Pregnant Women
Why it Matters
- Tobacco dependence interventions for women who are pregnant are especially cost-effective because they result in fewer low birth weight babies and perinatal deaths, fewer physical, cognitive, and behavioral problems during infancy and childhood and yield important health benefits for the mother.1
- Non-combusted tobacco products such as chewing tobacco, snuff, dissolvable tobacco strips and e-cigarettes also contain nicotine and have serious health implications for women who are pregnant and their fetuses. Nicotine and carbon monoxide in smokeless tobacco products may result in preterm birth.2
- Nicotine levels can also be higher for a fetus than the mother and can adversely impact fetal lung development.3
- Tobacco use in pregnancy is strongly associated with poverty, low levels of education, poor social support, depression, and psychological illness.4
- In 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy. In Pennsylvania it was 11.5%.5
- Most mothers who quit smoking during pregnancy relapse within six months of delivery. Though interventions targeting new mothers have been largely unsuccessful, relapse is often delayed until after weaning.6
- Between 47% and 63% of women who manage to quit smoking during pregnancy will relapse within the first six months following birth.7
- Relapse to smoking is associated with lower rates of breastfeeding among women.8
- Every year, roughly 3,600 babies in the U.S. die suddenly for unknown reasons. Researchers estimate that if we connected women who are pregnant and their families to treatment for nicotine dependency, we could prevent 800 of those deaths. Tobacco-free pregnancy initiatives have been effective in reaching families in rural areas through home visits from nurses or community members who have been trained to talk about health topics.9
What We Know About What Works
- A 2020 Cochrane Review assessed the effects of smoking cessation interventions during pregnancy on smoking behavior and perinatal outcomes.10
- Psychosocial interventions increased the proportion of women who had stopped smoking in late pregnancy (by 35%) and mean infant birthweight (by 56 g), and reduced the number of babies born with low birthweight (by 17%) and admitted to neonatal intensive care immediately after birth (by 22%)
- Psychosocial interventions did not appear to have any adverse effects
- Incentive-based interventions are effective
- Counseling interventions have a clear effect on stopping smoking, but no clear differences between different types of counseling were found
- Interventions that provide feedback had a clear impact Programs implemented by routine pregnancy staff are as effective as those implemented by researchers
- Interventions seem to be impactful on women from ethnic minority groups but not among women of indigenous groups
- Interventions that were borderline or less effective in the Cochrane Review include:
- Health education
- Social support interventions provided by peers or partners
- Interventions promoting breast feeding to incentivize continued smoking abstinence may be effective prior to weaning. Those promoting breast feeding longer than six months and partner smoking cessation may increase rates of long-term smoking abstinence lasting longer than two years postdelivery.11
- Incentives appear to boost cessation rates while they are in place.12
- Baby & Me – Tobacco Free was associated with significantly reduced odds of having a low birth weight infant and research has shown a protective effect for pre-term birth.13
- A number of case studies compiled by the Association of State and Territorial Health Officers (ASTHO) document positive results from integrating tobacco cessation into other programs targeting women who are pregnant. Examples include family planning, WIC, and public housing. https://astho.org/Prevention/Tobacco/Smoking-Cessation-Pregnancy/
- The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program from the Society for Public Health Education (SOPHE) is an evidence-based program shown to be effective in helping women who are pregnant to quit smoking. SOPHE offers Adopting SCRIPT in your Organization Training which trains health professionals to promote, implement and evaluate SCRIPT. https://www.sophe.org/focus-areas/script/
- A recent Cochrane Review looked at mobile phone-based smoking cessation studies through 2018 and determined that text messaging programs may be effective in supporting people to quit, increasing quit rates by 50% to 60%. This was in comparison to minimal support or as an addition to other forms of smoking cessation support. There was not enough evidence to determine the effect of smartphone apps.14
- Most women found receiving support by text preferable to face-to-face cessation support, with participants citing the greater regularity, convenience and non-judgmental style as particular advantages. The focus on the developing baby, the regularity of contact and the provision of gentle, encouraging messages were highlighted as particularly important elements of the program. Participants would have preferred a longer support
program with increased tailoring, greater customization of text timing and consideration of cutting down as an alternative/precursor to quitting.15 - Quit4Baby is one of the limited numbers of web-based programs available in the U.S. that have been evaluated. Research indicates higher self-reported abstinence rates and quits and high user satisfaction. Biochemical validation indicates no significant impact overall but significant impact for older people who smoke and those who enrolled in their second or third trimester. No impact was shown in the postpartum period.16
• There are also a limited number of apps (e.g. SmokefreeMOM, text4baby), but these have not been tested for efficacy. They are, however, positively reviewed by the women who use them.
