CLINICAL Management of in pregnant women Colin Mendelsohn Gillian S Gould Cheryl Oncken

Background In this article we review the natural is the most important preventable cause of adverse outcomes in smoking during and postpartum. The pregnancy. However, most smokers who become pregnant continue to smoke and growing list of health effects on the mother and most of those who quit relapse after delivery. child are outlined. Finally, we suggest updated evidence-based strategies for use by health Objective professionals during pregnancy and lactation. This article explores the relationship between smoking and pregnancy, and reviews the evidence for best practice intervention by general practitioners. Natural history of smoking, Discussion quitting and relapse in Continuing to smoke during pregnancy is strongly associated with socioeconomic pregnancy disadvantage, mental illness and Aboriginal and Torres Strait Islander populations. Pregnant smokers fall into three groups, which Quitting is more difficult for these groups and interventions assist only sixin every 100 pregnant smokers to quit. Behavioural counselling is the first-line treatment. require different approaches: Nicotine replacement therapy (NRT) can be offered if the smoker is unable to quit • Those who quit spontaneously when finding without it, although its efficacy is uncertain. Adequate doses of nicotine and good out they are pregnant. This group should be adherance may be required for the best results. The use of NRT in pregnancy is encouraged to maintain abstinence. likely to be less harmful than continuing to smoke. Women should be encouraged • Those who continue to smoke and require to quit smoking before becoming pregnant. assistance to quit. Keywords • Those who quit but relapse postpartum and may substance-related disorder; /pregnancy; Indigenous health services; benefit from further counselling. women’s health Spontaneous quitters Up to 45% of women who smoke before pregnancy stop before their first antenatal visit.8–10 Women who quit spontaneously are more likely to have Smoking in pregnancy is the most higher social status, no smoking partner, a lower important preventable cause of a wide degree of nicotine dependence, low parity and range of adverse pregnancy outcomes.1 less concern about weight gain.9,11,12 Quitting Smoking causes obstetric and fetal before conception or in the first trimester results complications and there is growing in similar rates of adverse pregnancy outcomes, evidence of serious harm extending into compared with non-smokers;5 however quitting childhood and even adulthood (Table 1). at any time during pregnancy produces health Unfortunately, most smokers who become benefits.13 Quitting before pregnancy also allows pregnant continue to smoke and most of the use of the full range of pharmacotherapies. those who quit relapse after delivery.2,3 Continuing smokers Pregnancy is a window of opportunity for health In Australia, 14.5% women report smoking while professionals to help smokers quit.4 Women are pregnant and 1 in 6 of these smokers quits before motivated to protect their baby’s health, and delivery.3 The real prevalence of smoking is likely quitting smoking during pregnancy reduces the risk to be higher, as up to 25% of pregnant smokers do of complications.4–6 However, general practitioners not disclose their smoking status,14 often because (GPs) are missing many opportunities to intervene.7 of the social stigma.15

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Smoking during pregnancy is strongly Table 1. Pregnancy-related health effects of smoking associated with socioeconomic disadvantage11 Health effect Comments and is particularly prevalent in Aboriginal and Fertility Delayed conception 2 months on average55 Torres Strait Islander populations (see below). Smoking is also a marker for mental illness and Infertility: female 60% increased risk of infertility 56 almost 50% of pregnant smokers have a mental (OR 1.6) health disorder of some kind.16 Smoking rates Infertility: male Decreased semen volume, are higher in young women and 37% of teenage sperm number and increased 1 mothers smoke during pregnancy.3 abnormal forms Assisted reproduction 44% reduced odds of a live Postpartum relapse birth per cycle (OR 0.54)57 Most mothers who quit smoking during Obstetric Spontaneous OR 1.81 pregnancy resume smoking within 6 months (<37 wks) ‘twice as great’1 of delivery and about 70% relapse within 12 previa OR 2.11 months.2 One reason for the high relapse rate is 1 that pregnant women often report suspending OR 1.6 their smoking only for the and plan to OR 1.1–3.21 17 resume smoking after the birth. Ectopic pregnancy OR 2.51 Stress in the arising from Premature rupture of OR 2.11 lack of sleep, caring for the infant, postnatal membranes depression and concerns about weight gain are 1 also likely contributors to the high relapse rate. Pre-eclampsia OR 0.51 (49% risk reduction) Other factors include having a smoking partner, Fetal Growth restriction 200 g lighter on average1 a higher smoking level before pregnancy, older Low (<2500 g) OR 3.0 (white women)1 age and socioeconomic disadvantage.18 Small for OR 3.8 >35 years 1 Aboriginal and Torres (<35 years = ns) Strait Islander pregnant Birth defects Limb reduction defects, , oral clefts, eye defects women and gastrointestinal effects Aboriginal and Torres Strait Islander pregnant (OR 1.25–1.50). Also many women need special consideration. One in other smaller effects58 two (49.3%) Aboriginal and Torres Strait Child and adult SIDS OR 2.2559 Islander women smoke while pregnant3 and Type 2 OR 1.160 there may be concomitant use of cannabis.19 26 Many Indigenous are unplanned; OR 1.52 women often present late to antenatal care and 1.5–5.4 mm Hg increase60 20,21 have fewer antenatal visits. As a result, HDL 0.14 mmol/L decrease61 opportunities for early Nicotine dependence Double the risk62 intervention may be missed. Owing to the normalisation of smoking Respiratory , lower respiratory , decreased lung in Aboriginal and Torres Strait Islander function63 households, it is difficult for pregnant women Cognition Impaired academic to avoid other smokers and obtain support from 22 performance and cognitive family and partners. Smoking is often linked abilities64 to difficult life circumstances and high levels Behaviour , ADHD, of stress. Reduced cigarette consumption is a antisocial behaviour65 frequent occurrence, as cessation is perceived as ‘too hard’. Few Aboriginal and Torres Psychiatric disorders Significant increase for most psychiatric disorders in early Strait Islander women maintain abstinence adulthood66 postpartum. For a more detailed review see OR = odds ratio; ns = not significant; HDL = high density lipoprotein Gould et al.23

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Health effects of smoking Studies in animals suggest that nicotine immediately after is preferred as in pregnancy is toxic to the fetal brain and impairs lung it allows more time for the nicotine and other The most common adverse fetal outcomes are development. Many other toxic compounds, chemicals to leave the breast milk before the growth restriction and preterm birth, both of including cyanide, polycyclic aromatic next feed.31 Encouraging pregnant women to which can lead to a range of serious health hydrocarbons, benzene and heavy metals such as breastfeed may help them to remain abstinent effects5 (Table 1). Nicotine reduces placental lead and cadmium cross the placenta.27 postpartum.31 blood flow and carbon monoxide lowers oxygen Non-smoking pregnant women are also availability to the fetus. The resulting decrease at risk from second-hand smoke, which Smoking interventions in in nutrient and oxygen delivery to the fetus leads increases the risk of stillbirth and congenital pregnancy to growth restriction.24 Carcinogens have also abnormalities,28 and reduces the birth weight by Interventions during pregnancy are modestly been implicated in .25 Babies 33 g or more.29 effective and assist six in every 100 smokers with low birth weight experience rapid catch-up to quit.6 Many lighter smokers quit unaided growth that can result in obesity and chronic Lactation when they find out they are pregnant and the diseases, such as coronary artery disease, Women who smoke may produce less milk30 remaining smokers may need more intensive diabetes mellitus and hypertension.26 and are less likely to breastfeed.31 Smoking treatment.11,32 The Australian Smoking Cessation guidelines state that neither of the two prescription medicines for smoking cessation, Table 2. Resources for general practitioners and patients varenicline and bupropion, has been shown to be General practitioner resources effective or safe in pregnant and breastfeeding • RACGP. Supporting smoking cessation: a guide for health professionals (www.racgp. smokers, and they are not recommended.32 org.au/your-practice/guidelines/smoking-cessation/) • Department of Health and Ageing (DOHA). Clinical Practice Guidelines Antenatal Identify pregnant smokers Care (www.health.gov.au/internet/publications/publishing.nsf/Content/clinical- practice-guidelines-ac-mod1~part-b~lifestyle-considerations~tobacco-smoking) Pregnant women should be assessed for smoking • Rural Health Education Foundation. Smoking and pregnancy: womb to breathe at every opportunity. Some women find it (www.rhef.com.au) difficult to admit that they smoke because of • Australian Association of Smoking Cessation Professionals (www.aascp.org.au) the social stigma. Disclosure of smoking can be National network of smoking cessation specialists increased by as much as 40% through the use • The Australian Indigenous HealthInfoNet (www.healthinfonet.ecu.edu.au/) of multiple-choice questions instead of a simple Patient resources yes/no question.13,33,34 • QUITLINE (tel: 137848) A hand-held carboxymeter measures • Quit4Baby website (www.quit4baby.com.au) expired carbon monoxide and is a valuable • Quit for you Quit for two smartphone app (www.quitnow.gov.au/internet/quitnow/ tool in general practice to motivate smoking publishing.nsf/Content/quit-now-apps) cessation.35 It is also very helpful for detecting Online resources active and during pregnancy,36 • NSW Government Ministry of Health (www.health.nsw.gov.au) but needs to be introduced sensitively to • QLD Health (www.health.qld.gov.au) minimise any embarrassment. • Quitnow: The National Tobacco Campaign (www.quitnow.gov.au) • Quit NSW. iCan Quit (www.icanquit.com.au) Counselling and other • Quit Tasmania (www.quittas.org.au) strategies • Quit Victoria (www.quit.org.au) Smoking should be addressed at every GP visit Brochures (available nationally) during pregnancy in view of its serious health • Quit for you Quit for two booklets and wristbands (email: [email protected]) impact. Behavioural counselling is recommended • Queensland Cancer Council. Smoking and pregnancy (tel: 131120) as first-line treatment in pregnancy,13,32 • Quit Victoria. Pregnancy and quitting smoking information sheet; Important news for although it is less effective than in the general fathers who smoke (www.quit.org.au/resource-centre/fact-sheets/stopping-smoking) population.13 Counselling in pregnancy produces • Illawarra Shoalhaven Local Health District. No Butts Baby (email: Lisa.franco@ a 4–6% increase in the quit rate, compared with sesiahs.health.nsw.gov.au; tel (02) 42216785) no counselling.6,13,37 Indigenous resources Counselling strategies include providing • Blow away the smokes DVD (www.blowawaythesmokes.com.au) information on the health effects, problem • Stickin’ it up the smokes facebook site (www.facebook.com/stickinitupthesmokes) solving and facilitating social support.13,38 • Quit for you Quit for two booklets and wristbands (email: [email protected]) Motivational interviewing seems to be less

48 REPRINTED FROM AUSTRALIAN FAMILY PHYSICIAN VOL. 43, NO. 1–2, JANUARY– FEBRUARY 2014 Management of smoking in pregnant women CLINICAL effective in pregnancy.39 Guidelines also increase birth weight when compared with We suggest a culturally sensitive, non- recommend pregnancy-specific self-help placebo.44,48 judgmental approach, as well as information materials13,32 (Table 2) and referral to Quitline.32 There is no evidence of increased rates to help women understand how smoking could A supportive partner can increase the ability of miscarriage, stillbirth, premature birth, harm the fetus, and the benefits of remaining of a pregnant smoker to quit successfully.9 admissions to neonatal intensive care or smoke-free after the birth. Inviting cooperation However, it is unclear if encouraging partners to neonatal death between NRT and control from partners and family may provide further support smoking cessation during pregnancy and groups.6 There is currently insufficient evidence support.23 postpartum is beneficial.40 to determine whether NRT is safe in pregnancy, but available data49 and expert opinion50 suggest Prevention of relapse Nicotine replacement therapy it is less harmful than continuing to smoke. Interventions to assist pregnant and postpartum (NRT) smokers to remain abstinent have not generally Guidelines