Byron C. Calhoun1
Department of Obstetrics and Gynecology, West Virginia University-Charleston, Charleston, WV, USA
Byron C. Calhoun
TobaccoNicotinePregnancyMorbidity and mortality
West Virginia leads the nation in the percentage of women who smoke while pregnant (35.7 %) . From 2000 to 2005, while most of the country experienced declines in smoking rates among pregnant women, West Virginia experienced an increase in smoking rates in all stages of reproduction. Smoking rates increased (36.2–45.8 %) prior to pregnancy, (29.4–35.7 %) during pregnancy, and (1.6–39.3 %) postpartum . Findings from the West Virginia Bureau for Public Health, Health Statistics Center indicated that during 2005, pregnant women in West Virginia who smoked were 63.2 % more likely than nonsmoking pregnant women to have their child die during his/her first year of life. In addition, they were 97.4 % more likely to give birth to a low birth weight baby and 281.8 % more likely to have a child die from Sudden Infant Death Syndrome within his/her first year when compared to those who did not smoke.
Tobacco abuse continues to be a major problem among adolescents. SAMHSA 2015 (using 2013 data as last completed year of analysis) reported that 5.6 % of adolescents age 12–17 (approximately 1.4 million adolescents) admitted to using cigarettes within a month of the 2013 survey . Cigarette usage was also higher in metropolitan areas (8.4 %) compared to rural areas (5.1 %). SAMHSA further reported that the number of US adolescents using cigarettes had dropped from 9.0 to 5.6 % from 2009 to 2013. There were significant drops in usage reported in whites, blacks, and Hispanics.
The detrimental effects of nicotine consumption during pregnancy are well established in the literature. Tobacco use has been demonstrated to cause significant changes within maternal and fetal cell transcriptomes involved in the deregulation of numerous biological processes important for growth and development . It also results in statistically significant reductions of placental vascularization . Both of these findings are related to subsequent fetal morbidities such as small for gestational age infants (SGA), intrauterine growth retardation (IUGR), and low birth weight [5–10]. Smoking includes additional increased risks for the following: cryptorchism in males , orofacial clefts , asthma and bronchopulmonary hyperreactivity [13, 14], placental abruption , fetal malpresentation , preterm birth [17, 18] and stillbirth [19, 20].
Demographics and Prevalence
For women abusing tobacco in pregnancy data shows 
· One in 5 women smoke prepregnancy
· Approximately 50 % of women quit smoking by late pregnancy
· Prenatal smokers
· Higher in <25 years of age; higher among non-Hispanic Whites, American Indians, or Alaska Natives
· More likely to be low-income and live with a smoker
· Among women who quit during pregnancy, almost ½ relapsed to smoking after delivery
Further barriers to tobacco cessation include a strong culture and a long history of tobacco use. The interplay of values, customs, attitudes, and beliefs all interconnect to work against attempts for tobacco cessation. Each area reinforces the others and any approach to tobacco cessation must account for these interactions (see figure below).
At prenatal screenings, patients are often asked in their medical history if they use tobacco. However, self-reported tobacco consumption may not be a reliable indicator of total exposure . Studies have shown discrepancy between self-reports of tobacco use and cotinine levels [22, 23]. The issue of the discordance and self-reporting while comparing cotinine levels rests on the frequency of smoking, maternal hydration (with urine testing), renal function, and maternal habitus. The use of maternal saliva to evaluate for cotinine may prove more useful in the future since it is less invasive, less affected by maternal hydration, and more stable as an indicator of level of use.
Another way to measure tobacco usage involves breath analyses of expired carbon monoxide (eCO). These can be less expensive and more rapid than urine drug testing; however, eCO level tests have shown poorer performance at measuring tobacco use than cotinine drugs screens . It has a half-life of 2–8 h, allowing detection of smoking over a 6–24 h period . This reduced half-life would require more frequent testing of eCO (i.e., more trips to the clinic) to obtain more representative measurements of tobacco use. In addition, the process of cigarette smoking is complex. Intake of nicotine during smoking depends on many variables (puff volume, depth of inhalation, the extent of dilution with room air, and the rate and intensity of puffing), all of which can be controlled by the individual .
Another alternative involves the major nicotine metabolite, cotinine, which has a half-life of around 16 h, providing a means of assessing tobacco use over a 3 to 4-day period . With a sensitivity of 89.5 % and specificity of 65.3 % , cotinine testing can be performed on saliva, urine, or blood samples. A study by Mathai et al. revealed that low birth weights due to smoking have greater correlation with urinary cotinine values than self-reports of tobacco use: “active maternal smoking was associated with a decrease in birth-weight of 12 g for every cigarette smoked in a day while there was a decrease of 25 g in birth-weight for every microgram of cotinine/mg of urinary creatinine” . These values could reveal more information regarding tobacco consumption, which is important to know in the context of pregnancy when studies have noted that there is a direct dose–response association between growth retardation and tobacco exposure .
Currently, ACOG recommends that every woman who enters prenatal care ought to be asked about tobacco usage and the 5A’s utilized :
· Ask about tobacco use
· Advise to quit (or at least decrease)
· Assess willingness to attempt quitting
· Assist in quit attempt
· Arrange follow-up
As of Oct 2010, the Affordable Care Act mandated that state Medicaid programs (approximately 40 % of births in US) must cover comprehensive tobacco treatment for pregnant women. Promotion of coverage among providers and enrollees is needed to actualize this benefit. One of the foremost strategies has been the use of tobacco quit-line resources. Analysis of quit-line services in ten states during 2006–2008 found:
· 1718 pregnant and 24,321 nonpregnant women enrolled in services.
