CHAPTER

3
Smoking
and
Pregnancy

By Susan E. Moner
3 Smoking and Pregnancy
Prepared by Susan E. Moner, MD1

Tobacco smoking is associated with adverse pregnancy

outcomes which may be preventable through smoking cessation
interventions. Advice, multiple component programs, behavioral
strategies, repeated contacts, and self-help manuals are effective
in decreasing tobacco smoking significantly in pregnant women.
Interventions are effective in diverse populations with varying
levels of nicotine dependence and at different periods of
gestation. A reduction in tobacco use increases birth weight,
decreases the incidence of low birth weight infants and is cost
effective. Cognitive ability is marginally improved in children of
mothers who have not smoked during gestation. Further
evaluative research is needed on interventions designed to
maintain abstinence. Prevention of tobacco-related illnesses in
the non-pregnant population is dealt with in Chapter 43.

Burden of Suffering
Smoking during pregnancy harms both the mother and her
developing fetus. Aside from increased morbidity and mortality from
cancers, cardiovascular and pulmonary disease in the mother, smoking
has been implicated in the etiology of abruptio placenta, placenta
previa, spontaneous abortion, premature delivery, and stillbirth.
Prenatal smoking is thought to account for about 18% of cases of low
birth weight (<2500 g), and also increases risk of shortened gestation,
respiratory distress syndrome, and sudden infant death syndrome.
Cigarette smoking is the principal cause of low birth weight in
developed countries. Intrauterine growth retardation is the most
strongly documented adverse effect of smoking during pregnancy. This
Cigarette smoking is is a significant public health concern because low birth weight is the
the principal cause of
most important single determinant of neonatal and infant morbidity
low birth weight in
developed countries
and mortality. Retarded fetal growth in the offspring of smokers may
be attributable to several factors, including the vasoconstricting
properties of nicotine, elevated fetal carboxyhemoglobin and
catecholamine levels, fetal tissue hypoxia, reduced delivery of
nutritional elements and elevation of heart rate and blood pressure.
Even after controlling for alcohol use, socioeconomic status, maternal
height, maternal weight and years of education, smoking has been
implicated in long-term effects such as poor cognitive performance on
achievement tests and decreased physical growth.

1
Spaulding Rehabilitation Hospital, Boston, Massachusetts

26
 In Canada, the incidence of low birth weight in infants of
mothers in all age groups declined from 6.6% of 343,000 births in
1971 to 4.6% of 377,00 births in 1989, a 30.3% decline over the
18 year period, comprising mainly birth weights of 1,500 to 2,499 g.
The prevalence of birth weights in this range decreased from 5.8% of
births in 1971 to 4.0% in 1989, while the prevalence of very low birth
weight (<1500 g) remained stable. Most of this decline in low birth
weight has been attributed to a decrease in smoking rates in women of
reproductive age. The Labour Force Survey Smoking Supplement
estimated that smoking rates for Canadian women of reproductive age
(15-44 years) declined from 37% in 1972 to 29% in 1986.
Exposure to environmental tobacco smoke (passive smoking)
may also have a modest adverse effect on birth weight.<1> Hair
concentrations of nicotine and cotinine in women and their newborn
infants provide biochemical evidence that infants of smokers and of
passive smokers have measurable systemic exposure to cigarette
smoke toxins. The clinical significance of this exposure is as yet
unclear.