for use of NRT The use of NRT (nicotine patch, gum, lozenge, been effective,9,53 with the possible exception mouth spray and inhalator) during pregnancy The Australian Smoking Cessation guidelines32 of self-help booklets for low-income women.54 has been controversial because of concerns recommend that pregnant smokers first try to Explaining the harm caused to the infant by about efficacy and safety, and many women are quit with counselling and support. NRT should second-hand smoke may help to motivate reluctant to use it. then be considered if the patient is unable to continuing abstinence.13,32 succeed without it, however, it should be used Efficacy and effectiveness under the supervision of a suitably qualified Conclusion A Cochrane review41 did not find any increase in health professional. Smoking during and after pregnancy is a major abstinence rates in late pregnancy from the use Intermittent, short-acting forms of NRT, such cause of adverse health outcomes for the of NRT, compared with controls, in randomised as the lozenge or mouth spray, are recommended mother and child during pregnancy and after placebo-controlled trials. However, real-world to deliver a lower total daily nicotine dose.32 birth, extending into adulthood. Quitting is studies suggest effectiveness in clinical practice. However, this may result in under-dosing and more difficult in this population and postpartum In one large non-randomised study in a clinical reduced effectiveness.51 The guidelines also relapse rates are high. setting, women prescribed combination NRT (a advise that if patches are used they should be All smokers should be encouraged to quit nicotine patch combined with a faster acting removed at bedtime.32 before conception when more treatment options form such as nicotine gum) had twice the quit Although guidelines recommend the smallest are available and therapy is more likely to rate of no medication or monotherapy.42 In effective dose of nicotine, larger doses or even succeed. another study, the addition of NRT to counselling combination therapy may be required. We Counselling should be provided to all tripled the effectiveness of counselling alone.43 support the use of adequate doses to relieve pregnant smokers and NRT considered after A recent randomised controlled trial (RCT) in cravings and withdrawal symptoms, and a full discussing the risks and benefits if women are a clinical setting demonstrated that nicotine course of at least 8 weeks’ treatment. The risks otherwise unable to quit. The efficacy and safety patches were efficacious in the short term, and benefits of NRT during pregnancy should of NRT in pregnancy is uncertain, yet NRT is compared with placebo (21.3% versus 11.7% at be explained without making the patient unduly considered to be safer than continuing to smoke. 4 weeks).44 Even short periods of abstinence are concerned. Adequate doses of nicotine and good adherence beneficial for fetal growth.45 are required for the best results. Smoking NRT during lactation The modest impact of NRT could be due cessation can have substantial and lifelong to inadequate dosing as nicotine clearance Breastfeeding mothers can use NRT once benefits for the mother and child and should be is increased by 60% in pregnancy.46 Poor the risks and benefits have been explained.32 an integral part of pregnancy care. adherence is also a likely cause of reduced Nicotine levels in the infant from NRT while Key points cessation outcomes. In one study, only 7.2% of breastfeeding are low and are unlikely to be pregnant women used the active nicotine patch harmful.49 Infant exposure can be reduced • Smoking during pregnancy is the most for more than one month.44 further by taking oral doses of NRT immediately important preventable cause of adverse after breastfeeding. pregnancy outcomes. Safety • Most smokers who become pregnant Aboriginal and Torres Strait Although nicotine is presumed to have some continue to smoke and most who quit relapse Islander pregnant women risk, clinical trials of therapeutic nicotine have after delivery. not generally reported adverse fetal effects.41 Access to treatment, including NRT, is more • Quitting smoking in pregnancy reduces the A Danish national birth cohort study suggests difficult for Aboriginal and Torres Strait Islander risk of complications. use of a single NRT product does not reduce pregnant women because of financial barriers • Behavioural counselling is recommended as birth weight.47 Two RCTs suggest that NRT may and a lack of culturally appropriate services.52 the first-line treatment.

