Tobacco Use and Nicotine Cessation During Pregnancy

SUMMARY:  

Rates of tobacco use during pregnancy have been declining, but, due to under-reporting, it is likely that use of nicotine containing products is increasing. Nicotine is still the most common type of substance use disorder in pregnancy, complicating an estimated 7.2% of US deliveries in 2016. There are many types of tobacco and nicotine products available including e-cigarettes and vaping products, hookah, chewable and sublabial products, and patches. All of these products pose a threat not only to maternal health, but also to fetal and infant health. Tobacco and nicotine products expose the fetus to toxins, alter fetal oxygenation, and may result in fetal developmental changes. All patients should be screened for nicotine use disorder in pregnancy and counseled about risks of use. The USPSTF recommends that “clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco.” 

Pregnancy Related Risks Associated with Nicotine Use 

• Prior to conception
  • Can lead to subfertility
• During pregnancy
  • Leading cause of low birth weight and preterm delivery in the US
  • Additional adverse outcomes: Miscarriage | Stillbirth | Congenital anomalies | FGR | Preterm birth | Placental abruption | Placenta previa | PPROM | Preeclampsia
• Postpartum
  • Associated with SIDS | Childhood lung diseases like asthma and pneumonia | Colic | Obesity | Bone fractures | Ear infections | Possibly cognitive-behavioral function
• Lactation
  • Nicotine use also negatively impacts lactation and potentially decreases both milk volume and duration of time a woman is able to breastfeed her newborn

• Ask all patients about the use of tobacco and nicotine containing products during preconception, prenatal, and postpartum appointments
• Counsel patients with any amount of nicotine use about cessation
• Screen for co-existent use of other substances and alcohol

Cessation Screening and Counseling 

• Use the 5 A’s
  • Ask at every visit how much a patient is using
  • Advise patient to stop using nicotine products and reinforce the benefits of quitting
  • Assess readiness to cut back or quit
  • Assist all patients wanting to cut back by offering behavioral therapy and other resources, like the national quit network hotline (1-800-QUIT-NOW)
  • Arrange to discuss progress at every visit. Patients who are not ready to reduce use can benefit from consistent motivational interviewing. Applaud patients for their success
• Behavioral therapy can have many different approaches including
  • Motivational interviewing | Cognitive behavioral therapy | Psychotherapy | Mindfulness | Monetary motivation | Additional approaches

Pharmacotherapy 

• Used in conjunction with behavioral therapy for patients who request supplementation to behavioral treatment alone or who are heavy users
• The USPSTF states that there is insufficient evidence about use of all pharmacotherapy in pregnancy and so the balance of risks vs benefits is unknown
• Prior to initiating pharmacotherapy, all patients should be asked about
  • Comorbid anxiety | Depression | Psychological conditions
• Due to little data, all pharmacotherapies should be individualized and only offered after engagement in shared decision making
• Patients on pharmacotherapy should be monitored closely

Medications

• Nicotine Replacement therapy
  • Small studies suggest nicotine replacement therapy in pregnancy is safe and effective and the general consensus is that it is safer than smoking in pregnancy
  • Patients should be started on a daily long-acting patch and offered short-acting gum or lozenges for craving symptoms

• Bupropion
  • Bupropion is a norepinephrine/dopamine-reuptake inhibitor antidepressant
  • Shown to have no teratogenic or adverse effects in pregnancy using animal models
  • Starting dose: 150mg for 3 days
  • Up-titrate to 150 BID
  • Patients should set a cessation date for 1 to 2 weeks after initiation of bupropion use
• Varenicline
  • Varenicline is a partial nicotinic receptor agonist
  • Small studies have shown that it is safe in pregnancy and potentially effective
  • Starting dose: 0.5mg pill
  • Up-titrate to 1mg daily by one week
  • The cessation date should be set to 1 to 2 weeks after initiation of varenicline
  • Varenicline has not been studied in lactation, and thus bupropion or NRT are preferred for lactating women

Note: ACOG states “Obstetrician-gynecologists and other obstetric care professionals should counsel women about the risks of smoking and the benefits of cessation and discuss the resources available to help with smoking cessation, which may include the use of varenicline and bupropion”

Tobacco Use Disorder 

• Some users of nicotine will qualify for the diagnosis of Tobacco Use Disorder | ICD-10 code F17.200
• DSM-V specifies tobacco use disorder into additional categories
  • Early remission: ≥3 months but <12 months or
  • Sustained remission: >12 months
  • Maintenance therapy vs a controlled environment

DSM-V Criteria and sub-features of Tobacco Use Disorder

A problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period

• Tobacco is often taken in larger amounts or over a longer period than was intended
• There is a persistent desire or unsuccessful efforts to cut down or control tobacco use
• A great deal of time is spent in activities necessary to obtain or use tobacco
• Craving, or a strong desire or urge to use tobacco
• Recurrent tobacco use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., interference with work)
• Continued tobacco use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of tobacco (e.g., arguments with others about tobacco use)
• Important social, occupational, or recreational activities are given up or reduced because of tobacco use
• Recurrent tobacco use in situations in which it is physically hazardous (e.g., smoking in bed)
• Tobacco use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by tobacco.
• Tolerance, as defined by either of the following
  • A need for markedly increased amounts of tobacco to achieve the desired effect
  • A markedly diminished effect with continued use of the same amount of tobacco
• Withdrawal, as manifested by either of the following
  • The characteristic withdrawal syndrome for tobacco which include 4 or more of the below symptoms, occurring within 24 hours of abrupt cessation
    • Irritability, frustration, or anger
    • Anxiety
    • Difficulty concentrating
    • Increased appetite
    • Restlessness
    • Depressed mood
    • Insomnia
  • Tobacco (or a closely related substance, such as nicotine) is taken to relieve or avoid withdrawal symptoms

KEY POINTS

• Risk factors for nicotine use include
  • Low educational attainment | Mental health disorders | Uninsured status | Lack of social support | Having a partner who also has nicotine use disorder
• Nicotine cessation in early pregnancy, specifically <15 weeks, reduces pregnancy and infant risks
• Screen all patients identified as using nicotine for ongoing nicotine use at each visit
• Offer psychosocial, behavioral, and pharmacotherapy to patients with nicotine use disorder
• Brief interventions can be effective and helpful in helping patients decrease nicotine use
• Rates of relapse postpartum are 50 to 60% within 6 months

Learn More – Primary Sources:

ACOG CO 807: Tobacco and Nicotine Cessation During Pregnancy

Smoking cessation in pregnancy: An update for maternity care practitioners

Infant morbidity and mortality attributable to prenatal smoking in the US. American journal of preventative medicine

Bupropion sustained release for pregnant smokers: a randomized, placebo-controlled trial

USPSTF: Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons

DSM V (Subscription Required)

SmokeFree Women (For Patients)