The most important
modifiable risk factor associated with adverse pregnancy outcome is
smoking. The National Center for Health Statistics reports that 25% of
American women of reproductive age and at least 11 percent of pregnant
women smoke during pregnancy . Adverse pregnancy outcomes associated
with smoking during pregnancy include increased risk for spontaneous
pregnancy loss, placenta previa, placental abruption, PPROM, preterm
labor and delivery, intrauterine growth restriction (IUGR), low birth
weight and perinatal mortality.
Dr. Rodriguez is a board-certified perinatologist and co-director of
maternal-fetal medicine at the Pomona Valley Hospital Medical Center in
Pomona , Calif.
Postnatal morbidity associated with smoking include sudden infant death
syndrome, respiratory infections, infantile colic, otitis media, childhood
obesity, hyperactivity and decreased school performance. [2-4].
The causes of adverse outcome due to cigarettes has been
attributed to impaired oxygen delivery to the fetus, carbon monoxide exposure,
direct damage to genetic material and direct toxicity of the more than 2500
substances found in cigarettes.
Successful smoking cessation before the third trimester eliminates most of the
reduced birth weight and associated morbidities caused by maternal smoking. It
is estimated that if all pregnant women in the United States stopped smoking,
there would be a 10% reduction in perinatal deaths, 35% reduction in low birth
weights and 15% reduction in preterm deliveries. 
The Clinical Practice guidelines released by the United States Department of
Health and Human services made 3 recommendations for treating tobacco use during
1. Because of the serious risks of smoking to the pregnant smoker and the fetus,
pregnant smokers should, whenever possible, be offered extended or augmented
psychological interventions that exceed minimal advice to quit.
2. Although abstinence early in pregnancy will produce the greatest
benefits to the fetus and mother, quitting at any point in pregnancy can yield
benefits. Thus clinicians should offer effective smoking cessation interventions
to pregnant smokers at t he first prenatal visit as well as throughout the
course of pregnancy.
3. Pharmacotherapy should be considered when a pregnant woman is otherwise
unable to quit and when the likelihood of quitting with its potential benefits,
outweighs the risks of the pharmacotherapy and potential continued smoking.
Tobacco dependence often requires recurring intervention to achieve success.
"Patients unwilling to try to quit using tobacco should be provided with a brief
intervention that is designed to increase their motivation to quit.
Encourage the patient to indicate why quitting is personally relevant, being as
specific as possible. This should include discussions of the multiple risks to
mother and fetus and infant from maternal smoking, and the benefits of quitting
for both. Advice should stress the outcome of her pregnancy, and that specific
harms for her and the baby can be reduced by quitting. The clinician should ask
the patient to identify barriers or impediments to quitting and note elements of
treatment (ie, problem-solving, pharmacotherapy) that could address barriers and
encourage support (for example, from family, friends, and co-workers) for her
decision to quit."
Patient Education Sheets
Techniques for helping patients stop smoking include counseling, cognitive and
behavioral therapy, hypnosis acupuncture, and pharmacologic therapy. Research
shows that brief counseling sessions of 5-15 minutes by health-care
professionals can significantly increase the rate of smoking cessation  This
intervention known as the 5A’s should be used during routine prenatal office
visits and include the following 5 steps: Ask, Advice, Assess, Assist and
ASK- 1 minute
• Ask the patient to choose the statement that best describes her smoking
A. I have NEVER smoked or have smoked LESS THAN 100 cigarettes in my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking
C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.
D. I smoke some now, but I have cut down on the number of cigarettes I smoke
SINCE I found out I was pregnant.
E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.
If the patient stopped smoking before or after she found out she was pregnant (B
or C), reinforce her decision to quit, congratulate her on success in quitting,
and encourage her to stay smoke free throughout pregnancy and postpartum.
If the patient is still smoking (D or E), document smoking status in her medical
record, and proceed to Advise, Assess, Assist, and Arrange.
ADVISE- 1 minute
• Provide clear, strong advice to quit with personalized messages about the
benefits of quitting and the impact of smoking and quitting on the woman and the
ASSESS- 1 minute
•Assess the willingness of the patient to attempt to quit within 30 days.
If the patient is ready to quit, proceed to Assist.
If the patient is not ready, provide information to motivate the patient to
quite, and proceed to Arrange.
ASSIST- 3 minutes+
•Suggest and encourage the use of problem-solving methods and skills for smoking
cessation (eg, identify “trigger” situations).
•Provide social support as part of the treatment (eg, “we can help you quit”).
• Arrange social support in the smoker’s environment (eg, identify “quit buddy”
and smoke-free space).
•Provide pregnancy-specific, self-help smoking cessation materials.
ARRANGE- 1 minute+
•Assess smoking status at subsequent prenatal visits and, if patient continues
to smoke, encourage cessation.