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• NRT can be offered, under the supervision of smoking cessation during pregnancy. Cochrane 24. Polakowski LL, Akinbami LJ, Mendola P. Prenatal Database of Syst Rev 2009, Issue 3. Art. No.: smoking cessation and the risk of delivering preterm a suitably qualified health professional, if the CD001055. 2009. and small-for-gestational-age newborns. Obstet patient is unable to quit without it. 7. Pullon S, Webster M, McLeod D, Benn C, Morgan S. Gynecol 2009;114:318–25. • Adequate doses of nicotine and good Smoking cessation and nicotine replacement therapy 25. Wang X, Zuckerman B, Pearson C et al. Maternal in current primary maternity care. Aust Fam Physician cigarette smoking, metabolic gene polymorphism, adherence are required for the best results. 2004;33:94–96. and infant birth weight. JAMA 2002;287:195–202. • The efficacy and safety of NRT in pregnancy 8. Woodby LL, Windsor RA, Snyder SW, Kohler CL, 26. Ino T. Maternal smoking during pregnancy and Diclemente CC. Predictors of smoking cessation offspring obesity: meta-analysis. Pediatr Int is uncertain. during pregnancy. Addiction 1999;94:283–92. 2010;52:94–99. 9. Solomon L, Quinn V. Spontaneous quitting: self-initi- 27. Shea AK, Steiner M. Cigarette smoking during preg- Authors ated smoking cessation in early pregnancy. Nicotine nancy. Nicotine Tob Res 2008;10:267–78. Colin Mendelsohn MBBS (Hons), General Tob Res 2004;6(Suppl 2):S203–16. 28. Leonardi-Bee J, Britton J, Venn A. Secondhand Practitioner and Tobacco Treatment Specialist, 10. Quinn VP, Mullen PD, Ershoff DH. Women who stop smoke and adverse fetal outcomes in nonsmok- Sydney, NSW. [email protected] smoking spontaneously prior to and ing pregnant women: a meta-analysis. Pediatrics predictors of relapse before delivery. Addict Behav 2011;127:734–41. Gillian S Gould MA (Arts Therapy), MBChB, 1991;16:29–40. 29. Leonardi-Bee J, Smyth A, Britton J, Coleman T. GDipECAT, GP and Tobacco Treatment Specialist, 11. Schneider S, Huy C, Schutz J, Diehl K. Smoking Environmental tobacco smoke and fetal health: PhD candidate (NHMRC/NHF postgraduate cessation during pregnancy: a systematic literature systematic review and meta-analysis. Arch Dis Child Indigenous research scholarship recipient), review. Drug Alcohol Rev 2010;29:81–90. Fetal Neonatal Ed 2008;93:F351–61. James Cook University, Cairns, QLD, Adjunct 12. Berg CJ, Park ER, Chang Y, Rigotti NA. Is concern 30. Hopkinson JM, Schanler RJ, Fraley JK, Garza Senior Lecturer, Southern Cross University, Coffs about post-cessation weight gain a barrier to C. Milk production by mothers of premature smoking cessation among pregnant women? infants: influence of cigarette smoking. Pediatrics Harbour, NSW Nicotine Tob Res 2008;10:1159–63. 1992;90:934–38. Cheryl Oncken MD, MPH, Professor of Medicine 13. Fiore M, Jaen C, Baker T, Bailey W, Benowitz N, 31. Kendzor DE, Businelle MS, Costello TJ, et al. Breast and Obstetrics and Gynecology, University of Curry S. Treating tobacco use and dependence: 2008 feeding is associated with postpartum smoking Connecticut School of Medicine, Connecticut, update. Rockville MD: USDHHS, US Public Health abstinence among women who quit smoking due to USA Service, 2008. pregnancy. Nicotine Tob Res 2010;12:983–88. 14. Shipton D, Tappin DM, Vadiveloo T, Crossley JA, 32. Zwar N, Richmond R, Borland R et al. Supporting Competing interests: A free nicotine and placebo Aitken DA, Chalmers J. Reliability of self reported smoking cessation: a guide for health professionals. inhaler was provided to Cheryl Oncken by Pfizer smoking status by pregnant women for estimating Melbourne: The Royal Australian College of General for an NIH-funded smoking cessation study in smoking prevalence: a retrospective, cross sectional Practitioners, 2011. Available at www.racgp.org.au/ pregnant women. Colin Mendelsohn is a paid study. BMJ 2009;339:b4347 download/documents/Guidelines/smoking-cessation. member of Pfizer Australia’s Champix Advisory 15. Wigginton B, Lee C. Stigma and hostility towards pdf [Accessed 12 December 2013]. pregnant smokers: Does individuating information 33. Mullen PD, Carbonari JP, Tabak ER, Glenday MC. Board. He has received payments for consultancy, reduce the effect? Psychol Health. 