may be seen as a less immediate problem relative to other issues; and
  • high levels of smoking by the woman’s partner or among family and friends make it harder to quit.
In some areas, women may use chewing tobacco (with or without pituri1) and enquiry about this may also be useful.

Practice points

bb. Health care professionals involved in the care of Aboriginal and Torres Strait Islander women should be aware of the high prevalence of smoking in some communities, and take account of this social norm when discussing smoking and supporting women to quit.
cc. Culturally appropriate smoking cessation services should be offered.

Effective smoking cessation interventions

A recent review of evidence regarding smoking cessation and prevention programs for Aboriginal and Torres Strait Islander Australians (Power et al 2009) identified that:
  • strategies at the individual level such as culturally appropriate counselling and/or NRT are likely to be effective for Aboriginal and Torres Strait Islander people who are motivated to quit;
  • brief interventions may be effective (Harvey et al 2002);
  • group-based programs need to be tailored to individual needs;
  • health workers who are able to quit smoking themselves will be in a stronger position to be a role model for others; and
  • a range of health promotion resources are available and may be used to support other interventions.

National action to reduce smoking in Aboriginal and Torres Strait Islander communities

The Australian Government is funding a national network of regional tobacco coordinators and tobacco action workers to work with Aboriginal and Torres Strait Islander communities to reduce the number of people smoking. This workforce will implement a range of community-based smoking prevention, awareness raising and cessation support activities tailored to local communities.
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Practice point

dd. In discussing smoking and supporting Aboriginal and Torres Strait Islander women to quit smoking, health professionals should draw on the expertise of anti-tobacco workers where available.

Adolescent women

Smoking is one of a range of risk-taking behaviours engaged in by adolescents. Adolescents who are pregnant and smoke may be at risk of other behaviours that compromise their health and that of the unborn baby (eg drinking alcohol)(Mohsin & Bauman 2005).

Very few studies have investigated the effectiveness of interventions designed to help young people stop smoking and none are specific to pregnancy in this age group. It is likely that interventions aimed at young people need to be different from those developed for adults, given differences in lifestyle and attitudes to smoking and quitting (NZ MOH 2007).

Smoking cessation programs that combine a variety of approaches show promise, including taking into account the young person’s preparation for quitting, supporting behavioural change and enhancing motivation (Grimshaw & Stanton 2010). Nicotine replacement has not yet been shown to be successful with adolescents (Grimshaw & Stanton 2010).

10.1.5 Practice summary — assessing smoking status and supporting women to quit

Assessing smoking status

When — At the first contact with all women and at subsequent contacts for women who report smoking or have recently quit
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
  • Discuss risks to the pregnancy — Explain that smoking during pregnancy makes it more likely that the baby will be born prematurely and that there are other serious risks to the pregnancy that can be life-threatening to mother or baby.
  • Discuss risks to the unborn baby — Discuss the increased risk of the baby having a low birth weight. Explain that this does not just mean that the baby will be small, it is known to contribute to the development of coronary heart disease, type 2 diabetes and obesity in adulthood.
  • Take a non-judgemental approach — Women may feel uncomfortable telling a health professional that they smoke. They may also underreport the amount that they smoke or answer in a way that does not really quantify their level of smoking (eg “half a pack a day”, “socially”). The important message to get across is that if they smoke, stopping smoking is the safest option.
  • Seek information about passive smoking — Women who are exposed to smoke from others smoking around them may be more likely to have low birth weight or premature babies. Explain that smoke-free environments give people of all ages the best chance to be healthy.

Supporting women to stop or reduce smoking

When — At subsequent antenatal contacts with women who smoke or have recently quit
  • Be aware of local smoking cessation programs — Provide women with advice on locally available supports for smoking cessation. Depending on location this may include community support groups, Quitline or State/ Territory quit services.
  • Inform decision-making — Help each woman to select smoking cessation options that are suitable to her needs. For example, NRT would be inappropriate for a woman who does not appear to be nicotine-dependent or only smokes when she is with friends.
  • Continue monitoring — While many women are able to stop smoking when they are pregnant, many relapse either during the pregnancy or after the birth. It is helpful to continue enquiring about a woman’s smoking or passive smoking and to offer advice about quitting or reducing the family’s exposure to smoke.

