Helping Patients To Stop Smoking
   By M.Hellen Rodriguez, MD
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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 [1]. 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. [3]

The Clinical Practice guidelines released by the United States Department of Health and Human services made 3 recommendations for treating tobacco use during pregnancy [7]:

    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."

Smoking Cessation Intervention

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 [5] 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 Arrange. [12]


ASK- 1 minute

    • Ask the patient to choose the statement that best describes her smoking status:

      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 now.
      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 fetus.

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 [8]


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 [1]:

    • Are already taking other medications that contain bupropion (such as Wellbutrin).
    • 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 group.

Nicotine replacement

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 insurance companies.

Smoke cessation success always depends on many factors, Intervention by health care providers has been shown to play a key role in its success.

Patient Education Sheets

Online Resources

1. Martin, J.A., et al. Births: Final Data for 2002. National Vital Statistics Reports, volume 52, number 10, December 17, 2003.
2. American College of Obstetricians and Gynecologists. Smoking and women's health. ACOG Educational Bulletin 240. Washington, DC: ACOG, 1997
3. U.S. Department of Health and Human Services. The Health Benefits of Smoking 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
4. ACOG educational bulletin. Smoking cessation during pregnancy. Number 260, September 2000. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2001;75:345-8.
5. U.S. Department of Health and Human Services. The Health Consequences of 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 1998.
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. Obstetrics and Gynecology. 2005 Oct;106(4):883-8.
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.)
11. Fiore MC, Bailey WC, Cohen SJ, et al.: 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

Created: 10/12/2005



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