Management of Smoking Cessation in Pregnant Women
The most appropriate management is B: Refer her to a smoking cessation support group and counseling, as behavioral interventions are the only intervention with established safety and effectiveness in pregnancy and should be the foundation of treatment. 1, 2
Why Behavioral Counseling is First-Line
Behavioral interventions substantially improve smoking abstinence in pregnant women (from approximately 11% to 15%), increase infant birthweight, and reduce risk for preterm birth, with minimal to no harms. 1 The evidence for this approach has high certainty, making it the clear first choice. 1
Key Components of Effective Behavioral Support
Provide intensive counseling with multiple sessions (≥4 sessions, ideally 8 or more), as more sessions correlate with better outcomes. 1
Use pregnancy-specific materials and messages about effects on both maternal and fetal health, as tailored counseling increases abstinence rates compared to brief generic advice alone. 1, 2
Include clear, strong advice to quit as soon as possible, emphasizing that quitting early in pregnancy provides the greatest benefit to the fetus, though cessation at any point yields substantial health benefits. 1, 2
Refer to specialized cessation counselors, support groups, or telephone quitlines, which are as effective as face-to-face counseling and remove barriers such as cost and time. 2
Addressing Her Concern About ADHD
Her concern about ADHD is valid—maternal smoking during pregnancy is associated with a 58% increased risk of ADHD in children (pooled RR = 1.58,95% CI = [1.33,1.88]). 3 This evidence strengthens the urgency of cessation efforts and should be acknowledged when counseling her.
Why Not Nicotine Replacement Therapy (NRT) as First-Line
The USPSTF found inadequate evidence on the benefits of NRT in pregnant women, and the balance of benefits and harms cannot be determined. 1 While NRT is effective in non-pregnant adults, the evidence specific to pregnancy is limited:
NRT should only be considered after behavioral interventions alone prove insufficient and following detailed discussion about the known risks of continued smoking versus the possible risks of NRT. 2
The FDA label states that if pregnant, only use NRT on the advice of a healthcare provider, as risks to the child are not fully known, though it is believed to be safer than smoking. 4
ACOG recommends NRT only after detailed discussion of risks and with close supervision. 2
If NRT is eventually needed, start with short-acting forms (gum, lozenges) rather than patches for more controlled nicotine exposure. 2
Why Not Abrupt Cessation Without Support
Telling her to stop abruptly without support ignores the powerful physical and psychological addiction to cigarettes and misses the opportunity for compassionate intervention that can be the critical element in prenatal smoking cessation. 5 This approach has no evidence base and abandons the patient when she needs structured support most.
Common Pitfalls to Avoid
Inadequate follow-up: Smoking cessation requires ongoing support and monitoring, with repeated quit attempts encouraged. 2
Underestimating the importance of intensive behavioral support: Brief counseling alone may be insufficient for heavy smokers; multiple sessions with pregnancy-specific materials are more effective. 2
Prematurely prescribing NRT: Behavioral counseling must be attempted first, as it is the only intervention with established safety in pregnancy. 2