Maneuver
The interventions developed to help pregnant smokers quit that
have been evaluated in published research studies include smoking
cessation advice, feedback and individual or group counselling.<2>
Nicotine replacement therapy has not been adequately studied in
pregnant women. Use of such therapy by pregnant women has been
advocated by Benowitz<3> because of its benefits as an adjunct to
smoking cessation therapy in non-pregnant populations. Nicotine
replacement cannot be recommended at present, however, since it
could conceivably contribute to adverse effects on the fetus and
because its efficacy in pregnant smokers has not yet been established.
Interventions aimed at reducing exposure to environmental tobacco
smoke have also not been evaluated.
“Smoking Cessation Advice” has been defined as providing
health education to tobacco smoking pregnant women to stop
smoking.<4-7> The underlying premise has been that if women were
aware of the adverse effects of smoking during pregnancy they would Knowledge
concerning adverse
stop smoking.<4> Such advice has usually included information about
health effects is
the effects of smoking on the fetus given directly by a physician or necessary but not
midwife, supplemented by a health education booklet. The advantage always sufficient to
of this intervention is that it is brief. In the trial reported by Lilley<7> induce patient
it lasted 10 minutes, and could be given by a physician or midwife, who compliance
would ordinarily be in contact with the patient for prenatal care.
However, knowledge concerning adverse health effects is necessary
but not always sufficient to induce patient compliance.<8> Since
addictions are complex behaviours with multifactorial origins, simply
giving women information about the ill-effects of smoking and advising

27
 them to quit without providing the support needed to achieve that
goal may not produce the desired result.
“Feedback” implies evaluating patient status prior to the
intervention through a carbon monoxide breath sample, a cotinine
blood sample, or a fetal ultrasound. Patients are provided with the
results of these measures, sometimes with comparative measures in
nonsmoking individuals. Health advice is given about how to improve
these measures through smoking cessation.
Multiple component intervention programs combine elements of
health education, self-help manuals on how to quit smoking, supportive
counselling and multiple follow-up contacts. These interventions are
more labour intensive than advice, feedback, or group counselling.

Effectiveness of Treatment
It is estimated that 25% to 40% of pregnant women smokers quit
smoking without any intervention for at least a brief time upon
learning they are pregnant.

Smoking Cessation Advice

There have been several randomized controlled trials<4-7> of
smoking cessation advice among pregnant women. Unfortunately,
design problems have included small sample size, poor description of
the intervention,<5,6> lack of uniform intervention delivery and
contamination of treatment and control groups.<6> Follow-up was
reported to be 66% to 100%. Outcomes were based on self-report
with only one study<5> reporting biochemical verification. Dropouts
were omitted from the final analysis in all studies using advice as the
intervention. Quit rates (stopping smoking for the remainder of the
pregnancy) were consistently higher (but not statistically higher) in the
experimental (6-14%) as opposed to the control groups (1-6%).
A 1993 meta-analysis found that advice significantly reduced the
proportion of smokers who continued smoking through pregnancy,
compared with smokers who received standard antenatal care (odds
ratio 0.39; 95% confidence interval (CI): 0.21-0.75).<9>
In primiparas, MacArthur<6> reported that mean birth weight in
the intervention group receiving advice was 68 g heavier than that of
controls (p<0.06). The author also noted that primiparas in the
intervention group were more likely to have received adequate advice.
Sixty one percent of primiparas recalled being advised to stop smoking
by the obstetrician or by the midwife, compared with only 45% of
multiparas. Mean birth weights of multiparas in the two groups were
not statistically different.

28
Feedback
Three trials have used feedback involving serum cotinine levels,
carbon monoxide levels, and ultrasound examinations.<10-12> Blood
tests and ultrasound are often already part of antenatal care; testing
carbon monoxide levels is non-invasive. Thus, minimal additional cost
or time was involved. Although these were randomized trials and
provided good descriptions of the interventions, design problems
included poor follow-up,<10,12> small subject numbers<10,11> and
omission of dropouts from analysis. Again, quit rates were higher (but
not statistically higher) in the experimental group. One trial was
designed to test a self-reported multifactorial lifestyle change which
included drinking and other health-related activities as well as smoking.
The number of smokers who reported a change in smoking behaviour
was low and the results could have been greatly influenced by omission
of drop-outs from the analysis.<11> Thus there is insufficient evidence
to evaluate the effectiveness of feedback.

