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Smoking in pregnancy: pathophysiology of harm and current evidence for monitoring and cessation

Authors:
  • Royal College of Surgeons in Ireland / Rotunda Hospital

Abstract and Figures

Smoking in pregnancy is a risk factor for miscarriage, stillbirth, placental abruption, preterm birth, low birthweight and neonatal morbidity and mortality. The adverse effects of cigarette smoke are primarily driven by carbon monoxide, tar and nicotine. Psychosocial interventions are effective in helping women to quit smoking during pregnancy. There is weak evidence that nicotine replacement therapy (NRT) with behavioural support can improve cessation rates in pregnancy. Electronic cigarettes are more popular among smokers, but evidence of their safety and effectiveness in pregnancy are lacking. This article is protected by copyright. All rights reserved.
Content may be subject to copyright.
Smoking in pregnancy: pathophysiology of harm and
current evidence for monitoring and cessation
Brendan P McDonnell BA MB MRCPI,
a
*Carmen Regan MD FRCPI MRCOG
b,c
a
Bernard Stuart Fellow in Perinatal Ultrasound, Coombe Women and Infants University Hospital, Dublin 8, Ireland
b
Consultant Obstetrician and Subspecialist in Maternal Fetal Medicine, Coombe Women and Infants University Hospital, Dublin 8, Ireland
c
Senior Lecturer, Royal College of Surgeons, Dublin 2, Ireland
*Correspondence: Brendan P McDonnell. Email: bmcdonnell@rcsi.ie
Accepted on 27 December 2018.
Key content
Smoking in pregnancy is a risk factor for miscarriage, stillbirth,
placental abruption, preterm birth, low birthweight and neonatal
morbidity and mortality.
The adverse effects of cigarette smoke are primarily driven by
carbon monoxide, tar and nicotine.
Psychosocial interventions are effective in helping women to quit
smoking during pregnancy.
There is weak evidence that nicotine replacement therapy (NRT)
with behavioural support can improve cessation rates
in pregnancy.
Electronic cigarettes are more popular among smokers, but
evidence of their safety and effectiveness in pregnancy are lacking.
Learning objectives
To understand the pathophysiology of harm from
cigarette smoking.
To describe the role of exhaled carbon monoxide testing among
pregnant women.
To review the evidence on the safety and use of NRT and electronic
cigarettes as methods of cessation.
Keywords: carbon monoxide monitoring / electronic cigarettes /
nicotine replacement therapy / pregnancy / smoking
Please cite this paper as: McDonnell BP, Regan C. Smoking in pregnancy: pathophysiology of harm and current evidence for monitoring and cessation.
The Obstetrician & Gynaecologist. 2019;21:16975. https://doi.org/10.1111/tog.12585
Introduction
Cigarette smoking in pregnancy has an adverse impact on
maternal and fetal health; smoking cessation is advocated to
eliminate this risk factor and improve pregnancy outcome.
Smoking has long been associated with increased rates of
miscarriage, stillbirth, placental abruption, preterm birth and
low birthweight.
1
Emerging evidence suggests that in utero
exposure to smoking has long-term neonatal adverse
outcomes such as impaired neurological development,
endocrine dysfunction and oncogenesis. These continue to
manifest into early and late childhood with a higher
incidence of sudden infant death syndrome, attention
deficit hyperactivity disorder, poor academic performance
in school and future smoking in adulthood.
2–4
In England, the prevalence of smoking at the time of
delivery has steadily declined from 15.1% in 2006/07 to 10.4%
in the first quarter of 2018, with a target of 6% or less by
2022.
5
Smoking strongly correlates with lower socio-
economic status and is a major cause of the health and life
expectancy inequalities encountered by women from deprived
backgrounds. Pregnant smokers are more likely to be
younger, be unemployed, have low educational attainment,
have a lack of social support and have increased incidence of
mental illness.
6
Women experiencing depression are four
times more likely to smoke than other women, and this
presents a challenge to smoking cessation services.
7
The pathophysiology of harm from
smoking
Cigarette smoke is a complex, heterogeneous mixture of
more than 4000 compounds, including nicotine, carbon
monoxide, carcinogens and heavy metals. In pregnancy,
cigarette smoke negatively impacts the fetus globally
restricting the supply of oxygen and nutrients, altering its
growth and affecting the development of organs such as the
brain and lungs.
8
Carbon monoxide
Carbon monoxide is a colourless and odourless gas produced
by the combustion of tobacco. The quantity of carbon
monoxide entering the system is influenced by the type of
tobacco product smoked and the depth and frequency of
ª2019 Royal College of Obstetricians and Gynaecologists 169
DOI: 10.1111/tog.12585
The Obstetrician & Gynaecologist
http://onlinetog.org
2019;21:16975 Review
inhalation.
9
Tobacco smoke is approximately 45 000 parts
per million (ppm) carbon monoxide, a concentration of
4.5% by volume. Absorbed carbon monoxide rapidly binds
to haemoglobin, forming carboxyhaemoglobin, where each
iron atom binds a molecule of carbon monoxide at the
expense of a molecule of oxygen. A smoker is exposed to
400500 ppm carbon monoxide over the time taken to
smoke a cigarette, producing a baseline carboxyhaemoglobin
of 4% (range 38%). This is in contrast with non-smokers,
who have an average 1% carboxyhaemoglobin in their blood.
Heavy smokers may have a carboxyhaemoglobin level of up
to 15%.
9
As the concentration of carbon monoxide increases,
there is a left shift of the oxygenhaemoglobin dissociation
curve, reflecting the greater affinity of haemoglobin for
carbon monoxide. This left shift impairs oxygen delivery to
the myometrium and fetoplacental unit.
10
Chronic exposure
to carbon monoxide through sources other than smoking
for example air pollution is also associated with fetal
growth restriction and preterm birth.
11,12
Tar
Tar is the combusted particulate matter contained in
cigarette smoke which forms a residue on the skin, mucous
membranes and lungs of smokers. Tar damages the
respiratory tract by mechanical and biochemical
mechanisms. It contains the majority of carcinogenic
compounds, such as polycyclic aromatic hydrocarbons,
aromatic amines and nitrosamines. These compounds
interfere with biochemical pathways and macromolecules,
leading to a pro-inflammatory state with widespread
oxidative damage.
13
The fetotoxic and teratogenic nature of
these compounds has been established in animal studies,
8
but
little research has been performed on their effects on the
human fetus. The heavy metal cadmium, contained in
cigarette smoke, is known to accumulate in the placenta
and has been associated with fetal growth restriction.
