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Pregnant and Breastfeeding Women  Clinical Considerations


The following clinical considerations are included in CAN-ADAPTT's guideline and have been approved by the Guideline Development Group (GDG). ​


·  There is limited evidence on harms associated with the use of NRT during pregnancy. Two prospective studies found no adverse maternal or fetal effects from the use of nicotine patch during pregnancy; however, one recent study demonstrated potential association between NRT and congenital defects. This data cannot support or exclude an association between first trimester NRT use and an increased risk of congenital defects due to several methodological issues. Therefore, until further information is available, the risks and benefits of smoking versus the use of NRT during pregnancy must be considered when counselling about smoking cessation options.

·  There is some evidence from RCTs that NRT may be efficacious in pregnancy in terms of decreasing tobacco use and improving pregnancy outcomes.  No safety concerns were identified in these trials.  Therefore, benefits of NRT seem to outweigh potential risks; NRT should be considered when counselling has been ineffective.
·  Despite preliminary evidence that continued smoking and relapse are more likely among pregnant women who have a smoking partner, there is limited data  regarding the benefits of partner involvement in smoking cessation interventions for pregnant smokers.  In non-pregnant populations, interventions to increase support did not find increased quitting rates.
·  Evidence from a recent systematic review and meta-analysis demonstrated negative perinatal outcomes (e.g. trend towards lower birth weight, smaller head circumference and congenital anomalies) associated with second-hand smoke exposure.  Therefore, pregnant and breastfeeding women should avoid this environmental risk.
·  Challenges in identification due to stigma associated with smoking during pregnancy.
·  Smoking cessation interventions should be considered for the full spectrum of care from preconception visit to 1 year postpartum.
·  Smoking cessation counselling and care of pregnant smokers may be conducted by physicians, allied healthcare professionals (e.g. social worker, pharmacist, community health representatives), midwives, doulas, prenatal advisors, postpartum supports, family home visitors, and others.
·  Nicotine replacement therapy (NRT) can be considered as a second line option for individuals who cannot quit after counselling interventions.
·  Depression during pregnancy is a common occurrence and the use of Zyban (bupropion) may be appropriate to treat both smoking and depression. There is limited evidence on the effectiveness of bupropion for smoking cessation during pregnancy.  In addition, there is no evidence of harm related to the use of bupropion during pregnancy and therefore, it may be considered for use as an alternative to NRT for a subpopulation of pregnant smokers (see Table 1 below).
·   Including partners, friends, and/or family in a pregnant smoker’s quit attempt is essential to increase the likelihood of successful smoking cessation interventions.
·  A smoke-free home environment should be encouraged for partners, friends, family members of pregnant and breastfeeding women to ensure safety from second-hand smoke/environmental tobacco smoke. 

Table 1 – Negative Eff​ects Associated with Cigarette Smoking
During Pregnancy and Breastfeeding

Cigarette smoking during pregnancy and breastfeeding is associated with numerous negative effects on mother, fetus, infant and adolescent.1
Pregnancy ​​Co​mplications

Neonatal Effects

Long-Term Effects

·  Subfertility 
(female and male)

·  Ectopic pregnancy (outside the uterus)

·  Spontaneous abortion (miscarriage)

·  Preterm labour

·  Premature rupture of membranes

·  Placental problems (previa & abruption)

·  Growth restriction
·  Low birth weight (on average ~200 grams smaller)

·  Increased perinatal mortality

·  Increased admission to the neonatal intensive care unit (NICU)

·  Sudden infant death syndrome (SIDS)

·  Decreased volume of breast milk and duration of breastfeeding
·  Childhood respiratory illnesses (asthma, pneumonia, bronchitis)

·  Other childhood medical problems (ear infections)

·  Learning problems (reading, mathematics, general ability)

·  Behavioral problems

·  Attention deficit hyperactivity disorder (ADHD)


   ​1. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005​ 

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   Pregnant and Breastfeeding Women​