Society Position Paper

Statement of the Public Affairs Committee of theTeratology Society on the Importance of Smoking

Cessation during Pregnancy

Jane Adams*Department of Psychology, University of Massachusetts, Boston

Received 25 August 2003; Accepted 15 September 2003

Reports on the harmful effects of smoking during preg-nancy began to proliferate during the 1980s. Since thattime, numerous studies have firmly established the risks tothe fetus that are associated with exposure. In 2001, theSurgeon General’s Report argued that the established ad-verse health consequences of smoking on women’s health“compel(s) the Nation to make reducing and preventingsmoking one of the highest contemporary priorities forwomen’s health” (US Department of Health and HumanServices [USDHHS], 2001). Herein, the Public Affairs Com-mittee of the Teratology Society argues that the nationmust make the reduction of women’s smoking duringpregnancy one of the highest priorities for fetal and childhealth. In the United States, cigarette smoking is the singlelargest preventable risk factor for pregnancy-related mor-bidity and mortality (Dempsey and Benowitz, 2001). In thisreport, we first examine the current prevalence of smokingduring pregnancy and its negative effects on the fetus andchild. We then examine the benefits of smoking cessationduring pregnancy and the success rates and characteristicsof women who are able to quit smoking during pregnancy.We then address the causes of the adverse outcomes ofpregnancy and examine whether complete smoking cessa-tion or nicotine replacement therapy may be necessary toameliorate the smoking-related effects on pregnancy out-come. Finally, we argue for the enactment of educationaland treatment programs for smoking cessation that aretargeted at the women at highest risks for smoking duringpregnancy and also argue for a clinical efficacy study thatwill examine the consequences of nicotine replacementtherapy upon maternal and fetal health.

PREVALENCE OF SMOKING AMONGPREGNANT WOMEN

National health statistics from 1998 indicated that 22% ofall women 18 years and older smoke cigarettes (USDHHS,2001). It is estimated that 12–24% of pregnant womensmoke, with the lower figure coming from self-reportedinformation and the higher figure from more direct sur-

veys (USDHHS, 2001). The National Center for HealthStatistics compiled birth certificate data from 46 states re-cording between 1989 and 1998. These data showed agradual decline in the self-reported prevalence of smokingduring pregnancy from 19.5% in 1989 to 12.9% in 1998.Analyses of these data suggested that the decline resultedfrom a decrease in smoking initiation among women asopposed to an increase in smoking cessation during preg-nancy. This self-reported information derived from birthcertificate data is likely to underestimate actual smokingconsumption, but the data do allow reasonably accurateassessments of the influence of certain variables uponsmoking prevalence. Most notable are the importance ofage, race, and educational level as determinants of a wom-an’s likelihood of smoking. Prevalence is higher among 18-to 24-year-old pregnant women than among younger orolder mothers. American Indian or Alaskan Native women(20.2%) and white women (16.2%) are now most likely tosmoke, whereas black women report intermediate levels(9.6%), and lowest levels occur in Hispanic (4%) and Asianor Pacific Islander women (3.1%). Equally striking is theassociation between advanced education and reducedsmoking prevalence during pregnancy (�8 years � 11.7%,9–11 years � 25.5%, 12 years � 16.8%, 13–15 years � 9.6%,and �16 years � 2.2%). Among women who reported

The Public Affairs Committee of the Teratology Society,2003: Christina D. Chambers (Chair), Jane Adams, SarahAli-Khan, Patricia Bittner, George P. Daston, J. DavidErickson, Karen Filkins, Thomas Flynn, Andrew G. Hen-drickx, Carole A. Kimmel, Devendra M. Kochhar, James L.Mills, Dorothy L. Quinn, Melissa Sherman Tassinari, andL. David Wise*Correspondence to: Jane Adams, Ph.D., Department of Psychology, Universityof Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125.E-mail: jane.adams@umb.edu

DOI: 10.1002/bdra.10140

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smoking, 68.6% reported smoking less than 10 cigarettesper day, 27.6% reported smoking 11–20 cigarettes per dayand only 3.8% reported smoking more than 20 cigarettesper day. These levels of consumption are believed to un-derestimate actual smoking behavior because studies inwhich nicotine or its primary metabolite, cotinine, are mea-sured directly in cord blood, maternal blood, or urinesamples consistently indicate intake levels higher thanthose recorded through self-report (Ellard et al., 1996).