14
The
effect of other compounds and the many additives to
cigarettes remains unclear.
Nicotine
Nicotine is an addictive alkaloid derived from tobacco and is
a potent stimulant of the parasympathetic nervous system. It
readily crosses the placenta and has a direct effect on the fetus
and the placental vasculature, in addition to its effect on the
maternal circulation.
15
Nicotine has been classed as a neuro-
teratogen and is known to bind nicotinic acetylcholine
receptors in the fetal brain, disrupting neurotransmitter
function and altering normal brain development.
16
These
developmental insults are thought to lead to the cognitive,
emotional and behavioural problems seen in children
of smokers, such as attention deficit hyperactivity disorder
and learning disabilities.
17
Additionally, exposure to
nicotine during fetal development is thought to increase
the later likelihood of addictive behaviours, including
smoking itself.
8
Carbon monoxide monitoring in pregnancy
The National Institute for Health and Care Excellence
18
recommends that all pregnant women be asked about their
smoking status at their maternity booking visit and at regular
intervals during their pregnancy and puerperium. It also
recommends biochemical screening of all pregnant women
via exhaled carbon monoxide. This identifies non-disclosing
smokers who can be referred on an ‘opt-out’ basis for
smoking cessation support. Referring all women with a
positive exhaled carbon monoxide reading results in larger
numbers accessing help and support, although it does not
necessarily result in higher numbers of biochemically verified
quitters.
19–21
Currently in the UK, a midwife or health support worker
administers the exhaled carbon monoxide test to women
presenting for their booking appointment. The test is
explained in advance and the result interpreted by the
midwife or health support worker and explained to the
patient. All current smokers, occasional smokers and smokers
who have quit in the previous 2 weeks are referred to their
local NHS Stop Smoking Services on an opt-out basis.
Women with high exhaled carbon monoxide levels (>4 ppm)
who deny smoking are referred to NHS Stop Smoking
Services for advice on second-hand smoking and smoke-free
homes.
18
Rarer causes of a high carbon monoxide reading in
the absence of smoking are exposure to carbon monoxide
through faulty gas appliances, air pollution and
lactose intolerance.
Non-disclosure of smoking status during pregnancy
prevents women from accessing appropriate smoking
cessation support and can lead to significant
underestimation of smoking prevalence. This non-
disclosure can be a result of recall bias, whereby the
woman is unable to accurately recall exposure, or of
unwillingness to disclose smoking status because of the
negative social perception of smoking in pregnancy.
22,23
A high carbon monoxide reading may help to motivate
some women to stop smoking as a form of feedback
intervention, with the subsequent referral to NHS Stop
Smoking Services acting as a ‘final push’ for cessation. In a
similar manner, a normal carbon monoxide reading is an
encouraging finding appreciated by women undergoing a
cessation attempt.
21
Before the introduction of carbon monoxide screening,
concerns had been expressed about the impact of discussing
smoking status on the relationship between the midwife and
the woman. Some suggested midwives prioritised a good
relationship with the patient over provision of smoking
cessation advice.
24
In the setting of a booking visit, there were
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Smoking in pregnancy
concerns about having sufficient time and resources for
carbon monoxide screening and smoking cessation advice,
especially when dealing with other issues such as alcohol use
and domestic violence.
24,25
However, since the introduction
of carbon monoxide screening, midwives report favourable
views towards providing smoking cessation advice and see it
as integral to their role, with high motivation levels
expressed.
26
Health support workers have found universal
carbon monoxide screening easy to implement and well
received by women, with screening now seen as part of the
daily routine.
21
Smoking cessation during pregnancy
The cessation rate in pregnancy is much higher than that of
the general population, with between 27% and 47% of
smokers quitting within the first trimester.
27
Many women
report quitting spontaneously when pregnancy is confirmed,
often within the first few days.
28
Factors associated with
spontaneous cessation include living in a household with a
non-smoking partner, smoking fewer cigarettes per day, a
previously successful quit attempt and more awareness of the
negative consequences of smoking.
6,29,30
Women who quit in
early pregnancy are more likely to maintain cessation than
are those who quit later.
31
Prospective longitudinal data suggest there is little change
in smoking status from the second trimester onwards, and in
fact intention to quit falls as the pregnancy progresses and in
the postpartum period.
29
Nonetheless, women may be
planning to quit at any time during pregnancy and
therefore smoking status and motivation to quit should be
re-addressed at each visit.
Postpartum relapse
Unfortunately, there is a high rate of relapse, with many women
smoking again before the end of pregnancy and in the early
postnatal period.
29,31,32
Less than a third of spontaneous
quitters in pregnancy remain abstinent 1 year postpartum.
33
Women who are single, who are parous, who have a partner or
household member who smokes, those with high depression
scores, and those with a heavier smoking habit prepregnancy
are most likely to relapse in the postpartum period.
32–34
Breastfeeding mothers are less likely to relapse.
32
Behavioural
interventions are generally unsuccessful in preventing long-
term postpartum relapse. Incentive-based therapies, while
effective in the short term, are associated with relapse once the
incentive is withdrawn.
35
In non-pregnant women, bupropion
and nicotine replacement therapy (NRT) individually have
shown promising results in preventing relapse after an initial
period of abstinence.
36
However, there are no clinical trials
using pharmacological agents specifically to prevent
postpartum relapse, and such treatments should be used with
caution in breastfeeding mothers because of a lack of
safety data.
37
Psychosocial interventions
Psychosocial interventions such as counselling, feedback and
provision of incentives are effective at achieving cessation in
pregnancy. Moreover, psychosocial interventions reduce the
incidence of low birthweight and neonatal intensive care unit
admission.
6
Such interventions are seen as positive by most
women, with evidence of an improved sense of wellbeing
without negative physical or psychological consequences.
All healthcare professionals should be comfortable in
asking about smoking status and providing basic smoking
cessation advice to their patients. Successful interventions
for smoking cessation begin with the identification of
smokers, giving clear advice to quit, and provision of
assistance for a cessation attempt. A useful strategy is to use
the five As approach to smoking cessation interventions
(Box 1).
38
Meta-analysis of counselling interventions has shown most
to be effective in achieving cessation in late pregnancy,
particularly when used in conjunction with other therapies,
or when tailored to the individual woman. However, it is
unclear which type of counselling (cognitive behavioural
therapy, motivational interviewing, psychotherapy or other)
is most effective.
