Tobacco smoking

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 AIHW 2016. 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.

12.1 Background

12.1.1 Smoking during pregnancy among Australian women

One in 9 women (11%) who gave birth in Australia in 2014 smoked at some time during their pregnancy, a decrease from 15% in 2009 AIHW 2016. Rates of smoking were slightly higher in the first 20 weeks of pregnancy (11%) compared with after 20 weeks of pregnancy (8%).

Among women who gave birth in 2014, some were more likely than others to smoke in the first 20 weeks of pregnancy. Proportions were highest among the following women, noting that some may fall into more than 1 of these categories AIHW 2016.

• Adolescent women: almost one-third (32%) of mothers under 20 smoked, compared with rates of 6% and 7% of mothers aged 35–39 and 40 and over, respectively.
• Aboriginal and Torres Strait Islander women: 44% of Indigenous mothers smoked, compared with 12% of non-Indigenous mothers (age-standardised percentages).
• Socioeconomic status: around one-fifth (19%) of mothers living in the lowest SES areas smoked, compared with 4% of mothers in the highest SES areas
• Geographical location: around one-third (34%) of mothers in Very remote and one-fifth (20%) in Remote areas smoked, compared with only 8% of women living in Major cities.

On average, women who smoked at any time during pregnancy AIHW 2016:

• attended their first antenatal visit later in pregnancy than those who did not smoke (15 vs 13 weeks)
• had one less antenatal care visit (nine visits) than women who did not smoke (ten visits).

These patterns were present even when taking into consideration the effect of differences in SES.

Prevalence of smoking during pregnancy is higher among women with severe 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.

12.1.2 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 perinatal mortality (DiFranza & Lew 1995), placental abruption (Castles et al 1999), 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), 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)
• 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).

12.2 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 under-report their smoking Walsh et al 1996, Windsor et al 1998, Gilligan et al 2009a. Questions about smoking should be phrased in a non-judgemental 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 12.7).

12.3 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 12.7).

12.3.1 Effectiveness of interventions

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% (relative risk [RR] 0.94; 95% CI 0.93–0.96)
• 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)
• smoking cessation may be influenced by concern about weight gain (Berg et al 2008).

12.3.2 Cost-effectiveness of interventions

An economic analysis conducted to inform the development of these Guidelines (see separate document on economic analyses) found that smoking cessation interventions for both pregnant women and the wider population may be cost-effective 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.

12.3.3 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.

12.3.4 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.

12.3.5 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 92 g 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.

12.4 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.

12.5 Considerations among specific population groups

As discussed in Section 12.1, the prevalence of smoking among Aboriginal and Torres Strait Islander women is high, with close to half of women smoking in the first 20 weeks of 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. Understanding community attitudes to smoking and language used when referring to tobacco products will support both assessment and intervention.

12.5.1 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)
• 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
• 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 pituri^[14]) and enquiry about this may also be useful.

Effective smoking cessation interventions

A 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
• 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.

12.5.2 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).

12.6 Practice summary: tobacco smoking

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.

What

• 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. Low birth weight 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 under report 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.

What

• 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.

12.7 Resources

12.7.1 Smoking cessation guidelines

• Bittoun R & Femia G (2010) Smoking cessation in pregnancy. Obstet Med 3: 90–93.
• 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.
• RACGP (2011)Supporting smoking cessation: a guide for health professionals. Melbourne: The Royal Australian College of General Practitioners.

12.7.2 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 and appropriately trained GPs can be accessed through Better Access to Mental Health Care (Medicare items).

12.7.3 Resources for Aboriginal and Torres Strait Islander women

Resources that are culturally appropriate to the area should be selected, taking into consideration local language and literacy.

• smokecheck NSW
• smokecheck Queensland
• Centre for Excellence in Indigenous Tobacco Control
• HealthInfoNet

12.7.4 Australian quit services

• Quitline — contacts us