10.1.6 Resources

Smoking cessation guidelines

Bittoun R & Femia G (2010) Smoking cessation in pregnancy. Obstet Med 3: 90–93. For more information please visit The Royal Society of Medicine Journals website.
Flenady V, New K, MacPhail J (2005) Smoking Cessation in Pregnancy. Clinical Practice Guideline. Working Party on Smoking Cessation in Pregnancy. Brisbane: Centre for Clinical Studies, Mater Health Services. For more information please visit Australia and New Zealand website.
NZ MOH (2007) Guidelines for Smoking Cessation. Wellington: Ministry of Health. For more information please visit New Zealand Ministry of Health website.
RACGP (2007) Smoking Cessation Guidelines for Australian General Practice. Melbourne: Royal Australian College of General Practitioners. For more information please visit - www.racgp.org.au/smoking/9a (This website link was valid at the time of submission).
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Psychological services

The beyondblue website includes a directory of medical and allied health professionals in mental health, including psychologists, clinical psychologists, social workers and mental health nurses.

Government funding to receive treatment from psychiatrists, psychologists, appropriately trained GPs, social workers, occupational therapists and nurses can be accessed through initiatives including Access to Allied Psychological Services (ATAPS), Better Access to Mental Health Care (Medicare items), Better Outcomes in Mental Health Care and the Mental Health Nurse Incentive Program.

Resources for Aboriginal and Torres Strait Islander women

smokecheck NSW website.
smokecheck Queensland — For more information please Queensland Health website.
smokecheck NT — www.healthinfonet.ecu.au/key-resources/programs-projects/ (This website link was valid at the time of submission).

A range of materials on smoking cessation can be found at: Resources that are culturally appropriate to the area should be selected, taking into consideration local language and literacy.

Australian quit services
National quitline
131 848

New South Wales
Tobacco and Health Branch, NSW Health
ph 02 9391 9111
fax 02 9424 5995
Email - tobacco@doh.health.nsw.gov.au
NSW Health Department website

Victoria
QUIT Victoria
ph 03 9663 7777
fax 03 9635 5510
Quit Victoria website

Queensland
Queensland Cancer Fund
ph 07 3258 2200
fax 07 3257 1306
Email - qldcf@qldcancer.com.au (There might be issue with this email as the website related to the website is not working)
http://www.qldcancer.com.au (This website link was valid at the time of submission)
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Western Australia
Tobacco Control Branch,
Department of Health
ph 08 9242 9633
fax 08 9382 0770
Quit WA website

South Australia
QUIT South Australia
ph 08 8291 4141
fax 08 8291 4194
Quit SA website

Tasmania
QUIT Tasmania
ph 03 6228 2921
fax 03 6228 4149
Quit Tasmania website

Australian Capital Territory
ph 02 6257 9999
fax 02 6257 5055
Cancer Council ACT website

Northern Territory
Tobacco Action Project, Department of Health and Community Services
ph 08 8999 2661
fax 08 8999 2420

10.1.7 References

ABS (2006) National Aboriginal and Torres Strait Islander Health Survey 2004–2005. ABS Cat No 4715.0. Canberra: Australian Bureau of Statistics.

AIHW (2011) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander People, An Overview 2011. Cat. no. IHW 42. Canberra: Australian Institute of Health and Welfare.

Ananth CV, Smulian JC, Vintzileos AM (1999) Incidence of placental abruption in relation to cigarette smoking and hypertensive disorders during pregnancy: A meta-analysis of observational studies. Obstetrics Gynecology 93: 622–28.

Berg CJ, Park ER, Chang Y et al (2008) Is concern about post-cessation weight gain a barrier to smoking cessation among pregnant women? Nicotine Tobacco Res 10(7): 1159–63.

Briggs V, Lindorff K, Ivers R (2003) Aboriginal and Torres Strait Islander Australians and tobacco. Tob Control 12(Suppl 2); 5–8.

Castles A, Adams EK, Melvin CL et al (1999) Effects of smoking during pregnancy: Five meta-analyses. Am J Preventive Med 16: 208–15.

Chan A, Keane RJ, Robinson JS (2001) The contribution of maternal smoking to preterm birth, small for gestational age and low birth weight among aboriginal and non-aboriginal births in South Australia. Med J Aust 174(8): 389–93.