Feedback interventions consist of providing women with
individual measurements of tobacco use (such as salivary or
urinary cotinine or exhaled carbon monoxide) and
information on fetal status in relation to smoking.
Feedback has been shown to be effective when provided
with other interventions such as counselling.
6
Financial incentives have been shown to improve smoking
cessation rates during pregnancy, but their use is
controversial.
39
Health education alone, social support from
Box 1. The ve As for brief smoking cessation interventions
38
Ask: Identify and document tobacco use status for every woman at
every visit. Ask about previous quit attempts.
Advise: In a clear, strong, and personalised manner, urge every smoker
to quit.
Assess: Determine willingness to quit. Asking a readiness score can be
a useful way of assessing readiness to quit, e.g. on a scale of 1 to 10
how ready are you to quit smoking?.
Assist: For the woman willing to make a quit attempt, refer to in-
house smoking cessation services or a local NHS Stop Smoking Service.
Discuss methods of cessation including counselling and the use of
nicotine replacement therapy.
Arrange: Schedule follow-up contact, usually a week after the quit
date. If the woman has quit, congratulate them and discuss any
obstacles and how to overcome them. For those still smoking, revisit
the ve As and encourage to set a new quit date.
ª2019 Royal College of Obstetricians and Gynaecologists 171
McDonnell and Regan
a family member or peer, or exercise interventions are of less
certain benefit as a means of cessation.
6
It is important to recognise that some women are not
prepared to stop smoking in pregnancy. The Transtheoretical
Model of Intentional Behaviour Change can provide a useful
starting point for the categorisation of the pregnant
smoker (Figure 1).
40,41
Nicotine replacement therapy
NRT seeks to replace cigarette smoking, with its harmful tar,
carbon monoxide and other compounds, with clean nicotine
delivered in a safe manner. The dose of NRT is gradually
reduced until a user can stop the therapy without excessive
psychological or physiological withdrawal symptoms.
18
Nicotine undergoes first pass metabolism in the liver,
limiting its oral bioavailability. NRT is therefore delivered
via mucosal or transdermal routes. Available forms of NRT
include transdermal patches, lozenges, chewing gum, oral
sprays, microtabs and inhalers.
42
Transdermal patches deliver
nicotine slowly over the course of a day, in contrast with the
other products that are faster acting and aim to counter acute
cravings. Accelerated metabolism of nicotine in pregnancy
results in lower serum concentrations of nicotine and its
metabolite cotinine, making sufficient dosage of NRT an
issue in a pregnant population.
43
Additionally, use of NRT
does not lead to the high serum levels of nicotine rapidly
achieved by smokers.
The use of NRT is a proven method of smoking cessation
in non-pregnant adults, with an increase of 5060% in
no intention on
changing behaviour
aware a problem
exists but with
no commitment
to action
intent on taking
action to address
the problem
of behaviour
sustained change;
new behaviour
replaces old
fall back into
old patterns of
behaviour
learn from each relapse
Figure 1. The Transtheoretical Model of Intentional Behaviour Change. Adapted from Pacheco.
40
172 ª2019 Royal College of Obstetricians and Gynaecologists
Smoking in pregnancy
cessation rate, regardless of the setting.
42
The evidence
suggests that NRT use in pregnancy does not influence
pregnancy outcomes such as birthweight or preterm labour.
Occasional mild adverse effects are encountered with patches,
such as skin irritation and headaches, but in general NRT is
well tolerated. Clinical trials have not detected an increase in
serious adverse events either during pregnancy or in the
neonatal period. Two-year-old children born to users of NRT
were more likely to survive without a developmental
impairment than were those born to women who smoked
and used placebo NRT.
42,44,45
Therefore, NRT use in
pregnancy may improve developmental outcomes for the
offspring of smokers.
Most trials of NRT use in pregnancy have used it as an
adjunct to behavioural support, with fewer comparing it
alone with placebo. There is weak evidence that NRT with
behavioural support can improve cessation rates in
pregnancy.
43
A 2018 Cochrane meta-analysis on NRT
found a significantly higher rate of cessation at the end of
pregnancy, but with no effect on postpartum cessation.
42
The
National Institute for Health and Care Excellence
18
and the
Royal College of Obstetricians and Gynaecologists
recommend the use of NRT in pregnancy as an adjunct to
a smoking cessation attempt in those who have not quit with
a psychosocial intervention alone.
Electronic cigarettes
Electronic cigarettes use a battery-powered element to heat
a solution of water, propylene glycol or glycerine, nicotine
and flavourings. This solution becomes aerosolised and is
inhaled by the user. Electronic cigarette use results in a
rapid rise of serum nicotine levels, reaching higher values
than those achieved by NRT. The use of electronic
cigarettes mimics the behavioural and psychosocial
aspects of conventional cigarette smoking, without the
associated harm. Electronic cigarettes do not contain
tobacco and do not combust their contents. They
therefore do not contain the carbon monoxide and tar
found in cigarette smoke.
46
Electronic cigarettes have been
regulated by UK and European Union law since 2016, with
the aim of standardising their form, content and
marketing. New-generation electronic cigarettes emit
minimal carcinogens, such as aldehydes, when tested
under conditions that mimic real use.
47
. Other purported
negative health effects appear to be minimal, and in studies
to date, they have not been associated with serious adverse
events in short-term to medium-term follow-up.
8
It is
estimated that electronic cigarettes have a theoretical harm
reduction of 95% compared with smoking cigarettes,
however, this estimate is not based on real-world use and
the true risks or benefits of electronic cigarette use are still
unknown.
9
Additionally, longitudinal data on safety and
the effects on pulmonary and cardiovascular health
are lacking.
Approximately 5.5% of the adult population in England
use electronic cigarettes, with their use increasing year on
year. The decline in the prevalence of cigarette smoking has
been mirrored with a rise in electronic cigarette use among
adults. There are currently approximately 2.6 million
electronic cigarette users in Great Britain, compared with
9 million tobacco smokers. The most frequently cited reasons
for using electronic cigarettes are health, wanting to cut
down, and wanting to quit smoking. The majority of
electronic cigarette users consider them safer than
cigarettes.
46
Concerns have been raised that electronic
cigarettes may re-normalise smoking or perhaps lead to
non-smokers taking up smoking through a ‘gateway drug’
effect. However, almost all electronic cigarette users are
current or ex-smokers, with ‘never-smoker’ users of
electronic cigarettes accounting for only 0.2% of total users.
