The prescription medicines bupropion (Zyban) and varenciline (Champix) are not approved for use during pregnancy.
Nicotine replacement products
If a women is pregnant or breastfeeding, it is recommended that she first try to quit without the use of nicotine replacement products (nicotine gum, inhalator, lozenges, mouth spray and patch). However, if she is unable to quit without medication, she may use these products to help her quit, after discussing it with the doctor overseeing her pregnancy.
Use of nicotine replacement products during pregnancy is not contraindicated, however it is also not free from risk. In theory, it is considered safer than smoking, because the pregnant mother avoids many other toxins in cigarette smoke that harm the foetus. However, there is little research on the safety of nicotine replacement products during pregnancy, so its real-life effects have not yet been established. Nicotine gum and patches cause increases in the mother's blood pressure and heart rate, and a smaller increase in foetal heart rate, but other nicotine replacement products produce a smaller effect than smoking. Nicotine (from cigarettes or by itself) changes hormone patterns, affecting the endocrine profile of the infant. It affects the structure and functioning of the oviduct (fallopian tube) in ways that may impair fertility and complicate the pregnancy. Nicotine impairs the transport of essential nutrients across the placenta. Nicotine can alter embryonic movements that are important in the early development of the organs. It may interfere with foetal brain and lung development, although the long-term effects are not clear.
Although nicotine is a toxin, pregnant women already expose their unborn child to nicotine if they continue to smoke. There is no evidence that using nicotine replacement products in pregnancy results in higher blood levels of nicotine than smoking. The argument for allowing use of nicotine replacement in pregnancy, despite potential risks, is that if it increases the chances of pregnant women quitting smoking, then withholding it would be harmful. Overall, nicotine replacement prodcuts are considered to be safer than continuing to smoke as cigarette smoke contains other chemicals known to be toxic to the foetus as well as nicotine.
Effectiveness of nicotine replacement among pregnant women
Few trials of the use of nicotine replacement products in pregnancy have been conducted, and the percentage of pregnant women who actually used them as the researchers intended varied considerably. The current evidence suggests that nicotine replacement in pregnant women does not work as well as it does in the general population, and that it has no significant advantage over counselling and behavioural support. However, in these studies many women were reluctant to use nicotine replacement, and either used a low dose (of the nicotine gum) or only used it for a short time. This could have affected the results. In the largest trial, women using a nicotine patch had a higher quit rate after four weeks, but had a similar quit rate to those who had used a placebo (a patch without nicotine) by the end of their pregnancy. More research is needed. Compared with use of a placebo, use of a nicotine replacement product by smokers trying to quit improves the birth weight of the babies and may improve birth outcomes (i.e. decrease the risk of low birth weight and preterm delivery). The safety of nicotine replacment in terms of foetal development and birth outcomes (compared to successfully quitting without it) remains unclear.
Use of nicotine replacement products in pregnancy
A pregnant woman considering using a nicotine replacement product to help her quit should first discuss the risks and benefits with her doctor or pharmacist, and also the doctor supervising her pregnancy.
Nicotine replacement should be used as early on in the pregnancy as possible (after quitting without it proves unsuccessful), with the aim of quitting and discontinuing use as soon as possible.
Intermittent forms of nicotine replacement - the gum, lozenge, inhaler or tablet - are recommended, as these products usually provide a lower overall daily dose than the patch. However, if the woman cannot tolerate these forms of nicotine replacement, for example, she suffers from nausea, the day only patch may be used. The patch must be removed before going to bed, as the effect of continual exposure to nicotine is unknown.
Nicotine replacement products work best for addicted smokers who want to quit. Signs of nicotine addiction include:
- smoking the first cigarette within 30 minutes of waking up
- smoking at least 10 cigarettes per day
- suffering from withdrawal symptoms within 24 hours of stopping smoking, such as cravings, irritability, anxiety, depression, restlessness, hunger, poor concentration or sleep disturbances.
If a woman reports cutting down due to pregnancy, but has other obvious symptoms of dependence, health professionals could take into account the number of cigarettes she previously smoked, if they suspect she is smoking her cigarettes harder (see "Cutting down").
Cravings (the urge or desire to smoke) are often triggered by situations in which the smoker is used to smoking. Women with cravings associated with people, places, routines, or emotions may benefit from counselling and behavioural support. Nicotine replacement works better when triggers for cravings are also reduced. Having a spouse who is a non-smoker or quits smoking is an advantage. Women who can make their home smokefree and get rid of all cigarettes in their home and car will have a better chance of success.
Use of nicotine replacement products while breastfeeding
Breastfeeding is recommended even if a mother smokes or uses a nicotine replacement product. Babies of smokers are more prone to chest illnesses, but breastfeeding helps prevent these infections. Breastfeeding also has several other advantages over bottle-feeding, reducing the risk of illness and death for the baby.
Women who are breastfeeding may use the gum, lozenge, inhaler or tablet to help them quit. The patch is not recommended. Nicotine from cigarettes and nicotine replacement products is found in breast milk. However, the amount of nicotine from nicotine replacement products is less than that from cigarettes, and less dangerous to her child than secondhand smoke. Women should breastfeed just before using nicotine replacement. This ensures that the longest possible time between use of nicotine replacement and breastfeeding, so the child is exposed to less nicotine.