What is the best treatment option for a pregnant woman with a history of smoking who is having difficulty quitting?

Recommended Treatment for Pregnant Smoker Unable to Quit

Intensive behavioral counseling interventions with at least 4 sessions should be provided as the first-line and most appropriate management for this pregnant woman who has been unsuccessful with initial quit attempts, as this is the only intervention with established safety and effectiveness in pregnancy. 1, 2

First-Line Approach: Intensive Behavioral Interventions

Behavioral counseling is the foundation of treatment and should be intensified immediately for pregnant women who have attempted but failed to quit smoking. 1, 2

• Effective behavioral interventions increase smoking abstinence rates from approximately 11% to 15% in pregnant women, which represents meaningful clinical benefit without medication risks. 3

• The counseling must be intensive (≥4 sessions) and provide more than minimal advice, as brief counseling alone is insufficient for women who have already failed initial quit attempts. 1, 2

• Sessions should include pregnancy-specific messaging about effects on both maternal and fetal health, including clear, strong advice about risks of fetal growth restriction, preterm birth, placental abruption, and low birthweight. 3, 1

• Provide tailored self-help materials specifically designed for pregnant smokers, as these increase abstinence rates compared to generic counseling alone. 3, 1

• Incorporate practical problem-solving skills training to recognize high-risk situations and develop coping strategies. 1

• Telephone counseling with at least 3 calls should supplement in-person support, as this is as effective as face-to-face counseling and removes barriers. 3, 2

Pharmacotherapy Considerations

Nicotine Replacement Therapy (NRT)

The evidence for NRT in pregnancy is insufficient to make a definitive recommendation, despite its effectiveness in non-pregnant populations. 3, 1

• NRT is FDA pregnancy category D, meaning there is positive evidence of fetal risk based on adverse reaction data. 3

• Low-certainty evidence from placebo-controlled trials shows no clear benefit (RR 1.21,95% CI 0.95 to 1.55), though non-placebo-controlled trials suggested possible benefit. 4

• If NRT is considered after behavioral interventions prove insufficient, it should only be used after detailed discussion of known risks of continued smoking versus possible risks of NRT, and under close physician supervision. 2

• When NRT is used, short-acting forms (gum, lozenges) are preferred over patches, as these allow more controlled nicotine exposure. 2

• Adherence to NRT in pregnancy is generally low, which limits its real-world effectiveness. 4

Bupropion

Bupropion should not be used in pregnancy due to lack of safety data and pregnancy category C classification. 3, 1

• No studies have evaluated bupropion's safety or efficacy specifically in pregnant women. 3

• Animal reproduction studies have shown adverse fetal effects. 3

• Low-certainty evidence shows no difference in smoking abstinence rates (RR 0.74,95% CI 0.21 to 2.64). 4

Clinical Algorithm

1. Immediately refer to specialized cessation counseling providing ≥4 intensive sessions with pregnancy-specific content. 1

2. Provide pregnancy-specific educational materials emphasizing benefits of quitting, particularly before 15 weeks gestation. 1

3. Arrange close follow-up at prenatal visits to assess smoking status and provide continued support. 1

4. Supplement with telephone counseling (minimum 3 calls) to provide ongoing support between visits. 3, 2

5. Only if intensive behavioral interventions fail, consider NRT after detailed shared decision-making discussion about risks and benefits, with close physician supervision. 2

Common Pitfalls to Avoid

• Offering pharmacotherapy as first-line treatment rather than intensive behavioral interventions is inappropriate, as behavioral interventions have proven efficacy and safety in pregnancy. 1

• Underestimating the effectiveness of intensive behavioral counseling leads to premature escalation to medications when adequate behavioral support may achieve meaningful cessation rates without medication risks. 1

• Assuming NRT is safe and effective based on non-pregnant population data, when pregnancy-specific evidence is insufficient and it carries pregnancy category D classification. 1

• Providing inadequate intensity of behavioral support (fewer than 4 sessions or lacking pregnancy-specific content) fails to maximize the proven safe and effective intervention. 1

• Inadequate follow-up undermines success, as smoking cessation requires ongoing support and monitoring with repeated quit attempts encouraged. 2

Answer to Multiple Choice Question

Based on the evidence, the answer is B: Non-nicotine gum and antenatal follow-up, as this represents intensive behavioral interventions (the only proven safe and effective approach) with close monitoring, rather than pharmacotherapy which lacks sufficient evidence for safety and efficacy in pregnancy. 1, 2