CONSEQUENCES OF SMOKING DURINGPREGNANCY

Pregnancies among women who smoke are marked byincreased risks for spontaneous abortion, perinatal placen-tal abnormalities, birth complications, increased prematu-rity, low birth weight, sudden death, increased postnatalhealth problems in their infants, and possible neurobehav-ioral changes (USDHHS, 1990, 2001; Levin and Slotkin,1998; Castles et al., 1999; Andres and Day, 2000). Smokingduring pregnancy has not been associated with major mal-formations. Andres and Day (2000) summarized the liter-ature on perinatal complications associated with smokingand indicated well-established associations between ma-ternal smoking during pregnancy and increased risks forplacenta previa, abruptio placentae, premature rupture ofthe membranes, prematurity, intrauterine growth retarda-tion, and sudden infant death syndrome. Indeed, it hasbeen suggested that smoking accounts for 15% of prema-ture births, 20–30% of infants with low birth weight (An-dres and Day, 2000), and approximately 24% of suddeninfant death syndrome deaths (Pollack, 2001). Based on themeta-analysis of data from studies on pregnancy-relatedsmoking risks, DiFranza and Lew (1995) suggested thatsmoking during pregnancy annually causes an estimated19,000 to 141,000 tobacco-induced miscarriages, 32,000 to61,000 infants born with low birth weight, 14,000 to 26,000infant admissions to neonatal intensive care units, 1900 to4800 infant deaths due to perinatal disorders, and 1200 to2200 deaths from sudden infant death syndrome. Taylorand Wadsworth (1987) reported that in a sample of morethan 12,000 children born to women who smoked duringpregnancy, maternal smoking significantly increased theincidence of bronchitis and of hospital admission for lowerrespiratory tract illness during the first five years of life.Prenatal and postnatal tobacco smoke exposure, whichvaries greatly across socioeconomic status and racial/eth-nic groups, also has been associated with increased child-hood asthma (Weitzman et al., 1990; Oliveti et al., 1996;Klinnert et al., 2002). Further, a growing number of studiessuggest that infants born to women who smoke duringpregnancy may be at increased risk for childhood obesity(vonKries et al., 2002; review by Slikker and Schwetz,2003). Exposure to secondhand tobacco smoke duringpregnancy also increases the risks for having a low birth-weight infant (Haddow et al., 1988; Martinez et al., 1994;Eskenazi, et al., 1995; Nafstad et al., 1998). There are alsomultiple reports associating smoking during pregnancywith compromised cognitive performance in the child(Streissguth et al., 1984; Kristjansson, et al. 1989; reviewedby Levin and Slotkin, 1998). Whereas the human situationpresents many variables whose influences can be ad-dressed only through statistical procedures, it is notewor-thy that there are many studies using rodents attesting toneurobehavioral compromise and neurochemical alter-

ations in offspring exposed to nicotine (reviewed by Levinand Slotkin, 1998) or carbon monoxide (reviewed by Tolcoset al., 2000) during prenatal development.

BENEFITS OF SMOKING REDUCTION ANDCESSATION DURING PREGNANCY

Fortunately, it has been shown that when a patient stopssmoking in early pregnancy, infant birth weights increasein relation to the decrease in cotinine level (Li et al., 1993).Women who quit smoking in the first three to four monthsof pregnancy are at no greater risks for having a low-birth-weight infant than are non-smoking women (USDHHS,1990) and smoking cessation also reduces the risks forhaving a premature infant (Lumley et al., 2000). Smokingcessation interventions for pregnant women result in fewerlow-birth-weight newborns and perinatal deaths; fewerphysical, cognitive, and behavioral problems during in-fancy and childhood; and important health benefits for themother (Fiore et al., 2000). Thus, clear benefits to fetal andchild health result when a woman stops smoking duringpregnancy. The benefits of lesser smoking reduction ornicotine replacement therapy have not been empiricallyexamined.