· Half of pregnant women received self-help materials only.
· Self-reported quit rates at 7 months after e nrollment in the subsample were 26.4 % for pregnant women .
The military reported similar findings in using a telephone quit-line approach in a cohort of 1298 nonpregnant military patients of both sexes with a 22 % tobacco abstinence rate at 12 months by using a proactive approach with counselors calling the patients to initiate a six-session interview for cessation .
A significant number of cofactors/myths surround the implementation of tobacco cessation by women:
· Daily life
· Being pregnant
· Significant others
· Other addictions
· Many thought nicotine was the most dangerous compound in cigarettes.
· Belief that Nicotine Replacement Therapy (NRT) delivered a “pure nicotine” that was worse for the baby than cigarette smoke.
In spite of these barriers, ACOG affirms the following:
· Prenatal care providers deliver a brief counseling session for patients who are willing to try to quit smoking.
· Counseling approaches, such as the 5A’s intervention (ask, advise, assess, assist, and arrange), which have been shown to be effective when initiated by healthcare providers.
· Quit lines can be used as support.
· NRT could be considered if behavioral therapy failed; however, cautioned of providing “close supervision” and considering risks of smoking and risks of NRT.
Taxation has made significant inroads into the sales of cigarettes in the nation. Studies have shown that as the price of cigarettes rises above $2 a package, the number of cigarettes sold began to decline. Further, as the price exceeded $6 the sales dropped precipitously.
Effective strategies with youth and young adults include:
· Cigarettes taxes
· 100 % smoke-free air laws
· Reduce out-of-pocket costs for cessation treatment
· Media campaigns
Public and private partnerships have made substantial gains in the establishment of healthier smoke-free environment. Virtually all federal, state, county, and city public buildings are now smoke free. Also, most public malls, stores, and places of business are now smoke free. In the last 15 years, the number of smoke-free restaurants and businesses have increased significantly in the United States. It is estimated that approximately 75 % of all private workplaces are smoke free, with about 30 % of restaurants and approximately 10 % of bars smoke free. Progress continues to be made but further work is necessary.
Most recently, the E-cigarettes present a challenge to present legislation and bans. Since these cigarettes do not produce “smoke” from tobacco and allegedly only water vapor, they are not commonly covered by the present smoking/tobacco bans. The FDA has received reports for possible side effects as well including:
· Congestive heart failure
· Other health problems
E-cigarettes have undergone no long-term studies and therefore there is no information regarding the potential risks of E-cigarettes when used as intended, how much nicotine or other potentially harmful chemicals are being inhaled during use, or whether there are any benefits associated with using these products. This in particular applies to pregnant patients for which no studies exist regarding the use of E-cigarettes in the context of pregnancy. Nor is there any data on what other chemicals or products might be inhaled with the use of E-cigarettes that cross the placenta to affect the fetus.
Healthcare partners have joined together as well to work with the local providers and politicians to continue to decrease tobacco use as part of healthcare provisions and healthcare benefits.
Colman et al. 2012 performed a Cochran database evaluation of NRT in the literature. They found six trials of NRT in pregnancy. None of the trials utilized bupropion or varenicline but only evaluated nicotine alone in abstinence/cessation. Coleman et al. 2012 found no difference in cessation in later pregnancy after using NRT as compared to control, RR = 1.33 [0.93–1.91]. They also found no difference in rates of poor birth outcomes (i.e., low birth weight, preterm) between NRT and controls. Significantly, they also found low adherence in NRT in at least one study with only 7 % on therapy at 4 weeks .
At present, there is insufficient evidence on efficacy and safety of NRT. Most providers and organizations believe more research is needed to better define the benefit/risk ratio. These concerns are due to the fact that nicotine is a known teratogen. However, it is also known that tobacco includes nicotine plus numerous other chemicals that are injurious to the woman and fetus (cadmium, lead, arsenic, etc).
There is also evidence in the literature whether providers/women would be willing to use NRT during pregnancy. In one study, 30 % of women reported discussing a cessation medication with their obstetric providers . Another study by Tong et al. 2008 found that 3 % of NJ pregnant smokers reported using NRT during pregnancy . ACOG believes that smoking cessation constitutes a vital goal for all pregnant women. So committed to this goal caused ACOG to endorse the web-based course “Smoking Cessation for Pregnancy and Beyond: A Virtual Clinic.” The program consists of
There is significant evidence that encouraging tobacco cessation has real impact in the perinatal outcome in smokers. This impact includes the following:
· Provider efforts have produced quit rates of approximately 10 %.
· Smoking Quit Line has also produced quit rates of 10 %+.
· 5A’s quit rates are approximately 20 % for smoking.
· Quitting smoking in pregnancy leads to improved birth outcomes, including a 25 % reduction preterm delivery.
· Cutting down leads to a 20 % reduction in preterm delivery and a 44 % reduction in NICU admissions.
· Seybold et al. 2012 found that among women in WV, reducing smoking to <8 cigarettes per day had a higher birth weight than those who did not reduce smoking (3.2 vs. 2.9 kg, p = 0.03) .
· Efforts must be persistent and consistent to impact.
Three strategies ought to be employed in every attempt at tobacco cessation within a group or practice:
· Ensure that patients are urged to quit at every prenatal care visit and that accurate information on available help is provided. Communicate in a personal way how smoking harms the health of every baby. For patients unable to quit, offer strategies to improve birth outcomes.
· Launch an education and media campaign to change language of the term, “low birth weight” and clearly communicate the impact of restricted fetal growth on the developing baby.
· For women who do quit during their pregnancy, provide encouragement and support for them to remain tobacco-free postpartum.
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