When counseling, cognitive and behavioral therapy are not successful, the use of
pharmacotherapy, Bupropion (Wellbutrin, pregnancy category B) or Nicotine
replacement products should be considered 
Pharmacotherapy for the treatment of smoking cessation is best started after
the first trimester.
Bupropion helps reduce the craving for cigarettes. The
pharmacokinetics is not entirely known. Bupropion does not contain Nicotine. The
patient is advised to begin using bupropion 1 to 2 weeks before they quit
smoking to build up the level of medication. Treatment with bupropion continues
for 7 to 12 weeks after the quit date but can be continued as long as 6 months
to a year.
Bupropion should not be used by patients who :
• Are already taking other medications that contain bupropion (such as
• Have seizures or a medical condition that makes them prone to seizures.
• Are taking a monoamine oxidase inhibitor (MAOI), such as isocarboxazid (Marplan), phenelzine
(Nardil), or tranylcypromine (Parnate).
• Have an eating disorder.
• Have an alcohol use problem.
When used as directed, bupropion reduces the following symptoms:
• Irritability, restlessness, anxiety
• Difficulty concentrating
• Feeling unhappy or depressed
• Bupropion is equally effective in helping patients who are depressed and
patients who are not depressed to quit smoking.
There is a small risk of having seizures when using bupropion. The risk
increases if the patient has had seizures in the past before using bupropion.
Bupropion should be used in conjunction with a complete smoking cessation
program that includes setting a quit date; having a plan in place for dealing
with things that make you automatically reach for a cigarette (smoking
triggers); and getting support from a health professional, counselor, or support
Nicotine is the addictive chemical in cigarettes. Nicotine
patches, gums, and sprays help prevent nicotine withdrawal when the patient quits.
Since nicotine is just one of many toxins in cigarette smoke, Nicotine
replacement is almost certainly safer than smoking. Gums and sprays are
considered safer than patches because the short bursts of nicotine they provide
add up to smaller doses of nicotine than what a patient will get from a patch
(or from smoking, for that matter). A patch may still be a good choice if the
patient is too nauseated to try anything else, but the patch should be removed
during the night to minimize nicotine in the system.
Hypnosis or Acupuncture
Neither of hypnosis or acupuncture has been studied
extensively, but there's not much evidence that they help smokers quit. However,
hypnosis and acupuncture are becoming more widespread — they're included in
several structured smoking cessation programs and are increasingly covered by
Smoke cessation success always depends on many factors, Intervention by health
care providers has been shown to play a key role in its success.
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Reports, volume 52, number 10, December 17, 2003.
2. American College of Obstetricians and Gynecologists. Smoking and women's
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Cessation.: US Department of Health and Human Services, Public Health Service,
Centers for Disease Control, Center for Chronic Disease Prevention and Heath
Promotion, Office on Smoking and Health, 1990
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September 2000. American College of Obstetricians and Gynecologists.
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Smoking: A Report of the Surgeon General—2004. Centers for Disease Control and
Prevention, Office on Smoking and Health, Atlanta Georgia, May 2004.
6. Consensus Workshop on Smoking Cessation during Pregnancy. Sponsored by the
Robert Wood Johnson Foundation and the Smoke-Free Families Program in
collaboration with the Health Resources and Services Administration and the
Centers for Disease Control and Prevention. Rockville, Maryland, 9-10 April
7. U.S. Department of Health and Human Services. Women and Smoking: A report of
the Surgeon General. Rockville: U.S. Department of Health and Human Services,
Public Health Service, Office of the Surgeon General, 2001.
8. ACOG Committee Opinion. Smoking cessation during pregnancy. Number 316,
October 2005. American College of Obstetricians and Gynecologists.
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9. Workshop on the Use of Pharmacotherapies for Smoking Cessation in Pregnancy.
Sponsors: National Institute for Child Health and Human Development and the
Smoke-Free Families Program. Rockville, Maryland, 19 May 1999.
10. Glynn TJ, Manley MW. How to help your patients stop smoking: a National
Cancer Institute manual for physicians Washington, DC: Smoking and Tobacco
Control Program, Division of Cancer Prevention, National Cancer Institute, US
Dept of Health and Human Services, November, 1990. (NIH publication 90-3064.)
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Treating Tobacco Use and Dependence.
Quick Reference Guide for Clinicians. Rockville, Md: Public Health Service, U.S.
Department of Health and Human Services, 2000.
Accessed October 1, 2005.
12. Data from Melvin C, Dolan Mullen P, Windsor RA, Whiteside HP, Goldenberg RL.
Recommended cessation counseling for pregnant women who smoke: a review of the
evidence. Tobacco control 2000;9:1-5