What’s Relevant in Pennsylvania
- 16.8% of women in Pennsylvania smoke, higher than the national average of 13.6%.17
- Pennsylvania ranks 26th in the country for low birthweight babies (8.4%) and 28th for infant mortality (6.1 deaths/1000 live births).18
- In Pennsylvania, women who are African American are three times more likely to die during or after pregnancy than women who are White (health.pa.gov).
- Tobacco use during pregnancy in Pennsylvania is higher for younger women, higher for women who are white non-Hispanic across all ages, and decreases as maternal education increases. It is highest in the Northwest Health District and lowest in the Southeast, including Philadelphia.19
- Baby and Me Tobacco Free—an evidence based, smoking cessation program created to reduce the burden of tobacco on the pregnant and postpartum population. Women attend four prenatal counseling cessation sessions to receive education and support for quitting smoking and staying quit, and test using a carbonmonoxide (CO) monitor (breath test). At prenatal sessions three and four women may receive diaper vouchers, if they test tobacco-free. They also receive diaper vouchers at monthly post-partum visits with CO testing. People who smoke and who are living with women who are pregnant can also enroll and may receive vouchers during post-partum period.
- The PA Free Quitline offers a Pregnant and Postpartum program that offers up to nine coaching sessions, incentives for each session completed and free NRT if medically eligible.
- Lehigh Valley Health Network-Schuylkill (LVHN) participated in the Tobacco Cessation Resource Project with an initiative focused on women who are pregnant and their household members who use tobacco.
What Other States Are Doing
- SoonerQuit Prenatal Program, Oklahoma https://www.astho.org/Oklahoma-Prenatal-Smoking-Cessation/. Successful training program for prenatal care providers and SoonerQuit media campaign targeting women who are pregnant
- North Carolina You Quit Two Quit. https://youquittwoquit.org/
- Plan First, a program in Alabama integrates tobacco cessation counseling and medication into its family planning program.
- California partnership between its quitline and WIC: Tobacco Control Network. “Working with WIC offices to increase access to smoking cessation services – 11/15/11.”
- SoonerQuit Prenatal Program, Oklahoma https://www.astho.org/Oklahoma-Prenatal-Smoking-Cessation/. Successful training program for prenatal care providers and SoonerQuit media campaign targeting women who are pregnant
- North Carolina You Quit Two Quit. http://www.youquittwoquit.com
- Plan First, a program in Alabama integrates tobacco cessation counseling and medication into its family planning program
- California partnership between its quitline and WIC: Tobacco Control Network. “Working with WIC offices to increase access to smoking cessation services – 11/15/11”
References and Resources
- Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN)
- Setting Universal Cessation Counseling Education and Screening Standards (SUCCESS) program for training nurses
providing prenatal care
- Setting Universal Cessation Counseling Education and Screening Standards (SUCCESS) program for training nurses
- Society of Public Health Educators (SOHPE)
- American College of Obstetricians and Gynecologists (ACOG)
- American Association for Respiratory Care (AARC)
- American Association of State and Territorial Health Officials (ASTHO)
- Smoking Cessation Strategies for Women Before, During, and After Pregnancy: Recommendations for State and Territorial Health Agencies. https://astho.org/Prevention/Tobacco/Smoking-Cessation-Pregnancy/
- Smoking Cessation Interventions in Pregnancy and Postpartum Care, Agency for Healthcare Research and Quality, February 25 2014. https://effectivehealthcare.ahrq.gov/products/smoking-pregnancy-infants/research
- Women.Smokefree.gov (http://women.smokefree.gov) provides free, accurate, evidence-based information and professional assistance to help support the immediate and long-term needs of women trying to quit smoking
- Healthy Start program, A Health Resources & Services Administration grant program to improve pregnancy outcomes and reduce infant mortality https://mchb.hrsa.gov/maternal-child-health-initiatives/healthy-start
- The Regional Pennsylvania Tobacco-Free Coalitions have specific resources available for those that are pregnant and would like to quit. Visit hughesdesignstudios.com/rptfc-staging to find all of the current resources. Specific resources include the PA Free Quitline, Pregnancy Incentive Program Video, as well as an Ask, Advise, Refer: Pregnancy and Tobacco Cessation Training.