In recognition of some of the harmful effects of smokingduring pregnancy and as a result of increased motivation,women are more likely to stop smoking during pregnancythan at other times (USDHHS, 2001). Indeed, approxi-mately one-third of women stop smoking upon planningto become pregnant or learning that they are pregnant(Walsh et al., 1997). Nevertheless, within one year afterchildbirth, the majority of mothers begin smoking again(Kahn et al., 2002a), thus exposing their children to harm-ful effects of sidestream smoke (Kahn et al., 2002b). It isimportant to understand who is most likely to be a smokerduring the childbearing years and who is least likely tostop smoking during pregnancy so that treatment pro-grams can be appropriately directed for highest benefit.

Research suggests that the women most likely to smokeare primarily 18- to 24-year-old women with 9–11 years ofeducation. Likewise, the women who are most likely toquit tend to represent groups who are least likely to smokein the first place, such as older women and women withgreater education (Kahn et al., 2002a). This suggests thatcessation programs must target groups of women who aremore likely to smoke and less likely to quit. The womenleast likely to quit tend to be less educated women underthe age of 25 who are also heavy smokers (Kahn et al.,2002a). Smoking cessation programs designed and imple-mented on behalf of these women are essential.

NICOTINE VERSUS CIGARETTE SMOKECONSTITUENTS AS MEDIATORS OF RISK

The role played by different components of tobaccosmoke in causing adverse effects on development is diffi-cult to examine in human studies. Tobacco smoke containsmore than 3000 chemicals (Hoffmann et al., 1997). Withinthis plethora, nicotine and carbon monoxide have receivedthe greatest attention in research studies, likely becausenicotine is the primary psychoactive agent and the agentresponsible for the addictive potency of cigarettes, andcarbon monoxide is a major constituent of tobacco smokewith well-established effects on oxygen delivery. Humanstudies that have attempted to sort out the role of nicotine

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have shown dose-related effects between maternal levelsof nicotine and a primary metabolite, cotinine, and risks forlow birth weight. Low birth weight is the endpoint mostoften studied, likely due to the ease and relative reliabilityof measurements as well as broad data availability in med-ical and birth certificate records. Nicotine readily crossesthe placenta and cord serum samples show concentrationsin the fetus that mirror or exceed maternal levels (Luck andNau, 1984; Luck et al., 1985; Koren, 1995). Peacock et al.(1991) compared birth weights in infants born to womenwho smoked low-yield cigarettes (low nicotine and carbonmonoxide) with that of higher-content cigarettes andfound a dose-related effect of nicotine and carbon monox-ide on low birth weight. The authors argued that risks forreduced birth weight were primarily present among thosewho smoked the equivalent of 13 or more high-yield cig-arettes per day. Ellard et al. (1996) examined the relation-ship between nicotine metabolite levels and birth-weightdeficits and found a dose-dependent relationship. Theyalso reported that infants born to smokers had an averagebirth-weight deficit of 226 gm. This is consistent with theSurgeon General’s Report of a deficit of approximately 200gm (USDHHS, 1990). The dose-response relationship sug-gests that perhaps babies exposed in utero to secondhandsmoke may also be at risk for reduced birth weight. Birth-weight deficits among babies born to passive smokers havebeen estimated at approximately 100 gm in work by Had-dow et al. (1988) and Martinez et al. (1994). Krishnamurthy(1991) examined the effects of the use of smokeless tobaccoduring pregnancy, thereby removing tobacco smoke con-stituents as contributors to adverse outcome, and reportedthat the use of smokeless tobacco also reduces infant birthweight. The role of nicotine is also emphasized in numer-ous animal studies that control for other exposure vari-ables (reviewed by Lichtensteiger et al., 1988; Lambers andClark, 1996; and Levin and Slotkin, 1998).

