Recommendations on treating tobacco dependence in pregnant women
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At the time of publication (November 2021), no nicotine-containing e-cigarettes were licensed as a medicine for stopping smoking by the Medicines and Healthcare products Regulatory Agency (MHRA) and commercially available in the UK market. All nicotine-containing e‑cigarettes in the UK that are not licensed as a medicine by the MHRA are regulated by the Tobacco and Related Products Regulations (2016), and cannot be marketed by the manufacturer for use for stopping smoking.
Other recommendations relevant to pregnant women are in the section on support to stop smoking in secondary care services.
These recommendations are for healthcare professionals providing maternity care.
1.18.1 Provide routine carbon monoxide testing at the first antenatal appointment and at the 36-week appointment to assess every pregnant woman's exposure to tobacco smoke. Provide carbon monoxide testing at all other antenatal appointments if the pregnant woman:
1.18.2 Provide an opt-out referral to receive stop-smoking support for all pregnant women who:
have a carbon monoxide reading of 4 ppm or above or
have previously been provided with an opt-out referral but have not yet engaged with stop-smoking support.
See also the section on identifying smoking among carers, family and other household members. 
1.18.3 Explain to the woman:
that it is normal practice to refer all pregnant women who smoke or have recently quit
that the carbon monoxide test will allow her to see a physical measure of her smoking and exposure to other people's smoking
what her carbon monoxide reading means, taking into consideration the time since she last smoked and the number of cigarettes smoked (and when) on the day of the test. 
1.18.4 If the pregnant woman does not smoke but has a carbon monoxide level of 3 ppm or more, help her to identify the source of carbon monoxide and reduce it. (Other sources include household or other secondhand smoke, heating appliances or traffic emissions.) 
1.18.5 If the pregnant woman has a high carbon monoxide reading (more than 10 ppm) but says she does not smoke:
1.18.6 Record carbon monoxide level and any feedback given in the pregnant woman's antenatal records. If her antenatal records are not available locally, use local protocols to record this information. 
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on identifying pregnant women who smoke and referring them for stop-smoking support.
Full details of the evidence and the committee's discussion are in evidence review H: opt-out stop-smoking support.
These recommendations are for people providing stop-smoking support or advice.
1.19.1 Contact all pregnant women who have been referred for help. Discuss smoking and pregnancy and the issues they face, using an impartial, person-centred approach. Invite them to use the service. If necessary (and resources permit), make at least 3 contacts using different methods. Advise the maternity booking midwife of the outcome. 
1.19.3 Provide information about the risks of smoking to an unborn child and the benefits of stopping for both mother and baby. 
1.19.4 Address any factors that prevent pregnant women from using stop-smoking support. This could include:
a lack of confidence in their ability to quit
lack of knowledge about the services on offer
difficulty accessing them
lack of suitable childcare
fear of failure and concerns about being stigmatised. 
1.19.5 If pregnant women are reluctant to attend the stop-smoking service, think about providing structured self-help materials or giving details of telephone quitlines or NHS online stop-smoking support. Also think about offering to visit them at home, or at another venue, if it is difficult for them to attend specialist services. 
1.19.6 Address any concerns pregnant women and their partners or family may have about stopping smoking and offer personalised information, advice and support on how to stop. 
1.19.7 Send information on smoking and pregnancy to women who opt out during the initial telephone call. This should include details on how to get help to quit at a later date. 
These recommendations are for people providing stop-smoking support or advice.
1.20.1 Provide the pregnant woman with intensive and ongoing support (brief interventions alone are unlikely to be sufficient) throughout pregnancy and beyond. This includes regularly monitoring her smoking status using carbon monoxide tests. Use carbon monoxide measurements to encourage her to quit and as a way to provide positive feedback once a quit attempt has been made. 
1.20.2 Biochemically validate that the pregnant woman has quit on the date she set and 4 weeks after. If possible, use urine or saliva cotinine tests, as these are more accurate than carbon monoxide tests. (They can detect exposure over the past few days rather than hours.) 