Group Counselling
In a group counselling intervention adapted by Loeb et al<13>
from the Multiple Risk Factor Intervention Trial, the significance of the
results was limited by the fact that only 10% of the treatment group
attended all counselling sessions. Experimental and control groups had
similar quit rates (15% and 14%, respectively). Two of three
trials<14,15> that compared counselling to usual care found
significantly increased abstinence rates after the intervention (14% vs.
8%; and 15% vs. 5%). One small trial of women attending a public
health clinic<16> found counselling made no difference (21% vs. 23%
abstinence during pregnancy) but the usual intervention was clearly
very effective. Most studies that compared post-partum recidivism
rates between counselling and control groups found higher relapse
rates among quitters in the control groups compared to those in the
intervention groups. Group counselling thus has had mixed results and
should be evaluated further.

Multiple Component Programs

Several trials have evaluated multiple component
programs.<17-22> All but two studies<21,22> were randomized trials,
and most had over one hundred subjects with 84-98% follow-up.
Except for two studies,<18,19> drop-outs were counted as treatment
failures.
Quit rates were significantly increased (p<0.05) by all behavioral
strategy interventions (quit rates, experimental groups 10-27%;
control groups 2-9%). Clinically significant birth weight differences
were observed, with decreased low (<2500 g) and very low birth
weight (<1500 g) in infants of those who quit smoking. One study

29
 found a 5.6% incidence of low birth weight in the intervention groups
compared with 6.52% incidence in the control groups.<19>
Ershoff,<19> Gillies<22> and Windsor<23> found smoking
cessation interventions were cost effective, comparing the cost of
hospital delivery in treated versus control groups including the cost of
the intervention. Ershoff found a benefit of 2.8 to 1 for the
intervention vs. the control group.
A 1993 meta-analysis of behavioral strategies found a significant
reduction in the proportion of smokers who continued smoking
through pregnancy, compared with standard antenatal care or with
personal advice supplemented by written materials (odds ratio 0.30;
95% CI: 0.23-0.38).<24> However, the author concluded that since
even the most effective strategies implemented during pregnancy have
a limited effect, obstetricians and midwives should also support
population strategies towards progressive reduction in cigarette
smoking for society as a whole. In a separate analysis of all
interventions to reduce smoking in pregnancy, Lumley concluded that
smoking cessation interventions result in a small increase in mean
birthweight. Effects on preterm birth and perinatal mortality were
unclear.

Maternal Smoking After Pregnancy

Postpartum recidivism was high in studies which included post-
intervention<4,22> and postpartum assessment.<18-21> Sexton found
that three years after completing the trial, 72% of those who quit
during pregnancy were smoking again and 91% of those who did not
quit during pregnancy were still smoking.
Thus, despite having achieved statistically significant quit rates
during pregnancy, these gains were not maintained and would not be
assumed to improve the mother’s long-term health in the majority of
cases. The clinically significant benefit may be limited to the offspring.

Long-term Effects of Maternal Smoking During

Pregnancy on Children
Most long-term studies of children whose mothers smoked
during pregnancy have focused on growth and neurocognitive ability.
Average height and weight of 3-year-old children whose mothers had
quit during pregnancy were significantly increased over children of
non-quitters (height p<0.001, weight p<0.05).<25> Whether the
differences found, (0.45 kg for weight and 1.13 cm for height) were
clinically significant may be open to question.
Several cohort and case-control studies have noted differences
in psychometric test results in children of women who smoked during
pregnancy and children of non-smokers.<26-33> Sexton and

30
colleagues<26> carried out cognitive testing in the three-year-old
offspring of mothers who had quit and in children of women who had
continued smoking during pregnancy. The Preschool Version of the
Minnesota Child Development Inventory and the McCarthy Scales of
Children’s Abilities were used as outcome measures. The General
Cognitive Index score in children of quitters averaged 5 points higher
than in children of non-quitters (p<0.01), even when babies of
<2,500 g birth weight were excluded and after controlling for other
variables such as socioeconomic status, maternal behaviour, maternal
time available to child and child characteristics. Statistically significant
differences of one to 3 points were also noted on the McCarthy
subscales. McCarthy suggests 15 points between pairs of subscales as a
rule of thumb for determining noteworthy differences. Other
investigators have reported inconsistent effects of smoking on
psychological testing – both 1) significantly lower scores in the
smoking group versus the non-smokers and 2) no significant
differences between children of smokers and non-smokers. Based on
the evidence, one would conclude that smoking during pregnancy may
be detrimental to the offspring or at best, smoking has no effect – in
no case has smoking been shown to coincide with improved
psychometric test scores.