Research on the effects of exposure to the carbon mon-oxide in tobacco smoke has shown adverse effects uponplacental and fetal physiology, fetal growth, brain devel-opment, neurochemistry, and function (Fechter and An-nau, 1977, 1980; Mactutus and Fechter, 1984, 1985; re-viewed by Levin and Slotkin, 1998; reviewed by Dempseyand Benowitz, 2001). Carbon monoxide binds to maternaland fetal hemoglobin sites with an affinity that is morethan 200 times that of oxygen (Dempsey and Benowitz,2001). In smokers, elevated carboxyhemoglobin levels in-terfere with normal placental function, maternal-fetal oxy-gen transport, and fetal circulation. The fetal hypoxia thatresults has been argued to be a major cause of fetal growthretardation.

Although progress has been made in understanding thecontributions of nicotine and carbon monoxide to the ad-verse outcomes of pregnancy in women who smoke, it hasalso become clear that the responsible players are morelikely a multitude of factors, such as altered metabolic,hormonal, neurochemical, enzymatic, immunologic, andother cellular morphological and physiological changes(Dempsey and Benowitz, 2001). As a result of contributionsfrom multiple smoking constituents, smoking cessationduring pregnancy is the optimal goal for the protection ofmaternal and fetal health. Nevertheless, given the potencyof nicotine as an addictive drug, complete smoking cessa-tion may not be a plausible goal for many pregnantwomen. Thus, it is critical that the benefits of nicotine

replacement therapy as an aid to smoking cessation also beexplored.

Recent research has indicated that vulnerability to theeffects of smoking on infant birth weight may be associatedwith certain maternal metabolic genotypes. CYP1A1 andGSTT1 genotypes are particularly susceptible to reducedinfant birth weight in response to maternal smoking(Wang et al., 2002). These genotypes fail to produce en-zymes relevant to the conversion of toxic metabolites ofcigarette smoke to less harmful compounds.

These data suggest that for women who smoke duringpregnancy, smoking cessation is the optimal treatment tobenefit fetal and child health. However, benefits may alsoresult when nicotine levels are greatly reduced and otherharmful constituents are removed through nicotine re-placement therapy. In addition to targeting smoking ces-sation programs to women with the highest risk demo-graphic features, it may also be helpful to identify womenat increased risk due to the presence of these genetic poly-morphisms.

CHARACTERISTICS OF EFFECTIVESMOKING CESSATION PROGRAMS

DURING PREGNANCY

Programs for reducing smoking during pregnancy in-clude those designed for differing levels of targeted usewith individual women, such as various forms of smokingcessation programs and nicotine replacement programs,and educational self-help programs designed with differ-ing levels of specificity to the target populations. Increasedcigarette prices have also been shown to be effective de-terrents for many women. Although one-third of womenelect to terminate smoking during pregnancy, the unsuc-cessful remainder benefit from intervention. High inten-sity, individualized interventions have been shown to in-crease quitting rates by about 8% (Lumley et al., 2000). In1993, Walsh and Redman argued that cognitive behavioralcounseling programs show the highest success rates. Thetwo main factors associated with success appear to beinvolvement in an intense counseling program adminis-tered by medical, nursing, or other trained clinicians andexposure to self-help materials that are specific to the char-acteristics of the individual (Walsh et al., 2001). It is appar-ently ineffective to simply provide risk information topregnant women, to enroll them in group behavior therapyprograms, or to distribute self-help materials designed fora generic audience (Walsh et al., 2001). These findings areconsistent with reports on the efficacy of different smokingcessation programs among the general population ofsmokers where a strong relationship has been shown be-tween session length of person-to-person smoking cessa-tion intervention programs and success in quitting (Fiore etal., 2000). As a result of these findings in studies of thegeneral population of smokers, in 2000, the US PublicHealth Service published Clinical Practice Guidelines forTreating Tobacco Use and Dependence (Fiore, Bailey, Cohen etal, 2000; JAMA Consensus Statement, 2000) and recom-mended that high-intensity interventions should be imple-mented with four or five counseling sessions conductedwhenever feasible.