It is noteworthy that electronic cigarettes are the most
common smoking cessation aid used in the UK today.
46
Studies of electronic cigarettes as a method of cessation are
heterogeneous, due to the constantly changing nature of the
technology. There have been no trials of electronic cigarettes
for smoking cessation compared with the recommended
regimen of behavioural support and NRT/medication.
Clinical trials of electronic cigarettes for smoking cessation
in non-pregnant adults have demonstrated their effectiveness
in reduction in cigarette consumption and smoking cessation
compared with placebo alone.
50–52
There is also evidence that
electronic cigarette use can encourage smoking cessation even
in smokers who do not want to quit.
The National Centre for Smoking Cessation and Training
recommends that smoking cessation services be open to
electronic cigarette use among non-pregnant smokers,
particularly those who have tried to quit with other
methods and failed. Multi-sessional behavioural support is
recommended to improve their chances of quitting.
There is a lack of safety data on the use of electronic
cigarettes in pregnancy, and their effectiveness for smoking
cessation in pregnancy has not been established.
43
There are
no randomised controlled trials of electronic cigarette use for
cessation in pregnancy and no published observational data
on obstetric outcomes in pregnant users of electronic
cigarettes. Women perceive electronic cigarettes as useful
aids for reducing cigarette consumption and achieving
cessation, while being less harmful than conventional
cigarettes.
53
In the limited research conducted to date,
many pregnant electronic cigarette users report dual use of
electronic cigarettes and cigarettes. One US study
54
found
that over half of pregnant women entering a smoking
cessation trial had previously used electronic cigarettes, with
these women reporting a higher cigarette consumption
prepregnancy and more failed quit attempts. Fourteen
ª2019 Royal College of Obstetricians and Gynaecologists 173
McDonnell and Regan
percent of women entering the trial were actively using
electronic cigarettes in pregnancy and had similar
characteristics, leading the authors to conclude that women
who find it more difficult to quit smoking are more likely to
use electronic cigarettes. In the UK, ‘Helping pregnant
smokers quit’ is a National Institute for Health Research
multicentre randomised controlled trial currently recruiting
pregnant smokers for a clinical trial comparing electronic
cigarettes versus usual care (behavioural support and NRT),
with the results expected in 2021.
Conclusion
Smoking in pregnancy is a major preventable risk factor for
maternal and neonatal morbidity. Maternal smoking rates are
declining, with a higher proportion of continued cigarette
smoking encountered in lower socio-economic groups. The
harm from cigarette smoking is primarily from carbon
monoxide and tar, which contribute to the complications
seen during pregnancy. Nicotine alters fetal brain
development and contributes to behavioural disorders in
the offspring of smokers.
Smoking cessation in pregnancy is a key part of the NHS
England initiative Saving Babies’ Lives, a care bundle for
reducing stillbirths, and all healthcare professionals should be
comfortable with providing smoking cessation advice.
The relatively high smoking cessation rate in pregnancy is
tempered by a high rate of relapse in the postnatal period, with
less than one-third of spontaneous quitters remaining
abstinent at 1 year postpartum. There is weak evidence that
NRT with behavioural support can improve cessation rates in
pregnancy, but with no effect on postpartum cessation.
The use of electronic cigarettes is becoming more
common, as women perceive them to be less harmful than
cigarettes. However, there is a lack of safety and efficacy data
on their use in pregnancy, and no data on obstetric outcomes
in pregnant users.
Further research is needed on pregnancy-specific cessation
methods for example, use of higher-dose NRT, electronic
cigarettes or pharmacotherapy as well as methods of
preventing postpartum relapse. More data are also needed on
outcomes in pregnant users of electronic cigarettes. Clinical
trials for new methods of smoking cessation should consider
the inclusion of pregnant women, because they are a group
particularly at risk from continued smoking.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
BPM researched and wrote the article; CR critically revised
and edited the article. Both authors approved the
final version.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.com/
journal/tog
Infographic S1. Smoking in pregnancy.
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ª2019 Royal College of Obstetricians and Gynaecologists 175
McDonnell and Regan
... O presente trabalho se caracteriza como produto de uma pesquisa bibliográfica, tendo sido produzido através de uma abordagem narrativa de natureza qualitativa, a partir da revisão e análise da literatura científica previamente publicada e selecionada por meio de estratégias específicas (ROTHER, et al., 2007). O uso materno do tabaco ou a exposição ao fumo passivo durante a gravidez está associado a efeitos deletérios ao desenvolvimento fetal e perinatal, resultando em retardo do crescimento intrauterino, baixo peso ao nascer, descolamento prematuro da placenta, disfunção endócrina, oncogênese, taxas aumentadas de aborto espontâneo, nascimentos pré-termo, aumento de natimortos e elevação do risco de síndrome da morte súbita do lactente (MCDONNELL et al., 2019;MCGRATH-MORROW et al., 2020). ...
... Os principais componentes do cigarro convencional que podem provocar efeitos adversos no desenvolvimento do embrião, sobretudo durante a organogênese, são a nicotina, o monóxido de carbono, além de outros compostos do alcatrão, que contribuem para o desenvolvimento de hipóxia fetal(MCDONNELL et al., 2019; MCGRATH-MORROW et al., 2020; CASPERS et al., 2013). Há evidências de que vários teratógenos na fumaça do cigarro afetam o desenvolvimento do embrião de forma multifatorial, seja por estresse oxidativo, por excitotoxicidade ou por apoptose mediada pelo antagonista glutamatérgico(DE ZEEUW et al., 2012).Pode haver, ainda, aumento do risco de teratogenicidade pelo favorecimento de alterações epigenéticas via metilação no DNA fetal, o que afeta a forma como o DNA expressa os genes e, consequentemente, podendo ocasionar alterações funcionais ou estruturais no concepto durante a gestação(JOUBERT et al., 2016).Efeitos teratogênicos do cigarro eletrônicoO uso de cigarros eletrônicos com alta concentração de nicotina tem crescido nos últimos anos, principalmente entre os jovens, incluindo nunca fumantes, embora a utilização dos cigarros eletrônicos esteja diretamente associada ao início do tabagismo através uso do cigarro convencional à base de tabaco (O'BRIEN,2021; DAI, 2019). ...