Clausson B, Cnattingius S, Axelsson O (1998) Preterm and term births of small for gestational age infants: A populationbased study of risk factors among nulliparous women. Brit J Obstet Gynaecol 105: 1011–17.
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Cunningham J (1994) Cigarette Smoking among Indigenous Australians. Occasional Paper. Canberra: Australian Bureau of Statistics.

Dennis CL & Kingston D (2008) A systematic review of telephone support for women during pregnancy and the early postpartum period. J Obstetric Gynecologic & Neonatal Nursing 37(3): 301–14.

DiFranza JR & Lew RA (1995) Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome. J Family Practice 40: 385–94.

Ebert LM & Fahy K (2007) Why do women continue to smoke in pregnancy? Women & Birth 20: 161–68.

Faden VB & Graubard BI (2000) Maternal substance use during pregnancy and developmental outcome at age three. J Substance Abuse 12: 329–40.

Frost FJ, Cawthorn ML, Tollestrup K et al (1994) Smoking prevalence during pregnancy for women who are and women who are not Medicaid-funded. Am J Preventive Med 10: 91–96.

Gilligan C, Sanson-Fisher R, Eades S et al (2009a) Assessing the accuracy of self-reported smoking status and impact of passive smoke exposure among pregnant Aboriginal and Torres Strait Islander women using cotinine biochemical validation. Drug Alcohol Rev 2009.

Gilligan C, Sanson-Fisher RW, D’Este C et al (2009b) Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women. Med J Aust 190(10): 557–61.

Gluckman PD, Hanson MA, Cooper C et al (2008) Effect of in-utero and early life conditions on adult health and disease. New Engl J Med 359(1): 61–73.

Graham H (1977) Smoking in pregnancy: the attitudes of pregnant mothers. Social Science Med 10: 399–405.

Graham H (1996) Smoking prevalence among women in the European community 1950-1990. Social Science Med 43: 243–54.

Grimshaw G & Stanton A (2006) Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003289. DOI: 10.1002/14651858.CD003289.pub4.

Harvey D, Tsey K, Cadet-James Y et al (2002) An evaluation of tobacco brief intervention training in three Indigenous health care settings in North Queensland. Aust NZ J Public Health 26(5); 426–31.

Hauck Y, Rock D, Jackiewicz T et al (2008) Healthy babies for mothers with serious mental illness: a case management framework for mental health clinicians. Int J Ment Health Nurs 17(6): 383–91.

Heath DL, Panaretto K, Manessis V et al (2006) Factors to consider in smoking interventions for Indigenous women. Aust J Primary Health 12(2): 131–35.

Hotham ED, Gilbert AL, Atkinson ER (2006) A randomised-controlled pilot study using nicotine patches with pregnant women. Addictive Behaviours, 31: 641–48.

Hunt J (2003) Trying to Make a Difference: Improving Pregnancy Outcomes, Care and Services for Australian Indigenous women [thesis]. Victoria: La Trobe University.

Kaplan SD, Lanier AP, Merritt RK et al (1997) Prevalence of tobacco use among Alaska natives: a review. Preventive Med 26: 460–65.

Khader YS, Al-Alkour N, Alzubi IM et al (2010) The Association Between Second Hand Smoke and Low Birth Weight and Preterm Delivery. Matern Child Health J Apr 3 2010. [Epub ahead of print].

King-Hele S, Webb RT, Mortensen PB (2009) Risk of stillbirth and neonatal death linked with maternal mental illness: a national cohort study. Arch Dis Child Fetal Neonatal Ed 94(2): F105–10.

Kleinman JC, Pierre MB Jr, Madans JH et al (1988) The effects of maternal smoking on fetal and infant mortality. Am J Epidemiol 127: 274–82.

Lassen TH, Madsen M, Skovgaard LT et al (2010) Maternal use of nicotine replacement therapy during pregnancy and offspring birthweight: a study within the Danish National Birth Cohort. Paediatr Perinat Epidemiol 24: 272–81.

Laws PJ, Grayson N & Sullivan EA (2006) Smoking and Pregnancy. Cat. no. PER 33. Sydney: AIHW National Perinatal Statistics Unit.

Laws PJ, Li Z, Sullivan EA (2010) Australia’s Mothers and Babies 2008. Perinatal statistics series no 24. Cat no PER 50. Canberra: Australian Institute of Health and Welfare.