1.20.3 When carrying out tests, check whether the pregnant woman is using nicotine replacement therapy (NRT) as this may raise her cotinine levels. Take into account that no measure can be 100% accurate. Some people may smoke so infrequently – or inhale so little – that their intake cannot reliably be distinguished from that from passive smoking. 
1.20.4 If the pregnant woman stopped smoking in the 2 weeks before her maternity booking appointment, continue to provide support in line with the recommendations above and stop-smoking support practice protocols. 
1.20.5 Establish links with contraceptive services, fertility clinics and antenatal and postnatal services so that everyone working in those organisations knows about local stop-smoking support. Ensure they understand what these services offer and how to refer people to them. 
For pregnant women taking prescribed medicines, also see the section on medicine dosages for people who have stopped smoking.
1.20.7 Consider NRT at the earliest opportunity in pregnancy and continue to provide it after pregnancy if the woman needs it to prevent a relapse to smoking, including if the pregnancy does not continue (see BNF information on NRT). 
1.20.8 Give pregnant women clear and consistent information about NRT. Explain:
that it may help them stop smoking and reduce their cravings
how to use NRT correctly, including how to get a high enough dose of nicotine to control cravings, prevent compensatory smoking and stop successfully. 
1.20.9 Advise pregnant women who are using nicotine patches to remove them before going to bed. 
1.20.10 Emphasise to pregnant women that:
most smoking-related health problems are caused by other components in tobacco smoke, not by the nicotine
any risks from using NRT are much lower than those of smoking
nicotine levels in NRT are much lower than in tobacco, and the way these products deliver nicotine makes them considerably less addictive than smoking. 
1.20.11 Do not offer varenicline or bupropion to pregnant or breastfeeding women. 
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on nicotine replacement therapy and other pharmacological support.
Full details of the evidence and the committee's discussion are in evidence review J: nicotine replacement therapy and e-cigarettes in pregnancy: update.
These recommendations are for providers of stop-smoking support.
1.20.12 In addition to NRT and behavioural support, offer voucher incentives to support women to stop smoking during pregnancy, as follows:
refer women to an incentive scheme at the first maternity booking appointment or at the next available opportunity
provide vouchers only for abstinence validated using a biochemical method, such as a carbon monoxide test with a reading of less than 4 ppm
stagger incentives until at least the end of pregnancy (incentives totalling around £400 have been shown to be effective)
do not exclude women who have relapsed or those whose pregnancy does not continue from continuing to take part in the scheme and try again
ensure vouchers cannot be used to buy products that could be harmful during pregnancy (for example, alcohol and cigarettes). 
1.20.13 Consider providing voucher incentives jointly to the pregnant woman and to a friend or family member that she has chosen to support her during her quit attempt. 
1.20.14 Ensure staff are trained to promote and deliver incentive schemes to pregnant women to stop smoking. 
For a short explanation of why the committee made the 2021 recommendations and how they might affect practice, see the rationale and impact section on incentives to stop smoking.
Full details of the evidence and the committee's discussion are in evidence review I: incentives during pregnancy.
These recommendations are to help providers of stop-smoking support reach all pregnant women, including those whose circumstances may make it more difficult to use services (for example, because of cultural or sociodemographic factors, age or language).
1.20.15 Involve pregnant women who find it difficult to use or access existing stop-smoking support in the planning and development of services. 
1.20.16 Collaborate with the family nurse partnership and other outreach schemes to identify additional opportunities for providing intensive and ongoing support to pregnant women to stop smoking. (Note: family nurses make frequent home visits.) 
1.20.17 Work in partnership with agencies that support pregnant women who have complex social and emotional needs. This includes substance misuse services, youth and teenage pregnancy support and mental health services. 
These recommendations are for providers of stop-smoking support. See also the section on identifying smoking among carers, family and other household members.
1.20.18 Offer pregnant women's partners who smoke help to stop. Use an intervention that comprises 3 or more elements and multiple contacts. Discuss with them which options to use – and in which order, taking into account:
contraindications and the potential for adverse effects from stop-smoking pharmacotherapies
the likelihood that they will follow the course of treatment
their previous experience of stop-smoking aids
do not favour one course of treatment over another; together, choose the one that seems most likely to succeed taking into account the above.