Chapter
Full-text available
Desde os períodos mais remotos, nas civilizações primitivas, substâncias presentes na natureza eram utilizadas para fins diversos, como a caça e extermínio de inimigos. Com a evolução da humanidade, muitos esforços têm sido feitos para o avanço no conhecimento acerca do uso seguro de substâncias presentes em diversos contextos da vida, através da identificação e caracterização do potencial tóxico e das condições de exposição a estas substâncias que podem repercutir em perigo para os seres vivos. Deste modo, o objetivo principal destes avanços consiste em prevenir agravos relacionados ao contato ou exposição com substâncias potencialmente tóxicas. Em nosso cotidiano, estamos constantemente expostos a potenciais agentes tóxicos, mesmo que não percebamos, a exemplo dos medicamentos, alimentos, substâncias presentes nos meios ocupacional e ambiental, além das substâncias produzidas e usadas intencionalmente por exercer atividades tóxicas no organismo, como as drogas de abusos lícitas e ilícitas. Assim, a Toxicologia surge como a ciência que, em suas diferentes áreas de atuação, busca compreender a natureza, os mecanismos das ações tóxicas e as alterações biológicas resultantes da exposição de um organismo vivo a diferentes substâncias químicas. No contexto da saúde humana, o papel principal desta ciência é a avaliação de risco e o estabelecimento de medidas preventivas e corretivas para a utilização segura destas substâncias pelo homem. O estudo acerca de acidentes por animais peçonhentos também se enquadra no escopo da Toxicologia. A Organização Mundial de Saúde (OMS) estima que ocorrem 5 milhões de acidentes por picada de serpente por ano, resultando em 2,5 milhões de envenenamentos e em, pelo menos, 100.000 mortes. Portanto, tanto as intoxicações exógenas como os envenenamentos por animais peçonhentos correspondem a relevantes situações de risco à saúde que requerem atendimento especializado, constituindo um sério problema sanitário mundial. De modo agudo, as intoxicações e envenenamentos ocorrem em diversos contextos, como intenção suicida, acidentes, abuso de substâncias, prescrições médicas equivocadas, dentre outros. Porém, também a exposição crônica a substâncias com potencial tóxico pode desencadear consequências deletérias ao organismo a longo prazo, a exemplo da mutagênese e da carcinogênese. Este cenário requer a formação aaaaa LLLLLLLLLIIIII de profissionais de diferentes áreas do conhecimento, especialmente da área da saúde, com visão integrada, multidisciplinar e abrangente sobre Toxicologia. Neste contexto, a proposta da obra “Toxicologia: uma abordagem multidisciplinar” é trazer, ao leitor, estudos que contemplam as diversas áreas da Toxicologia demonstrando o impacto de diferentes tipos de substâncias sobre a saúde humana.
... O presente trabalho se caracteriza como produto de uma pesquisa bibliográfica, tendo sido produzido através de uma abordagem narrativa de natureza qualitativa, a partir da revisão e análise da literatura científica previamente publicada e selecionada por meio de estratégias específicas (ROTHER, et al., 2007). O uso materno do tabaco ou a exposição ao fumo passivo durante a gravidez está associado a efeitos deletérios ao desenvolvimento fetal e perinatal, resultando em retardo do crescimento intrauterino, baixo peso ao nascer, descolamento prematuro da placenta, disfunção endócrina, oncogênese, taxas aumentadas de aborto espontâneo, nascimentos pré-termo, aumento de natimortos e elevação do risco de síndrome da morte súbita do lactente (MCDONNELL et al., 2019;MCGRATH-MORROW et al., 2020). ...
... Os principais componentes do cigarro convencional que podem provocar efeitos adversos no desenvolvimento do embrião, sobretudo durante a organogênese, são a nicotina, o monóxido de carbono, além de outros compostos do alcatrão, que contribuem para o desenvolvimento de hipóxia fetal(MCDONNELL et al., 2019; MCGRATH-MORROW et al., 2020; CASPERS et al., 2013). Há evidências de que vários teratógenos na fumaça do cigarro afetam o desenvolvimento do embrião de forma multifatorial, seja por estresse oxidativo, por excitotoxicidade ou por apoptose mediada pelo antagonista glutamatérgico(DE ZEEUW et al., 2012).Pode haver, ainda, aumento do risco de teratogenicidade pelo favorecimento de alterações epigenéticas via metilação no DNA fetal, o que afeta a forma como o DNA expressa os genes e, consequentemente, podendo ocasionar alterações funcionais ou estruturais no concepto durante a gestação(JOUBERT et al., 2016).Efeitos teratogênicos do cigarro eletrônicoO uso de cigarros eletrônicos com alta concentração de nicotina tem crescido nos últimos anos, principalmente entre os jovens, incluindo nunca fumantes, embora a utilização dos cigarros eletrônicos esteja diretamente associada ao início do tabagismo através uso do cigarro convencional à base de tabaco (O'BRIEN,2021; DAI, 2019). ...
Chapter
Full-text available
Desde os períodos mais remotos, nas civilizações primitivas, substâncias presentes na natureza eram utilizadas para fins diversos, como a caça e extermínio de inimigos. Com a evolução da humanidade, muitos esforços têm sido feitos para o avanço no conhecimento acerca do uso seguro de substâncias presentes em diversos contextos da vida, através da identificação e caracterização do potencial tóxico e das condições de exposição a estas substâncias que podem repercutir em perigo para os seres vivos. Deste modo, o objetivo principal destes avanços consiste em prevenir agravos relacionados ao contato ou exposição com substâncias potencialmente tóxicas. Em nosso cotidiano, estamos constantemente expostos a potenciais agentes tóxicos, mesmo que não percebamos, a exemplo dos medicamentos, alimentos, substâncias presentes nos meios ocupacional e ambiental, além das substâncias produzidas e usadas intencionalmente por exercer atividades tóxicas no organismo, como as drogas de abusos lícitas e ilícitas. Assim, a Toxicologia surge como a ciência que, em suas diferentes áreas de atuação, busca compreender a natureza, os mecanismos das ações tóxicas e as alterações biológicas resultantes da exposição de um organismo vivo a diferentes substâncias químicas. No contexto da saúde humana, o papel principal desta ciência é a avaliação de risco e o estabelecimento de medidas preventivas e corretivas para a utilização segura destas substâncias pelo homem. O estudo acerca de acidentes por animais peçonhentos também se enquadra no escopo da Toxicologia. A Organização Mundial de Saúde (OMS) estima que ocorrem 5 milhões de acidentes por picada de serpente por ano, resultando em 2,5 milhões de envenenamentos e em, pelo menos, 100.000 mortes. Portanto, tanto as intoxicações exógenas como os envenenamentos por animais peçonhentos correspondem a relevantes situações de risco à saúde que requerem atendimento especializado, constituindo um sério problema sanitário mundial. De modo agudo, as intoxicações e envenenamentos ocorrem em diversos contextos, como intenção suicida, acidentes, abuso de substâncias, prescrições médicas equivocadas, dentre outros. Porém, também a exposição crônica a substâncias com potencial tóxico pode desencadear consequências deletérias ao organismo a longo prazo, a exemplo da mutagênese e da carcinogênese. Este cenário requer a formação aaaaa LLLLLLLLLIIIII de profissionais de diferentes áreas do conhecimento, especialmente da área da saúde, com visão integrada, multidisciplinar e abrangente sobre Toxicologia. Neste contexto, a proposta da obra “Toxicologia: uma abordagem multidisciplinar” é trazer, ao leitor, estudos que contemplam as diversas áreas da Toxicologia demonstrando o impacto de diferentes tipos de substâncias sobre a saúde humana.