Characteristics of Women Who Quit Smoking

During Pregnancy
Four percent of women deny smoking even in the face of
biochemical evidence to the contrary. To determine how well women
who reported quitting smoking prior to pregnancy were able to
maintain that status, several authors have studied “spontaneous Women who quit
smoking had higher
quitters” (i.e. women who quit smoking in response to pregnancy
socioeconomic levels,
before the start of prenatal care). In a randomized controlled trial by were older, had
Quinn, Mullen, and Ershoff,<19,34> spontaneous quitters were defined smoked fewer
as women who stated that they had quit smoking since becoming cigarettes and were
pregnant and had not smoked for at least 24 hours. This group was better educated
compared to a group who reported smoking at least seven cigarettes
per week prior to pregnancy. Spontaneous quitters and smokers
differed significantly in the following respects: 1) Spontaneous quitters
had been lighter smokers prior to pregnancy; 2) they were less likely
to have another smoker in their household; 3) indicated a stronger
belief in the harmful effect of maternal smoking on fetal health; 4) had
a history of fewer miscarriages; and 5) had entered prenatal care
earlier. Compared to women who maintained cessation as measured
by urine cotinine levels, women who relapsed had less confidence in
their ability to stay off cigarettes, were more likely to be multigravidas,
and believed less strongly in the harmful effects of maternal smoking
on fetal health. Other authors have found that women who quit
smoking had higher socioeconomic levels, were older, had smoked

31
 fewer cigarettes, and were better educated than women who
continued smoking.

Recommendations of Others
The Canadian Nurses Association and the U.S. Preventive
Services Task Force<35> recommend that pregnant women receive
smoking cessation education. The Canadian Medical Association,
American College of Physicians, American College of Obstetricians
and Gynecologists, and the American Academy of Pediatrics,
recommend that physicians encourage smoking cessation. The Royal
College of Physicians and Surgeons of Canada recommend that
smokers who wish to stop smoking should receive effective help.

Conclusions and Recommendations

Interventions which include advice, multiple components,
behavioral strategies, support, multiple contacts, and self-help manuals
are effective in significantly decreasing tobacco smoking in pregnant
women. Interventions work with diverse populations with different
levels of nicotine dependence and at different stages of gestation.
Decrease in tobacco use has a beneficial effect on increasing
average birth weight and decreasing the incidence of low birth weight
infants. Smoking cessation interventions are cost effective as a result of
decreasing the number of low birth weight infants. Cognitive ability is
also improved in children of mothers who did not smoke during
gestation. Thus, there is good evidence to recommend smoking
cessation interventions for all pregnant women who smoke
(A Recommendation).

Unanswered Questions (Research Agenda)

More research is needed on interventions to maintain
abstinence post-delivery.

Evidence
Information retrieval sources were in consultation with
Addiction Research Foundation Library and Fudger Medical Library at
Toronto General Hospital using MEDLINE, 1966 to 1993. Key words
used include: Smoking, smoking cessation, tobacco; infant, low birth
weight, small for gestational age, newborn; birth weight, fetus, growth
retardation; abnormalities, brain development; growth, brain growth;
psychometrics; child development; pregnancy; prenatal care, exposure,
delayed effects; longitudinal studies; evaluation studies.
Science Citation Index, 1990-1992: Author’s names in clinical
trials.

32
 Expert consultation and review of literature files of: Smoking
Cessation Clinic, Community Treatment Research Unit, Addiction
Research Foundation Dr. R Frecker. Prevention, Health Promotion,
Addiction Research Foundation, M. Pope, and reference sections from
articles.
This review was initiated in January 1993 and the
recommendations were finalized by the Task Force in June 1993.

