Remember that quitting is a process not an event

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Close to half of pregnant women who smoke either seriously consider or take steps towards stopping during pregnancy. Pregnant smokers vary in their readiness to quit and life situations and will require various interventions to cope with symptoms of withdrawal. Tailored approaches to smoking cessation take into account both the patient’s readiness to quit and other life circumstances, such as socioeconomic status, cultural backgrounds, level of social support, level of nicotine addiction, and other substance-use issues.

Breastfeeding and Harm Reduction

Nicotine is water- and lipid-soluble and so can be secreted in breast milk.The concentration of nicotine in breast milk will vary depending on how many cigarettes have been smoked since the last breastfeeding session and how much time has passed since the mother has last smoked a cigarette. Even so, Health Canada recommendations clearly indicate that smoking is not a contraindication to breastfeeding.

Motivation to quit is a dynamic factor that changes throughout pregnancy and postpartum. Factors associated with early pregnancy may influence motivation. For example:

  • Nausea
    Women may lose the desire to smoke if they are experiencing nausea. However, the desire may return when this sickness has passed.
  • Not feeling pregnant
    Women who do not feel pregnant may be less inclined to quit or think about quitting.
  • Unplanned pregnancy
    Women who have not planned to get pregnant may not have thought about quitting smoking.

For patients who find it difficult to even think about giving up tobacco, it may be helpful to suggest stopping during pregnancy or cutting down, as opposed to quitting altogether. Cutting down to fewer than 10 cigarettes per day may be a practical alternative for women who are not able to quit altogether. The “Start Thinking About Reducing Secondhand Smoke” (STARSS) program, which focuses on supporting mothers in tobacco-reduction efforts, found that when women attempt to reduce smoking, they often quit smoking or become more confident and interested in quitting smoking.

PRACTICE TIPS

  • Ask the woman questions about her smoking history and her motivations for quitting or reducing
    What is her smoking history? Has she ever tried quitting before? For how long did she quit last time? Can she suggest any reasons for past relapses? What things are happening in her life right now that could make it easy or difficult to quit?
  • Don’t assume expectant mothers know that tobacco is harmful to the fetus
    Some women are not necessarily well-informed about the health effects of smoking on the fetus. Ask her what she knows about the harmful health effects of tobacco and then what her concerns are, if any. Offer to provide her with information about the health effects of smoking for herself.
  • Remember that it’s never too late to quit smoking
    If a woman comes to your practice late in pregnancy, she may feel that damage has already been done to the fetus and that it’s too late to quit smoking. Remind the woman that quitting at any time has immediate health benefits for both herself and the fetus, regardless of previous smoking or future relapse.
  • Encourage harm reduction among pregnant smokers who are not ready to quit
    Discuss a range of options for changing smoking behaviours with women and assess readiness and opportunities for change. You can suggest decreasing the number of cigarettes smoked, brief periods of cessation at any point in pregnancy and around delivery, and encourage other health-promoting behaviours such as exercise and improved nutrition.
  • Nicotine replacement therapy is an option
    NRTs are not completely free of risk, but evidence suggests that NRTs are less harmful than smoking during pregnancy because both the woman and fetus receive less nicotine and no exposure to carbon monoxide and other toxic substances. For some groups of women, where other avenues to quit or reduce have not been successful, NRTs may be an option to discuss further.
  • Continue to encourage women who have quit smoking when they found out they were pregnant

RESOURCES

  • Getting Ready to Quit
  • Decisional Balance Tool: Positives and Negatives of Smoking
  • How to Use a Decisional Balance List with Patients:
    A decisional balance list acknowledges the drawbacks of quitting and the advantages of continuing to smoke as well as the benefits of quitting and drawbacks to continuing. Such lists help people fully explore their ambivalence about change, and help them acknowledge and find alternative ways to address the costs of quitting and the benefits of continuing to smoke.When working with a decisional balance list, you might ask the following questions:
    • When you place the benefits of quitting and the benefits of continuing beside each other, which list is longer?
    • Are there other, healthier ways you can achieve some of the benefits of continuing to smoke?
    • When you place the costs of quitting and the costs of continuing side by side, which list is longer? Are there ways that you could reduce the disadvantages of quitting?

    Tell women to take their time in making these lists—they don’t have to be filled out in one session. In fact, women may benefit from taking the list home and filling it out over a period of time. Suggest that these lists can help a woman weigh reasons for change and that you are willing to discuss them with her together now or as her pregnancy progresses.

    Taking the time to work through both the benefits and costs of quitting and continuing can help a woman make more effective long-term change. These lists can help tip the “decisional balance” to quitting.

FURTHER READING

Action on Women’s Addictions, Research and Education (AWARE). (2007). National rollout of STARSS (Start Thinking about Reducing Secondhand Smoke) final report. Free full-text »

Ebert, L., van der Rieta, P., and Fahya, K. (2009). What do midwives need to understand/know about smoking in pregnancy? Women and Birth, 22(1): 35-40. PMID: 19117827 doi:10.1016/j.wombi.2008.11.001

Greaves, L. (2002) The young female smoker: What can the physician do? The Female Patient, 27: 17-21.

Nichter, M., Nichter, M., Adrian, S., Goldade, K., Tesler, L., and Muramoto, M. (2008). Smoking and harm-reduction efforts among postpartum women. Qualitative Health Research, 18(9): 1184-94. PMID: 18689532. Free full-text »

Oncken, C.A. and Kranzler, H.R. (2009). Review: What do we know about the role of pharmacotherapy for smoking cessation before or during pregnancy? Nicotine and Tobacco Research, 11 (11): 1265-1273. PMID: 19717542  doi: 10.1093/ntr/ntp136 Free full-text »

 

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