... Smoking is a known independent risk factor for adverse pregnancy outcomes, including miscarriage, stillbirth, placental abruption, PTB, low birthweight, and neonatal morbidity and mortality (73). Hence, smoking should be avoided by pregnant women with RA to prevent the worsening status of RA and PTB. ...
During pregnancy, many diseases are correlated with different adverse outcomes. In turn, pregnancy affects the body, leading to increased disease susceptibility. This interplay between diseased states and pregnancy outcomes is illustrated in the effect of the chronic autoimmune disorder, rheumatoid arthritis (RA), and the adverse outcome, preterm birth (PTB). RA is a systemic disorder characterized by inflammation of the joints and other body organs. Joint pain and swelling are the most prominent manifestations of RA during pregnancy. However, the exact role of RA on PTB among pregnant women has yet to be established. This review highlighted the immunologic mechanisms involved in PTB in pregnant patients with RA. The immune cell population in pregnant women with RA exhibits higher activity of macrophages, dendritic cells, neutrophils, helper T (Th) 1 cells, and Vδ1 cells, but lower activity of CD4 + CD25high T regulatory (CD24 + CD25high Treg), Th2, and Vδ2 cells. Increased pro-inflammatory cytokines IL-6, TNF-α, and IFN-γ and decreased anti-inflammatory cytokines IL-12 and IL-10 are also exhibited by pregnant patients with RA. This review also discussed factors that may predict the risk of PTB in RA. These include disease activity and severity of RA, laboratory parameters (cytokines and immune cell population), and sociodemographic factors such as ethnicity, smoking, alcohol intake, and the level of education. Current findings on the underlying immunological mechanisms of RA can help identify possible strategies to prevent PTB.
... Besides that, smoking has been mentioned as a negative influencer of embryogenesis, as it may cause recurrent abortions, intrauterine growth retardation, fetal distress, preterm labor, low-birth weight, as well as potential teratogenicity [9,10]. ...
Article
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Objective Smoking is considered as a growing epidemic worldwide, and it was found to have negative influence on health, causing a variety of diseases in both sexes, such as pulmonary fibrosis, chronic obstructive pulmonary disease, cerebrovascular and cardiovascular disorders, pulmonary and extrapulmonary malignancies, infertility, erectile dysfunction, recurrent abortions, and teratogenicity. In addition, several studies have been conducted owing to concerns on its effect on the endocrinal system in males, especially its effects on testosterone levels; however, this concern is still debatable, and all reported results were conflicting. Patients and methods Herein, the cohort study was conducted on a subgroup of smoking males (n=155) to evaluate its effect on serum total testosterone (T), estradiol (E2), as well as T/E2 ratio compared with a non-smoking control group (n=134). Results Our results have shown that there was a significant statistical difference between smoker and non-smoker groups concerning serum total testosterone (T), estradiol (E2), and subsequently T/E2 ratio, with P values of 0.002, less than 0.001, and less than 0.001, respectively. In addition, there was a statistically significant negative correlation between the duration of smoking and T. However, there was no correlation between duration of smoking and either E2 or T/E2 ratio. Conclusion Thus, the current study added further evidence to the unsettled debate suggesting negative harmful effects of smoking on serum testosterone level.
... 45 states that smoking during pregnancy increases the risk of health problems for developing babies, including preterm birth, low birth weight, and birth defects of the mouth and lip. Smoking during and after pregnancy also increases the risk of sudden infant death syndrome (SIDS) 46 stated that the harm from cigarette smoking is primarily from carbon monoxide and tar, which contribute to the complications seen during pregnancy. Nicotine alters fetal brain development and contributes to behavioral disorders in the offspring of smokers. ...
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Background The prevalence of tobacco use in Southeast Asia communities is 56% which 15% of them are female active smokers. Several studies explain that working status, neighborhood, marital status, and education are factors that cause smoking behavior in women. A scientific study is needed to obtain valid assumptions regarding the relationship of these determinants. This study aimed to analyze the determinant of smoking behavior among female workers in the Philippines and Indonesia. Methods The data is processed from 2017 PDHS and use female workers in the Philippines and Indonesia as the study population. The sample size is 11,375 female workers in the Philippines and 26,712 female workers in Indonesia. Apart from smoking behavior as the dependent variable, other variables analyzed were the place of residence, age, marital, education, parity, currently pregnant, and wealth status. The analysis in the final stage uses binary logistic regression. Results The results show that female workers in both countries from urban areas have a higher likelihood of becoming smokers than those who live in rural areas. Age group is finding as one of the smoking behavior determinants among female workers in both countries. Female workers with long-distance marriage and married / living with a partner have a lower probability of becoming a smoker than those who have marital status in the widowed/divorced category. Education level and parity are also finding as one of the smoking behavior determinants among them. Meanwhile, pregnancy found to be a protective factor for them to become a smoker. Finally, the multivariate test results found that wealth status is also a determinant of smoking behavior for female workers in both countries. Conclusions It was concluded that the seven variables analyzed are the determinants of smoking behavior among female workers in the Philippines and Indonesia. The seven variables are type of place, age, marital, education, parity, pregnancy, and wealth status.
... The prevalence of smoking in pregnant women is more important than other groups and due to the effects of smoking on the health of the pregnant women, and their fetus such as reduced fetal size, stillbirth, increased perinatal death, death infant, miscarriage, placental abruption, premature birth, premature lung aging, and chronic disease of obstructive pulmonary [159][160][161][162], it is necessary to pay more attention to this issue. Endangering the health of mother and fetus can affect the quality of life of family and society, and will have devastating consequences for the psychology, socioeconomic, and social aspects. ...
