Smoking in pregnancy poses a significant health problem for both parent and baby.

Many people who smoke will quit by themselves before becoming pregnant, and others will stop once their pregnancy is confirmed. For some people, however, considerable help is needed to stop smoking successfully (Papadakis & Hermon 2019).

The research evidence is clear: cigarettes contain numerous harmful substances, and those who smoke during pregnancy are more likely to have babies with birth defects than non-smokers.

As smoking during pregnancy adversely affects so many different aspects of health, it remains one of the greatest factors that could potentially improve birth outcomes (Greenhalgh et al. 2021).

Risks for the Birthing Parent

It’s well known that smoking can impair fertility (Your Fertility 2024), and in addition to the general risks of smoking, pregnant people also face additional pregnancy-related health risks including:

• Ectopic pregnancy
• Placenta praevia
• Pre-eclampsia
• Venous thromboembolism.

(DoHaAC 2023; Queensland Health 2021)

Risks for the Fetus

Smoking while pregnant is well-known to be harmful to the growing fetus, with an increased risk of:

• Miscarriage
• Stillbirth
• IVF failure
• Intrauterine growth restriction
• Premature birth
• Birth defects e.g. cleft lip or cleft palate
• Sudden infant death syndrome (SIDS).

(DoHaAC 2023; Quit 2024)

Nicotine, together with the multiple carcinogenic pollutants found in cigarettes, is detrimental to healthy fetal development. It’s generally agreed that unless further research proves otherwise, public health information should make patients aware of these potential risks and provide practical help and encouragement to quit smoking early in pregnancy, and ideally before conception.

Nicotine Replacement Therapy May Not be the Answer

As nicotine addiction is the factor that stops many people from giving up smoking during pregnancy, the use of nicotine replacement therapy (NRT) has been suggested as a lower risk to the fetus. However, the long-term effects of NRT are unknown (RANZCOG 2020).

That said, there is a general view that NRT during pregnancy is safer than smoking. At the same time, it’s widely acknowledged that total abstinence from all forms of nicotine should be advised from preconception through to birth.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2020) recommends that non-pharmacological interventions be used as first-line therapy, however, NRT may be considered in patients who cannot achieve abstinence with non-pharmacological interventions alone.

In these cases, NRT should be used at ‘the most effective dose for the shortest duration possible’ to reduce fetal exposure to nicotine (RANZCOG 2020).

Although pregnancy is often a strong motivator for smoking cessation, many people continue to smoke, and more effective strategies to help them become non-smokers are urgently needed.

How Can Nurses and Midwives Help?

It’s now widely accepted that any contact with a pregnant patient from preconception through to postnatal visits provides an opportunity to give advice on smoking cessation, but many midwives remain unclear on what exactly this advice should be.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2020) suggests that practitioners should follow the ‘Ask, Advise, Help’ model to help pregnant patients become non-smokers:

• Ask and record smoking status, verifying it with a carbon monoxide monitor
• Advise the patient briefly about the importance of quitting and the most effective ways to quit
• Help refer them to interventions and cessation services.

Although these guidelines are clear about the need to help pregnant patients stop smoking, it’s also clear that practitioners lack confidence and training on how to communicate this message in a way that actually achieves behavioural change.

Research carried out by Longman et al. (2018) explored the enablers and barriers to the implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines suggest that practitioners follow the 5 A’s of cessation:

• Ask
• Advise
• Assess
• Assist
• Arrange to follow up.

Identified barriers to implementing these guidelines included knowledge and skills gaps, reluctance to engage in ‘difficult conversations’, as well as perceiving smoking as a social activity (Longman et al. 2018).

Finding innovative and effective ways to reduce smoking in pregnancy remains a priority. To date, there is still relatively little evidence on the efficacy of smoking cessation interventions before or after pregnancy, or on preventing relapse after quitting during pregnancy (NIHR 2017).

Smoking remains one of the few modifiable risk factors in pregnancy, yet it continues to be a worldwide public health concern.

From the patient’s point of view, this is an invisible problem, and as long as smoking continues to be viewed as an acceptable social activity rather than as an addiction, it’s unlikely that significant progress will be made.