Smoking cessation in populations with special needs
There are several population groups for whom there are particular implications regarding nicotine dependence and the effects of smoking, as well as the use of medicines for smoking cessation. Many of these groups (children and adolescents, pregnant and lactating women, people with mental illnesses, people with substance use disorders and people with smoking-related diseases) have not been studied in clinical trials of pharmacotherapy for smoking cessation. However, the same guidelines for quitting smoking apply to all groups – every opportunity should be taken to offer all smokers advice and support to stop smoking. Counselling and behavioural interventions may be modified to be appropriate for the individual smoker.7 In addition, all nicotine-dependent smokers should be offered pharmacotherapy and referred for intensive treatment to the telephone Quitline (13 7848), other cessation programs or local face-to-face services where available.
Aboriginal and Torres Strait Islander people are highly represented in many categories of those with special needs: pregnant women, adolescents, prisoners, people with substance use problems and people with smoking-related diseases such as diabetes.
Pregnant and breastfeeding women
As well as the serious long-term health consequences for the mother, cigarette smoking by pregnant women causes a range of adverse fetal outcomes including stillbirth, spontaneous abortion, reduced fetal growth, premature birth, low birth weight (a key indicator of infant health), placental abruption, sudden infant death, cleft palate, cleft lip and childhood cancers.11 Approximately 14.5% of women in Australia smoke during pregnancy.182,183
Pregnant women who are most disadvantaged are more than four times more likely to smoke than women who are least disadvantaged (28% compared to 6%) and Aboriginal and Torres Strait Islander women are more than three times more likely to smoke during pregnancy than non-Indigenous women (49.3%).183
Although 20–30% of women quit when they become pregnant, about 70% of these women relapse either during pregnancy or after the baby is born. This is an important group of smokers to identify as they have made a quit attempt and are motivated. Smoking cessation interventions have been shown to be effective during pregnancy – overall by approximately 6%.184 Relapse in the postpartum period is high although there is evidence that this rate could be reduced by smoking cessation interventions at this time, but the difference is not significant at longer follow-up.184 Health professionals should inform pregnant women and new mothers of the dangers of passive smoking to newborn babies and young children.
The only safe level of smoking in pregnancy is not smoking at all because:
- any level of nicotine or tobacco smoke exposure increases the risk of adverse effects25,184-187
- the greatest gain in health benefits comes from quitting rather than cutting down.15,24,188
Quitting before conception or in the first trimester results in similar rates of adverse pregnancy outcomes, compared with non-smokers,189 and quitting at any time during pregnancy produces health benefits. Therefore, health professionals should offer cessation interventions to pregnant smokers as soon as possible in the pregnancy, throughout the pregnancy, and beyond.
Many pregnant women do not disclose their smoking status to a health professional – some guidelines recommend multiple choice question formats to improve disclosure. Health professionals should encourage pregnant smokers to attempt cessation using counselling, advice and support interventions before using pharmacological approaches as the efficacy and safety of these approaches during pregnancy are not well documented.24 Pharmacotherapy should be considered for pregnant women only if the increased likelihood of quitting outweighs the harmful effects on the fetus of nicotine replacement therapy and possible continued smoking.24 Pregnant women should be encouraged to use Quitline, which in some states has special programs of support which extend into the postpartum period, when risk of relapse is high. If quit attempts are unsuccessful without the use of medications, and the woman is motivated to quit, NRT (usually oral forms) can be considered.
There is limited evidence of the effectiveness of NRT in helping pregnant women stop smoking.184 The main benefits of using NRT are the removal of the other toxins contained in tobacco smoke and the lower dose of nicotine delivered by NRT than tobacco smoke.14 NRT can be used by pregnant and breastfeeding mothers, but the risks and benefits should be explained carefully to the woman by a suitably qualified health professional and the clinician supervising the pregnancy should be consulted.7,17
In general, intermittent (oral) NRT should be used during pregnancy to deliver a lower total daily nicotine dose.14 However, larger doses or even combination therapy may be required to relieve cravings and withdrawal symptoms in pregnancy due to the faster clearance of nicotine.105 If patches are used by pregnant women, they should be removed before going to bed to protect the fetus from continuous exposure to nicotine. While nicotine passes from mother to child in breast milk, it is unlikely to be dangerous.116 Women who continue to smoke after the birth should be encouraged to breastfeed their babies. Women who are unable to quit smoking completely can be given strategies to minimise exposure to the baby of secondhand smoke.