Article
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Background This systematic and meta-analysis review aimed to provide an updated estimate of the prevalence of ever and current cigarette smoking in women, in geographic areas worldwide, and demonstrate a trend of the prevalence of smoking over time by using a cumulative meta-analysis. Methods Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies published on the prevalence of ever and current cigarette smoking in women. We searched PubMed, Web of Science (ISI), Scopus, and Ovid from January 2010 to April 2020. The reference lists of the studies included in this review were also screened. Data were reviewed and extracted independently by two authors. A random effects model was used to estimate the pooled prevalence of ever and current cigarette smoking in women. Sources of heterogeneity among the studies were determined using subgroup analysis and meta-regression. Results The pooled prevalence of ever and current cigarette smoking in women was 28% and 17%, respectively. The pooled prevalence of ever cigarette smoking in adolescent girls/students of the school, adult women, pregnant women, and women with the disease was 23%, 27%, 32%, and 38%, respectively. The pooled prevalence of ever cigarette smoking in the continents of Oceania, Asia, Europe, America, and Africa was 36%, 14%, 38%, 31%, and 32%, respectively. Conclusions The prevalence of cigarette smoking among women is very high, which is significant in all subgroups of adolescents, adults, and pregnant women. Therefore, it is necessary to design and implement appropriate educational programs for them, especially in schools, to reduce the side effects and prevalence of smoking among women.
... Taylor et al. rightly conclude that available evidence is not currently clear regarding whether maternal use of NRT during pregnancy is harmful to the foetus, however, the strongest data available provide no suggestion that NRT might be harmful. When making decisions about support for smoking cessation in pregnancy, it is important to remember that evidence is certain when it comes to the harms of smoking on both mother and foetus alike, and supporting women to quit smoking during pregnancy should be prioritised [6]. ...
... La fumée de tabac est un mélange hétérogène contenant plus de 4000 composés, y compris de la nicotine, du monoxyde de carbone (CO) et des métaux lourds. 2 Ces composés sont présents dans la fumée inhalée et exhalée, rendant les risques d'exposition au tabagisme passif des femmes enceintes également conséquents. ...
Article
Full-text available
In Switzerland, about 13 % of pregnant women smoke, giving birth to more than 11'000 infants per year exposed to tobacco in utero. Although this proportion is stable since the 2000's, the users of nicotine with new devices (electronic cigarettes, inhaled heated tobacco, sniffed or chewed tobacco) are increasing. The literature is unanimous about deleterious effects of prenatal exposure to tobacco smoke on the fetus, with multiple short- and long-term consequences. Available data suggest that in utero exposure to e-cigarette could also expose the fetus to a similar profile of adverse effects. In this article, we review briefly the known epidemiological and mechanistic data on the short- and long-term effects of prenatal cigarette smoke and nicotine consumption.
Chapter
Use of substances including alcohol, tobacco and drugs is common in people of reproductive age, can lead to dependence and is a major global health concern. Despite targeted public health policies and campaigns, population surveys (National Institute on Drug Abuse (NIH) 2020; European Drug Report 2019) continue to highlight widespread use of substances, often in combination, which have substantial negative implications for health in general and the potential to harm future generations (Stephenson et al. 2018). Healthcare professionals need to be aware of the complex psychological, physiological and social factors that may be linked to substance use and be prepared to offer counselling and referral for specialist services. Pregnancy, however, can be a ‘window of opportunity’ and a motivating factor for women and their partners to change their behaviour and minimise risk with help to quit or cut down on substance use (Solomon and Quinn 2004). Preconception care offers the opportunity to further reduce risk by helping to modify consumption prior to pregnancy.
Article
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Background Electronic cigarettes (ECs) are increasingly used for reducing or stopping smoking, with some studies showing positive outcomes. However, little is known about views on ECs during pregnancy or postpartum and previous studies have nearly all been conducted in the US and have methodological limitations, such as not distinguishing between smokers and ex/non-smokers. A greater understanding of this topic will help to inform both clinicians and EC interventions. We elicited views and experiences of ECs among UK pregnant or recently pregnant women. Methods We conducted semi-structured telephone interviews, using topic guides, with pregnant or recently pregnant women, who were current or recent ex-smokers. To ensure broad views of ECs were obtained, recruitment was from several geographical locations and via various avenues of recruitment. This included stop smoking services, antenatal and health visitor clinics, a pregnancy website and an informal network. Participants were 15 pregnant and 15 postpartum women, including nine current EC users, 11 ex-users, and 10 never-users. Five women who were interviewed in pregnancy were later interviewed in postpartum to explore if their views had changed. Audio data was transcribed verbatim and framework analysis was applied. ResultsFive main themes emerged: motivations for use (e.g., for stopping or reducing smoking), social stigma (e.g., avoiding use in public, preferring ‘discrete’ NRT), using the EC (e.g., mostly used at home); consumer aspects (e.g., limited advice available), and harm perceptions (e.g., viewed as less harmful than smoking; concerns about safety and addiction). ConclusionsECs were viewed positively by some pregnant and postpartum women and seen as less harmful than smoking and useful as aids for reducing and stopping smoking. However, due to perceived social stigma, some women feel uncomfortable using ECs in public, especially during pregnancy, and had concerns about safety and nicotine dependence. Health professionals and designers of EC interventions need to provide women with up-to-date and consistent information and advice about safety and dependence, as well as considering the influence of social stigma.
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Objectives Pregnancy motivates women to try stopping smoking, but little is known about timing of their quit attempts and how quitting intentions change during pregnancy and postpartum. Using longitudinal data, this study aimed to document women’s smoking and quitting behaviour throughout pregnancy and after delivery. Design Longitudinal cohort survey with questionnaires at baseline (8–26 weeks’ gestation), late pregnancy (34–36 weeks) and 3 months after delivery. Setting Two maternity hospitals in one National Health Service hospital trust, Nottingham, England. Participants 850 pregnant women, aged 16 years or over, who were current smokers or had smoked in the 3 months before pregnancy, were recruited between August 2011 and August 2012. Outcome measures Self-reported smoking behaviour, quit attempts and quitting intentions. Results Smoking rates, adjusting for non-response at follow-up, were 57.4% (95% CI 54.1 to 60.7) at baseline, 59.1% (95% CI 54.9 to 63.4) in late pregnancy and 67.1% (95% CI 62.7 to 71.5) 3 months postpartum. At baseline, 272 of 488 current smokers had tried to quit since becoming pregnant (55.7%, 95% CI 51.3 to 60.1); 51.3% (95% CI 44.7 to 58.0) tried quitting between baseline and late pregnancy and 27.4% (95% CI 21.7 to 33.2) after childbirth. The percentage who intended to quit within the next month fell as pregnancy progressed, from 40.4% (95% CI 36.1 to 44.8) at baseline to 29.7% (95% CI 23.8 to 35.6) in late pregnancy and 14.2% (95% CI 10.0 to 18.3) postpartum. Postpartum relapse was lower among women who quit in the 3 months before pregnancy (17.8%, 95% CI 6.1 to 29.4) than those who stopped between baseline and late pregnancy (42.9%, 95% CI 24.6 to 61.3). Conclusions Many pregnant smokers make quit attempts throughout pregnancy and postpartum, but intention to quit decreases over time; there is no evidence that smoking rates fall during gestation.