Lewis LN, Hickey M, Doherty DA et al (2009) How do pregnancy outcomes differ in teenage mothers? A Western Australian study. Med J Aust 190(10): 537–41.
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Li C, Windsor R, Perkins L, Lowe J et al (1993) The impact on birthweight and gestational age of cotinine validated smoking reduction during pregnancy. JAMA 269: 1519–24.

Lumley J (1987) Stopping smoking. Brit J Obstet Gynaecol 94: 289–92.

Lumley J, Chamberlain C, Dowswell T et al (2009) Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001055. DOI: 10.1002/14651858.CD001055.pub3.

MacArthur C, Knox EG, Lancashire RJ (2001) Effects at age nine of maternal smoking in pregnancy: experimental and observational findings. Brit J Obstet Gynaecol 108: 67–73.

Matevosyan NR (2011) Pregnancy and postpartum specifics in women with schizophrenia: a meta-study. Arch Gynecol Obstet 283(2): 141–47.

McDermott L, Dobson A, Russell A (2004) Changes in smoking behaviour among young women over life stage transitions. Aust N Z J Public Health 28(4): 330–35.

Mohsin M & Bauman AE (2005) Socio-demographic factors associated with smoking and smoking cessation among 426,344 pregnant women in New South Wales, Australia. BMC Public Health 5: 138–47.

Nilsson E, Lichtenstein P, Cnattingius S et al (2002) Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res 58(2–3): 221–29.

NZ MOH (2007) New Zealand Guidelines for Smoking Cessation. Wellington: Ministry of Health.

Oncken C, Dornelas E, Greene J et al (2008) Nicotine gum for pregnant smokers: a randomized controlled trial. Obstet Gynaecol 112(4): 859–67.

Panjari M, Bell RJ, Astbury J et al (1997) Women who spontaneously quit smoking in early pregnancy. Aust NZ J Obstet Gynaecol 37(3): 271–78.

Power J, Grealy C, Rintoul D (2009) Tobacco interventions for Indigenous Australians: a review of current evidence. Health Promotion J Aust 20(3): 186–94.

RACGP (2007) Smoking Cessation Guidelines for Australian General Practice. Melbourne: Royal Australian College of General Practitioners. www.racgp.org.au/smoking/9a (This website link was valid at the time of submission).

Raymond EG, Cnattingius S, Kiely JL (1994) Effects of maternal age, parity and smoking on the risk of stillbirth. Brit J Obstet Gynaecol 101: 301–06.

Shah NR & Bracken MB (2000) A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery. Am J Obstet Gynecol 182: 465–72.

Smith CL, Rivard EK, Edick CM (2006) Smoking cessation therapy in pregnancy. J Pharm Tech 22(3): 161–67.

Stotts AL, Groff JY, Velasquez MM et al (2009) Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy. Nicotine Tobacco Res 11(8): 961–68.

Tappin DM, Ford RP, Nelson KP et al (1996) Prevalence of smoking in early pregnancy by census area, measured by anonymous cotinine testing of residual antenatal blood samples. NZ Med J 109: 101–03.

US DHHS (2004) The Health Consequences of Smoking. 2004 Surgeon General’s Report. US Department of Health and Human Services.

von Kries R, Toschke AM, Koletzko B et al (2002) Maternal smoking during pregnancy and childhood obesity. Am J Epidemiol 156: 954–61.

Walsh R, Redman S, Adamson L (1996) The accuracy of self-reports of smoking status in pregnant women. Addictive Behaviour (5):675–79.

Wiemann CM, Berenson AB, San Miguel VV (1994) Tobacco, alcohol and illicit drug use among pregnant women: age and racial/ethnic differences. J Reproductive Med 39: 769–76.

Windsor R, Boyd N, Orleans C (1998) A meta-evaluation of smoking cessation intervention research among pregnant women: Improving the science and art. Health Education Research 13(3): 419–38.

Windsor R, Li C, Boyd N et al (1999) The use of significant reduction rates to evaluate health education methods for pregnant smokers: a new harm reduction – behavioral indicator. Health Ed Behavior 26: 648–62.
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Wood L, France K, Hunt K et al (2008) indigenous women and smoking during pregnancy: knowledge, cultural contexts and barriers to cessation. Social Sci Med 66: 2378–89.

Wyszynski DF, Duffy DL, Beaty TH (1997) Maternal cigarette smoking and oral clefts: a meta-analysis. Cleft Palate-Craniofacial J 34: 206–10.

1 The collective name for wild tobacco plants in Central Australia.