Acknowledgements
Funding for this report was provided by Health Canada under
the Government of Canada’s Brighter Futures Initiatives. The Task
Force thanks Helen P. Batty, MD, CCFP, MEd, FCFP, Associate
Professor, Department of Family and Community Medicine, University
of Toronto, Toronto, Ontario and Douglas M.C. Wilson, MD, CCFP,
FCFP, Professor of Family Medicine, McMaster University, Hamilton,
Ontario for reviewing the draft report.

Selected References
1. Fortier I, Marcoux S, Brisson J: Passive smoking during
pregnancy and the risk of delivering a small-for-gestational-age
infant. Am J Epidemiol 1994; 139: 294-301
2. Lumley J: Stopping smoking-again. [editorial] Br J Obstet
Gynaecol 1991; 98: 847-849
3. Benowitz NL: Nicotine replacement therapy during pregnancy.
JAMA 1991; 266: 3174-3177
4. Baric L, MacArthur C, Sherwood M: A study of health education
aspects of smoking in pregnancy. Int J Health Educ 1976; 19
(Suppl 2): 1-15
5. Burling T, et al : Changes in smoking during pregnancy. Paper
presented at the Society for Behavioral Medicine, Philadelphia,
PA, May 25, 1984
6. McArthur C, Newton JR, Knox EG: Effect of anti-smoking health
education on infant size at birth: a randomized controlled trial.
Br J Obstet Gynaecol 1987; 94: 295-300
7. Lilley J and Forster DP: A randomized controlled trial of
individual counselling of smokers in pregnancy. Public Health
1986; 100: 309-315
8. Meichenbaun D, Turk D: Facilitating treatment adherence: a
practitioner’s guidebook. New York: Plenum, 1987
9. Lumley J: Advice as a strategy for reducing smoking in
pregnancy. In Pregnancy and Childbirth Module (eds. Enkin
MW, Keirse MJNC, Renfrew MJ, Neilson JP), “Cochrane
Database of Systematic Reviews”: Review No. 03394,
2 October 1993. Published through “Cochrane Updates on
Disk”, Oxford: Update Software, 1993, Disk Issue 2

33
 10. Bauman KE, Bryan ES, Dent CW, et al : The influence of
observing carbon monoxide levels on cigarette smoking by
public prenatal patients. Am J Public Health 1983; 73:
1089-1091
11. Reading AE, Campbell S, Cox DN, et al : Health beliefs and
health care behaviours in pregnancy. Psychol Med 1982; 12:
379-383
12. Haddow JE, Knight GJ, Kloza EM, et al : Cotinine-assisted
intervention in pregnancy to reduce smoking and low birth
weight delivery. Br J Obstet Gynaecol 1991; 98: 859-865
13. Loeb B, et al : A randomized trial of smoking intervention during
pregnancy. Paper presented to the American Public Health
Association Annual Meeting, Dallas, TX, Nov. 15, 1983
14. Windsor RA, Lowe JB, Perkins LL, et al : Health education for
pregnant smokers: its behavioural impact and cost benefit. Am J
Public Health 1993; 83: 201-206
15. O’Connor AM, Davies BL, Dulberg CS, et al : Effectiveness of a
pregnancy smoking cessation program. JOGNN 1992; 21:
385-392
16. Petersen L, Handel J, Kotch J, et al : Smoking reduction during
pregnancy by a program of self-help and clinical support.
Obstet Gynecol 1992; 79(6): 924-930
17. Windsor RA, Cutler g, Morris J, et al : The effectiveness of
smoking cessation methods for smokers in public health
maternity clinics: a randomized trial. Am J Public Health 1985;
75: 1389-1392
18. Sexton M and Hebel JR: A clinical trial of change in maternal
smoking and its effect on birth weight. JAMA 1984; 251:
911-915
19. Ershoff DH, Quinn VP, Mullen PD, et al : Pregnancy and
medical cost outcomes of a self-help prenatal smoking
cessation program in a HMO. Public Health Rep 1990; 105:
340-347
20. Mayer JP, Hawkins B, Todd R: A randomized evaluation of
smoking cessation interventions for pregnant women at a WIC
clinic. Am J Public Health 1990; 80: 76-78
21. Hjalmarson AIM, Hahn L, Svanberg B: Stopping smoking in
pregnancy: effect of a self-help manual in controlled trial. Br J
Obstet Gynaecol 1991; 98: 260-264
22. Gilies PA, et al : Successful anti-smoking intervention in
pregnancy – behaviour change, “clinical indicators” or both? In
Durston B, Jamrozik K (eds): Tobacco and Health 1990, The
Global War. Procedings of the Seventh World Conference on
Tobacco and Health, 1st-5th April 1990, Perth, Western
Australia
23. Windsor RA, Warner KE, Cutter GR: A cost-effectiveness
analysis of self-help smoking cessation methods for pregnant
women. Public Health Rep 1988; 103: 83-88