Neither of the two prescription medicines for smoking cessation in Australia, varenicline and bupropion, has been shown to be effective or safe for smoking cessation treatment in pregnant and breastfeeding smokers and they are not recommended. If a woman becomes pregnant while taking either agent, treatment should be ceased, and, if she agrees, reporting her pregnancy outcome to health authorities and the manufacturer may over time help better understand any risk.
All woman of childbearing age should be encouraged to stop smoking ideally before conception. Smoking cessation policy is intended to minimise the effects of smoking among all women – long-term reduction in nicotine exposure during pregnancy can be achieved only by encouraging adolescent girls and young women not to start smoking.24 It is also important to advise partners of pregnant women not to smoke around them and to encourage them to quit, as this can improve quit rates.
Recommended smoking cessation treatment
- Pregnant women should be encouraged to stop smoking completely.
- They should be offered intense support and proactive telephone counselling.
- Self-help material can supplement advice and support.
- If these interventions are not successful, health professionals should consider NRT, after clear explanation of the risks involved.
- Those who do quit should be supported to stay non-smokers long-term.
There is currently a lack of evidence on the safety of pharmacotherapy in pregnancy, but international guidelines recommend use of NRT in certain circumstances. Level V
Use of NRT should be considered when a pregnant woman is otherwise unable to quit. Intermittent NRT is preferred to patches (lower total daily nicotine dose). Strength C
- Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW, 2011. Available at http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421314 [accessed 12 August 2011].
- Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking cessation guidelines for Australian general practice: practice handbook. Canberra: Australian Government Department of Health and Ageing, 2004.
- Fiore MC, Jaén CR, Baker TB, Bailey WC, et al. for the Guideline Panel. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, May 2008. Available at http://www.ncbi.nlm.nih.gov/books/NBK63952/ [accessed 20 March 2011].
- Ministry of Health. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health, 2007. Available at http://www.health.govt.nz/publication/new-zealand-guidelines-helping-people-stop-smoking [accessed 23 March 2011].
- World Health Organization. WHO report on the global tobacco epidemic: The MPOWER Package. Geneva: World Health Organization, 2008. Available at http://whqlibdoc.who.int/publications/2008/9789241596282_eng.pdf [accessed 23 March 2010].
- Scollo MM, Winstanley MH, editors. Tobacco in Australia: facts and issues. A comprehensive online resource. 3rd edn. Melbourne: Cancer Council Victoria, 2008. Available from www. tobaccoinaustralia.org.au [accessed 25 March 2011].
- US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
- Australian Bureau of Statistics. 4831.0.55.001. Tobacco smoking in Australia: a snapshot 2004–05. September 2006. Available at www.abs.gov.au/ausstats/abs@.nsf/ mf/4831.0.55.001 [accessed 28 March 2011].
- Mendelsohn C. Optimising nicotine replacement therapy in clinical practice. Aust Fam Phys 2013;42(5): 305−9.
- Dempsey DA, Benowitz NL. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Saf 2001;24(4):277−322.
- Laws P, Abeywardana S, Walker J, Sullivan E. Australia’s mothers and babies 2005. Perinatal statistics series no. 20. Cat. no. PER 40. Sydney: AIHW National Perinatal Statistics Unit; 2007.
- AIHW, Li Z, Zeki R, Hilder L & Sullivan EA 2012. Australia’s mothers and babies 2010. Perinatal statistics series no. 27. Cat. no. PER 57. Canberra: AIHW.
- Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009, Issue 3. Art. no. CD001055.
- Aliyu MH, Lynch O, Wilson RE, Alio AP, Kristensen S, Marty PJ, et al. Association between tobacco use in pregnancy and placenta-associated syndromes: a population-based study. Arch Gynecol Obstet 2010;283:729–34.
- Rogers JM. Tobacco and pregnancy. Reprod Toxicol 2009;28:152–60.
- Einarson A, Riordan S. Smoking in pregnancy and lactation: a review of risks and cessation strategies. Eur J Clin Pharmacol 2009;65:325–30.
- Committee on Environmental Health; Committee on Substance Abuse; Committee on Adolescence; Committee on Native American Child. From the American Academy of Pediatrics: Policy statement-tobacco use: a pediatric disease. Pediatrics 2009;124:1474–87.
- Bickerstaff M1, Beckmann M, Gibbons K, Flenady V. Recent cessation of smoking and its effect on pregnancy outcomes. Aust N Z J Obstet Gynaecol. 2012 Feb;52(1):54-8.