2013;28:862–73. Improving disclosure of smoking by pregnant women. educational presentations, travel and related 16. Goodwin RD, Keyes K, Simuro N. Mental disorders Am J Obstet Gynecol 1991;165:409–13. expenses from Pfizer Australia, GlaxoSmithKline and nicotine dependence among pregnant women in 34. Clinical Practice Guidelines Antenatal and Johnson & Johnson. the United States. Obstet Gynecol 2007;109:875–83. care – Module 1. Department of Health and 17. Roske K, Hannover W, Grempler J, et al. Post-partum Ageing. Available at www.health.gov.au/ Provenance and peer review: Not commissioned; intention to resume smoking. Health Educ Res internet/publications/publishing.nsf/Content/ externally peer reviewed. 2006;21:386–92. clinical-practice-guidelines-ac-mod1~part-b~lifestyle- 18. Grover KW, Zvolensky MJ, Lemeshow AR, Galea S, considerations~tobacco-smoking. 2012 [Accesssed References Goodwin RD. Does quitting smoking during preg- 24 June 2013]. 1. The health consequences of smoking: a report of nancy have a long-term impact on smoking status? 35. Ripoll J, Girauta H, Ramos M et al. Clinical trial on the Surgeon General. [Atlanta, Ga.]: Dept. of Health Drug Alcohol Depend 2012;123:110–14. the efficacy of exhaled carbon monoxide measure- and Human Services, Centers for Disease Control 19. Passey ME, Sanson-Fisher RW, D’Este CA, Stirling ment in smoking cessation in primary health care. and Prevention, National Center for Chronic Disease JM. Tobacco, alcohol and cannabis use during BMC Public Health 2012;12:322. Prevention and Health Promotion, Office on Smoking pregnancy: clustering of risks. Drug Alcohol Depend 36. National Institute of Clinical Excellence. Quitting and Health; Washington, DC 2004. 2013; S0376–8716(13)00370-0. doi: 10.1016/j.drugal- smoking in pregnancy and following . NICE 2. : a report of the surgeon cdep.2013.09.008. [Epub ahead of print]. public health guidance 26. 2010. Available at www. general. Atlanta (GA). Office on Smoking and Health 20. Westenberg L, van der Klis KA, Chan A, Dekker G, nice.org.uk/nicemedia/live/13023/49345/49345.pdf (US). Centers for Disease Control and Prevention (US). Keane RJ. Aboriginal teenage pregnancies compared [Accessed 8 July 2013]. 2001. with non-Aboriginal in South Australia 1995-1999. 37. Filion KB, Abenhaim HA, Mottillo S et al. The effect 3. Li Z, Zeki R, Hilder L, Sullivan E. Australia’s mothers Aust N Z J Obstet Gynaecol 2002;42:187–92. of smoking cessation counselling in pregnant and babies 2010. Perinatal statistics series no. 27. 21. Trinh LT, Rubin G. Late entry to antenatal care in New women: a meta-analysis of randomised controlled Cat. no. PER 57. Canberra: AIHW National Perinatal South Wales, Australia. Reprod Health 2006;3:8. trials. BJOG 2011;118:1422–28. Epidemiology and Statistics Unit. Available at 22. Gould GS, Munn J, Avuri S, Hoff S, Cadet-James 38. Lorencatto F, West R, Michie S. Specifying www.aihw.gov.au/WorkArea/DownloadAsset. Y, McEwen A, et al. ‘Nobody smokes in the house evidence-based behavior change techniques to aid aspx?id=60129542372 [Accessed 12 December 2013]. if there’s a new baby in it’: Aboriginal perspectives smoking cessation in pregnancy. Nicotine Tob Res 4. McBride CM, Emmons KM, Lipkus IM. Understanding on in pregnancy and in the house- 2012;14:1019–26. the potential of teachable moments: the case of hold in regional NSW Australia. Women and Birth. 39. Hayes CB, Collins C, O’Carroll H, et al. Effectiveness smoking cessation. Health Educ Res 2003;18:156–70. 2013;26:246–53. of motivational interviewing in influencing smoking 5. Bickerstaff M, Beckmann M, Gibbons K, Flenady 23. Gould GS, Munn J, Watters T, McEwen A, Clough cessation in pregnant and postpartum disadvantaged V. Recent cessation of smoking and its effect on AR. Knowledge and views about maternal tobacco women. Nicotine Tob Res 2013;15:969–77. pregnancy outcomes. Aust NZ J Obstet Gynaecol smoking and barriers for cessation in Aboriginal 40. Hemsing N, Greaves L, O’Leary R, Chan K, Okoli 2012;52:54–58. and Torres Strait Islanders: A systematic review and C. Partner support for smoking cessation during 6. Lumley J, Chamberlain C, Dowswell T, Oliver S, meta-ethnography. Nicotine Tob Res 2013;15:863– pregnancy: a systematic review. Nicotine Tob Res Oakley L, Watson L. Interventions for promoting 74. 2012;14:767–76.