34
24. Lumley J: Behavioural strategies for reducing smoking in
pregnancy. In Pregnancy and Childbirth Module (eds. Enkin
MW, Keirse MJNC, Renfrew MJ, Neilson JP), “Cochrane
Database of Systematic Reviews”: Review No. 03397,
27 September 1993. Published through “Cochrane Updates on
Disk”, Oxford: Update Software, 1993, Disk Issue 2
25. Fox NL, Sexton M, Hebel JR: Prenatal exposure to tobacco.
Effects on physical growth at age three. Int J Epidemiol 1990;
19: 66-71
26. Sexton M, Fox NL, Hebel JR: Prenatal exposure to tobacco.
Effects on cognitive functioning at age three. Int J Epidemiol
1990; 19: 72-77
27. Fergusson DM, Lloyd M: Smoking during pregnancy and its
effects on child cognitive ability from the ages of 8 to 12 years.
Paediatr Perinatal Epidemiol 1991; 5: 189-200
28. Baghurst PA, Tong SL, Woodward A, et al : Effects of maternal
smoking upon neuropsychological development in early
childhood: importance of taking account of social and
environmental factors. Paediatr Perinatal Epidemiol 1992; 6:
403-415
29. Makin J, Fried PA, Watkinson B: A comparison of active and
passive smoking during pregnancy: long-term effects.
Neurotoxicol Teratol 1991; 13: 5-12
30. Naeye R, Peters EC: Mental development of children whose
mothers smoked during pregnancy. Obstetr Gynaecol 1984; 64:
601-607
31. Bauman K, Flewelling RL, LaPrelle J: Parental cigarette
smoking and cognitive performance of children. Health Psychol
1991; 10: 282-288
32. Rantakallio P, Koiranen M: Neurological handicaps among
children whose mothers smoked during pregnancy. Prev Med
1987; 16: 597-606
33. Hardy JB and Mellits ED: Does maternal smoking during
pregnancy have a long-term effect on the child? Lancet 1972;
1332-1336
34. Quinn VP, Mullen PD, Ershoff DH: Women who stop smoking
spontaneously prior to prenatal care and predictors of relapse
before delivery. Addict Behav 1991; 16: 29-40
35. U.S. Preventive Services Task Force: Guide to Clinical
Preventive Services: an Assessment of the Effectiveness of
169 Interventions. Williams & Wilkins, Baltimore, Md, 1989:
289-292

35
 S U M M A R Y T A B L E C H A P T E R 3

Smoking and Pregnancy

MANEUVER EFFECTIVENESS LEVEL OF EVIDENCE RECOMMENDATION

<REF>
Smoking cessation Smoking cessation
intervention including interventions improve
advice, multiple quit rates.
component programs
and/or behavioral
strategies
Smoking cessation
decreases incidence of
low birth weight
infants.
Randomized controlled Good evidence to
trials<14,17-20> and include smoking
meta-analysis of cessation interventions
randomized controlled in the periodic health
trials<9,24> (I) examination of
pregnant women who
Randomized controlled smoke (A)
trials<18,19> (I)

Smoking cessation Randomized controlled

interventions are cost trials<19,23> (I)
effective.

Smoking cessation Cohort studies<26-33>

improves cognitive (II-2)
ability in children of
mothers who quit
smoking during
gestation.

36