Although intensive, individualized smoking cessationprograms are most effective in achieving abstinence amongsmokers, other measures can be helpful in curtailing smok-ing or its initiation. Ringel and Evans (2001) investigated

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the effects of higher cigarette prices (due to excise taxincreases) on consumption by pregnant women, with par-ticular attention to the effects on women at highest risks foradverse outcomes. Using natality data from 1989 (the first-year smoking data were available) to 1995, they deter-mined that for every 10% increase in price, smoking par-ticipation rates among pregnant women fell by 7%.Further, pregnant women were found to be more respon-sive to tax increases in cigarette costs than was the generaladult population. Whereas most of the age, ethnic, andeducational groups examined demonstrated responsive-ness to the tax hikes, effects were most pronounced amongwomen who had demographic characteristics associatedwith increased likelihood of quitting anyway during preg-nancy: white women, older women, married women, andmore-educated women. Ringel and Evans (2001) did notfind evidence to support that tax increases reduced thesmoking consumption of women who continue to smokeduring pregnancy. These data therefore support the con-cept that increases in excise taxes on cigarettes are effectiveadjunctive measures that assist in reducing smoking ratesduring pregnancy and thereby are an aid to improvingmaternal and child health.

CURRENT AVAILABILITY OF SMOKINGCESSATION PROGRAMS DURING

PREGNANCY

A survey of health maintenance organization (HMO)practices in the state of California during 1997 revealedthat coverage of smoking cessation programs during preg-nancy was limited (Pickett et al., 2001). The survey focusedon coverage of individual, group, and telephone counsel-ing and self-help kits and found that only 8% of HMOsprovided all of these options, whereas 92% covered at leastone treatment, and 8% provided no coverage for tobaccodependency treatment during pregnancy. In 2000, the Clin-ical Practice Guidelines for Treating Tobacco Use and Depen-dence (Fiore et al., 2000), which represent consensus by aconsortium of seven governmental and nonprofit organi-zations, argued that providing smoking cessation treat-ment options to all patients who smoke should become astandard practice of ethical medical care and that tobaccodependence treatments identified as effective should be acovered benefit of all insurance plans, both public andprivate (Fiore et al., 2000). To date, this is not yet manda-tory and many women are denied coverage of smokingcessation programs during pregnancy.

NECESSARY ACTIONS

It is imperative that all health-care practitioners, relevantgoverning bodies, and public and private health care pro-viders take further actions that will reduce smoking duringpregnancy and thereby improve fetal outcome and childhealth. The Public Affairs Committee of the TeratologySociety proposes that policies and actions must:

1. Increase the availability of individualized, intensivecounseling programs for smoking cessation to pregnantwomen

2. Target increased availability to young women withless than a high school educational level who are heavysmokers

3. Increase the smoking cessation program training ofmedical and other counseling professionals for service de-livery to pregnant women

4. Provide funding for the conduct of a large clinicaltrial study to determine the efficacy and risks associatedwith nicotine replacement therapy in women who arelikely to be unsuccessful at quitting smoking during preg-nancy

5. Enact legislation calling for mandatory coverage ofindividualized smoking cessation programs during preg-nancy by all private, state, and federal health insuranceproviders.

6. The Public Affairs Committee of the Teratology Soci-ety urges the United States government to sign the WorldHealth Organization tobacco control treaty known as theFramework Convention on Tobacco Control, to fully com-ply with its requirements and suggestions, and to expandthe application of tobacco control actions as recommendedabove in order to specifically acknowledge the additionalneed for tobacco control on behalf of pregnant women andtheir children.

During the past several years, the World Health Orga-nization has been working to gain consensus on a tobaccocontrol treaty known as the Framework Convention onTobacco Control. This treaty was passed on May 21, 2003 atthe 56th World Health Assembly. Treaty content obligatesthe countries that sign and ratify it to adopt bans on theadvertising of tobacco products, to consider imposinghigher taxes on tobacco, to require that all ingredients belisted on packaging, and to assign broader legal liabilityupon tobacco product manufacturers. As of October 2003,74 countries have signed this treaty. The United States isnot yet one of them although, the United States did vote forthe treaty at the World Health Organization meeting, andTommy Thompson, the Secretary of Health and HumanServices, has indicated support.

ACKNOWLEDGMENTSThe Committee and author of this statement wish to

thank Patricia Janulewicz from the University of Massa-chusetts, Boston for supportive “reference-mining” activi-ties.

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