Contraceptive Pearl: Tobacco use in pregnancy and preconception

Washington State Health Care Authority sent this bulletin at 08/04/2025 08:00 AM PDT

August 4, 2025

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Tobacco use in pregnancy and preconception

This bulletin is being sent by the Health Care Authority (HCA) in partnership with the Reproductive Health Access Project (RHAP).

Written by Sondos Kasab, Pharm.D. candidate and Regina Ginzburg, Pharm.D., CDCES, BC-ADM

Tobacco use can interfere with fertility.^1,2 In people with testes, tobacco use can lead to sperm defects. In people with uteruses, tobacco smoke leads to increased testosterone and decreased estradiol and progesterone levels. This hormonal imbalance decreases the ovarian reserve and disrupts ovulation.²

Perinatal risks of tobacco use include orofacial clefts, fetal growth restriction, placenta previa, placental abruption, preterm premature rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function.³ Children of those who smoke during pregnancy are at higher risk of respiratory infections, asthma, infantile colic, bone fractures, and childhood obesity. Secondhand tobacco exposure during pregnancy is associated with similar risks and complications.

All those who are pregnant or planning a pregnancy should be informed of the significant risks associated with tobacco use.^3,4 The pre-pregnancy period is an important time to assist parents-to-be to stop smoking permanently to prevent tobacco-related pregnancy and long-term health complications.

During pregnancy, the greatest benefit of smoking cessation is before 15 weeks gestation, as smoking in the third trimester has the strongest association with fetal growth restriction.^3,5 However, quitting at any point in pregnancy can yield benefits. Pregnancy influences many to stop smoking and approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy.³ Effective psychosocial interventions with counseling, health education, incentives, and peer or social support are recommended by the World Health Organization.⁶

There is currently insufficient evidence for using nicotine replacement therapy (NRT) during pregnancy.³ In one systematic review, NRT was linked to increased rates of smoking cessation during pregnancy but not long-term cessation.⁷ Efficacy has been inconsistent, likely due to low adherence rates. Additionally, increased metabolism of nicotine in pregnancy can lead to lower nicotine levels. Therefore, NRT can be cautiously considered if counseling alone is ineffective and only after a comprehensive discussion with the patient about the known risks of continued smoking, the possible risks of NRT, and the need for close supervision.^3,8 Possible risks associated with NRT include infantile colic and attention deficit hyperactivity disorder. However, congenital abnormalities and developmental delays have not been associated with NRT.⁹

Two oral tablets have been approved for smoking cessation therapy: bupropion and varenicline.^10,11 Bupropion antagonizes nicotinic receptor function and can decrease withdrawal symptoms.¹² Varenicl “reward” from smoking.¹⁰ The use of either medication, however, is not recommended during pregnancy.⁶ Although varenicline has not been shown to be teratogenic in small studies and does not increase the risk of major congenital malformations or other adverse birth outcomes, some animal studies have shown pregnancy-related adverse outcomes like decreased fetal weight.^10,13 Bupropion crosses the placenta;¹¹while it has not been shown to increase the risk of overall congenital malformations, there is conflicting evidence regarding cardiovascular malformations.¹¹

Currently, the recommended modality of smoking cessation in pregnancy is intensive behavioral therapy, which includes multiple individual or group counseling sessions.⁸ Digital modalities, such as messaging, smartphone applications, artificial intelligence-based or internet-based interventions, can also be offered. The table below exhibits some examples of online resources that can be used for assistance to quit smoking. NRT products should only be considered if behavioral therapy alone has not produced adequate smoking cessation.

Resources for quitting smoking

US Centers for Disease Control and Prevention
- 1-800-QUIT-NOW (1-800-784-8669). Phone and texting helpline in multiple languages.
- Phone app (free)
Substance Abuse & Mental Health Services Administration
- 1-800-662-HELP (4357). 24/7 phone helpline in English and Spanish for individuals and families facing mental and/or substance use disorders.
QuitNow
- Phone app (cost involved).
Kwit
- Gamification phone app (cost involved).
Smokefree
- Phone app with milestone tracking and daily goals (cost involved).
Max Kisten Quit Smoking NOW
- Phone app with hypnotherapy (cost involved).
ButtOut
- Phone app with community chats and milestone maker.

References

See RHAP's original post for sources

About HCA and RHAP partnership

HCA and RHAP are partnering to support the reproductive health provider community’s access to accurate, evidence-based clinical information.

If you are an enrolled Apple Health provider, HCA will pay to print items from the RHAP resource library.

Materials such as the birth control choices fact sheet or MEC for initiating contraception chart are available for bulk printing.

To order bulk printing

Email: Brandy Bautista
Include the following information:

"Washington Health Care Authority" in the body of the email
Items you'd like to order
Quantities
Business address
Delivery address (if different than your business address)

Contact

Email Andrea Estes, Sexual and Reproductive Health Programs Innovation Manager at HCA, with questions regarding this partnership.

About the Health Care Authority (HCA)

Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible.

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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