Article
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\textbf{Introduction}$: UK guidance recommends routine exhaled carbon monoxide (CO) screening for pregnant women and “opt-out” referrals to stop smoking services (SSS) of those with CO ≥ 4 ppm. We explored staff views on this referral pathway when implemented in one UK hospital Trust. $\textbf{Methods}$: Seventeen semi-structured interviews with staff involved in the implementation of the new referral pathway: six antenatal clinic staff (before and after implementation); five SSS staff (after). Data were analyzed using framework analysis. $\textbf{Results}$: Two themes were identified: (1) views on implementation of the pathway and (2) impact of the pathway on the women. Generally, staff felt that following training, referrals were less arduous to implement and better received than expected. The majority believed this pathway helped engage women motivated to quit and offered a unique chance to impart smoking cessation knowledge to hard-to-reach women, who might not otherwise contact SSS. An unexpected issue arose during implementation—dealing with non-smokers with high CO readings. $\textbf{Conclusions}$: According to staff, the “opt-out” referral pathway is an acceptable addition to routine antenatal care. It can help engage hard-to-reach women and educate them about the dangers of smoking in pregnancy. Incorporating advice on dealing with non-smokers with high CO into routine staff training could help future implementations.
Article
Background E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments. Methods We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms. Results A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath. Conclusions E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608.)
Article
Background: Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence. Objectives: To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long-term smoking cessation, compared to placebo or 'no NRT' interventions. Search methods: We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017. Selection criteria: Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow-up of less than six months, except for those in pregnancy (where less than six months, these were excluded from the main analysis). We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews. Data collection and analysis: Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model. Main results: We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. A subset of six trials conducted in pregnant women found a statistically significant benefit of NRT on abstinence close to the time of delivery (RR 1.32, 95% CI 1.04 to 1.69; 2129 participants); in the four trials that followed up participants post-partum the result was no longer statistically significant (RR 1.29, 95% CI 0.90 to 1.86; 1675 participants). Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare. Authors' conclusions: There is high-quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non-ischaemic chest pain and palpitations.
Article
Purpose: A recent study identified high aldehyde emissions from e-cigarettes (ECs), that when converted to reasonable daily human EC liquid consumption, 5 g/day, gave formaldehyde exposure equivalent to 604-3257 tobacco cigarettes. We replicated this study and also tested a new-generation atomizer under verified realistic (no dry puff) conditions. Design: CE4v2 atomizers were tested at 3.8 V and 4.8 V, and a Nautilus Mini atomizer was tested at 9.0 W and 13.5 W. All measurements were performed in a laboratory ISO-accredited for EC aerosol collection and aldehyde measurements. Results: CE4v2 generated dry puffs at both voltage settings. Formaldehyde levels were >10-fold lower, acetaldehyde 6-9-fold lower and acrolein 16-26-fold lower than reported in the previous study. Nautilus Mini did not generate dry puffs, and minimal aldehydes were emitted despite >100% higher aerosol production per puff compared to CE4v2 (formaldehyde: 16.7 and 16.5 μg/g; acetaldehyde: 9.6 and 10.3 μg/g; acrolein: 8.6 and 11.7 μg/g at 9.0 W and 13.5 W, respectively). EC liquid consumption of 5 g/day reduces aldehyde exposure by 94.4-99.8% compared to smoking 20 tobacco cigarettes. Conclusion: Checking for dry puffs is essential for EC emission testing. Under realistic conditions, new-generation ECs emit minimal aldehydes/g liquid at both low and high power. Validated methods should be used when analyzing EC aerosol.
Article
Introduction Electronic cigarette use is rapidly gaining in popularity. However, little is known about correlates and reasons for electronic cigarette use by women of reproductive age, a group for which the safety and efficacy of electronic cigarette use is of particular interest. Methods As part of a clinical trial for smoking cessation, we surveyed pregnant smokers about their lifetime use of electronic cigarettes, previous use of any adjunctive treatments for smoking cessation, and use of electronic cigarettes during pregnancy. We examined associations between electronic cigarette use and participant characteristics. Results Fifty-three percent (55/103) of participants had previously tried electronic cigarettes. Ever users smoked more cigarettes per day before pregnancy (p = .049), had a greater number of previous quit attempts (p = .033), and were more likely to identify as being Hispanic or non-Hispanic white than never users (p = .027). Fifteen percent of participants (15/103) reported previous use of electronic cigarettes for smoking cessation, which was more common than the use of any specific FDA-approved smoking cessation medication. Fourteen percent of participants (14/103) reported electronic cigarette use during pregnancy, most commonly to quit smoking. A history of substance abuse (p = .043) and more previous quit attempts (p = .018) were associated with electronic cigarette use during pregnancy. Conclusions Use of electronic cigarettes to quit smoking may be common in women of reproductive age, including those who are pregnant. More research is needed to determine the risks and benefits of electronic cigarette use in this population of smokers. Implications This study shows that electronic cigarettes are used by women of reproductive age, including pregnant smokers. The implications of this finding are that there is an urgent need to examine the risks and benefits of electronic cigarette use, especially by pregnant women. The study also shows that electronic cigarettes are commonly used as a smoking cessation aid in women of reproductive age. The greater likelihood of electronic cigarette use compared to proven adjunctive smoking treatments suggests that electronic cigarettes should be examined as a potential aid to cessation in this population.
Article
Background: Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries. Objectives: To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. Search methods: In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors. Selection criteria: Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy. Data collection and analysis: Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14. Main results: The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I(2) = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions. Authors' conclusions: Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.