Priority Populations
- African American/Black
- Asian American / Native Hawaiian / Pacific Islander
- Behavioral Health Population
- Chronic Conditions/ Diseases
- Hispanic / Latinx
- People Experiencing Homelessness
- Justice Involved Individuals
- LGBTQA / Sexual Gender Minority (SGM)
- Low Income Individuals
- People in the Military or Veterans
- Older Tobacco Users
- People with Disabilities (PWD)
- Pregnant Women
- Rural Geographic Areas / Amish and Mennonite
- Smokeless Tobacco Products
- Youth and Young Adult Nicotine Consumption and Tobacco Use
- Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. https://www.ncbi.nlm.nih.gov/books/NBK63952/
- Centers for Disease Control and Prevention. Smoking During Pregnancy. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm
- Holbrook B. The Effects of Nicotine on Human Fetal Development. Embryo Today. 13 June 2016. https://doi.org/10.1002/bdrc.21128
- Goodwin R., Cheslack-Postava K., Nelson D., Smith P., Wali M., Hasin D., Nomura Y., Galea S. Smoking during pregnancy in the United States, 2005-2014: The role of depression. Drug and Alcohol Dependence. Volume 179, 1 October 2017, Pages 159-166. https://doi.org/10.1016/j.drugalcdep.2017.06.021
- Drake P., Driscoll Mathews T. Cigarette Smoking During Pregnancy: United States 2016. NCHS Data Brief No. 305, February 2018. https://www.cdc.gov/nchs/products/databriefs/db305.htm#fig1
- https://academic.oup.com/ntr/article-abstract/19/3/367/2631739/Postpartum-Smoking-Relapse-and-Breast-Feeding
- Ibid.
- Ibid.
- FrameWorks Institute. (2020). Justice in the Air: Framing Tobacco-RelatedHealth
- Disparities. Washington, DC: FrameWorks Institute.
- Chamberlain_C, O’Mara-Eves_A, Porter_J, Coleman_T, Perlen_SM, Thomas_J, McKenzie_JE. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD001055. DOI:10.1002/14651858.CD001055.pub5. Updated 2020 (no change to conclusions).
- Logan C, Rothenbacher D, Genuneit J. MSc, Postpartum Smoking Relapse and Breast Feeding: Defining the Window of Opportunity for Intervention, Nicotine & Tobacco Research, Volume 19, Issue 3, 1 March 2017, Pages 367–372. https://doi.org/10.1093/ntr/ntw224. https://academic.oup.com/ntr/article-abstract/19/3/367/2631739
- Ibid.
- Zang X, Devasia R, Czarnecki G et.al. Effects of Incentive-Based Smoking Cessation Program for Pregnant Women on Birth Outcomes. Matern Child Health J (2017) 21:745-751. COI 10.1007/s10995-016-2166-y. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378728/pdf/10995_2016_Article_2166.pdf
- Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y, Dobson R. Mobile phone text messaging and app-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2019, Issue 10. Art No.: CD006611.
DOI: 10.1002/14651858.CD006611.pub5. - Sloan M, Hopewell S, Coleman T, Cooper S, Naughton F. Smoking Cessation Support by Text Message During Pregnancy: A Qualitative Study of Views and Experiences of the MiQuit Intervention. Nicotine Tob Res. 2017;19(5):572-577. doi:10.1093/ntr/ntw241.
- Abrams L, Johnson P, Leavitt L, Cleary S, Bushar J, Brandon T, Chiang, S. A Randomized Trial of Text Messaging for Smoking Cessation in Pregnant Women. American Journal of Preventive Medicine Volume 53, Issue 6, December 2017. https://doi.org/10.1016/j.amepre.2017.08.002
- America’s Health Rankings analysis of CDC, Behavioral Risk Factor Surveillance System, United Health Foundation, AmericasHealthRankings.org, Accessed 2020.
- CDC WONDER Natality Data, 2016-2017
- Pennsylvania Tobacco Facts 2010-2016.