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41. Coleman T, Chamberlain C, Davey MA, Cooper SE, 53. Hajek P, Stead LF, West R, Jarvis M, Lancaster T. 65. Button TM, Thapar A, McGuffin P. Relationship Leonardi-Bee J. Pharmacological interventions for Relapse prevention interventions for smoking cessa- between antisocial behaviour, attention-deficit promoting smoking cessation during pregnancy. tion. Cochrane Database Syst Rev 2009(1):CD003999. hyperactivity disorder and maternal prenatal Cochrane Database Syst Rev 2012;9:CD010078. 54. Brandon TH, Simmons VN, Meade CD, et al. Self- smoking. Br J Psychiatry 2005;187:155–60. 42. Brose LS, McEwen A, West R. Association between help booklets for preventing postpartum smoking 66. Ekblad M, Gissler M, Lehtonen L, Korkeila J. Prenatal nicotine replacement therapy use in pregnancy relapse: a randomized trial. Am J Public Health smoking exposure and the risk of psychiatric mor- and smoking cessation. Drug Alcohol Depend 2012;102:2109–15. bidity into young adulthood. Arch Gen Psychiatry 2013;132:660–664. 55. Zenzes MT. Smoking and reproduction: gene damage 2010;67:841–49. 43. Pollak KI, Oncken CA, Lipkus IM, et al. Nicotine to human gametes and embryos. Hum Reprod replacement and behavioral therapy for smoking Update 2000;6:122–31. cessation in pregnancy. Am J Prev Med 56. Augood C, Duckitt K, Templeton AA. Smoking and 2007;33:297–305. female infertility: a systematic review and meta- 44. Coleman T, Cooper S, Thornton JG, et al. A rand- analysis. Hum Reprod 1998;13:1532–39. omized trial of nicotine-replacement therapy patches 57. Waylen AL, Metwally M, Jones GL, Wilkinson AJ, in pregnancy. N Engl J Med 2012;366:808–18. Ledger WL. Effects of cigarette smoking upon clinical 45. Heil SH, Higgins ST, Bernstein IM, et al. Effects outcomes of assisted reproduction: a meta-analysis. of voucher-based incentives on abstinence from Hum Reprod Update 2009;15:31–44. cigarette smoking and fetal growth among pregnant 58. Hackshaw A, Rodeck C, Boniface S. Maternal women. Addiction 2008;103:1009–18. smoking in pregnancy and birth defects: a systematic 46. Dempsey D, Jacob P, 3rd, Benowitz NL. Accelerated review based on 173 687 malformed cases and 11.7 metabolism of nicotine and cotinine in pregnant million controls. Hum Reprod Update 2011;17:589– smokers. J Pharmacol Exp Ther 2002;301:594–98. 604. 47. Lassen TH, Madsen M, Skovgaard LT, Strandberg- 59. Zhang K, Wang X. Maternal smoking and increased Larsen K, Olsen J, Andersen AM. Maternal use of risk of sudden infant death syndrome: a meta-analy- nicotine replacement therapy during pregnancy and sis. Leg Med (Tokyo). 2013;15:115–21. offspring birthweight: a study within the Danish 60. Rogers JM. Tobacco and pregnancy. Reprod Toxicol National Birth Cohort. Paediatr Perinat Epidemiol 2009;28:152–60. 2010;24:272–81. 61. Ayer JG, Belousova E, Harmer JA, David C, Marks 48. Oncken C, Dornelas E, Greene J, et al. Nicotine gum GB, Celermajer DS. Maternal cigarette smoking is for pregnant smokers: a randomized controlled trial. associated with reduced high-density lipoprotein Obstet Gynecol 2008;112:859–67. cholesterol in healthy 8-year-old children. Eur Heart J 49. Dempsey DA, Benowitz NL. Risks and benefits of 2011;32:2446–53. nicotine to aid smoking cessation in pregnancy. Drug 62. Buka SL, Shenassa ED, Niaura R. Elevated risk of Saf 2001;24:277–322. tobacco dependence among offspring of mothers 50. Zwar N, Bell J, Peters M, Christie M, Mendelsohn who smoked during pregnancy: a 30-year prospective C. Nicotine and nicotine replacement therapy – the study. Am J Psychiatry 2003;160:1978–84. facts. Australian Pharmacist 2006;25:969–73. 63. Carlsen KH, Carlsen KC. Respiratory effects of 51. Mendelsohn C. Optimising nicotine replacement tobacco smoking on infants and young children. therapy in clinical practice. Aust Fam Physician Paediatr Respir Rev 2008;9:11–19. 2013;42:305–09. 64. Clifford A, Lang L, Chen R. Effects of maternal 52. Gould G, McEwen A, Munn J. Jumping the hurdles cigarette smoking during pregnancy on cognitive for smoking cessation in Indigenous pregnant women parameters of children and young adults: a literature in Australia. J Smok Cessat 2011;6:33–36. review. Neurotoxicol Teratol 2012;34:560–70.

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