Tobacco use in any form during pregnancy presents a significant risk to the pregnancy, pregnant patient, and developing fetus while also remaining a significant cause of morbidity and mortality compared with pregnant nonsmokers.1–4 A proactive approach to screening (preferably before pregnancy) for tobacco use with persistent pregnancy-specific and evidence-based management and strategic follow-up promotes tobacco cessation and builds on any baseline motivation to quit.4 This approach can be used to screen for alcohol and other substance use, which also can have profound effects on pregnancy outcomes.
THE PROBLEM NOT OFTEN ADMITTED
Despite the reported decline of tobacco use during pregnancy in the United States in recent years, 4.6% of pregnant women smoke during pregnancy.1 Electronic vapor products such as electronic cigarettes (e-cigarettes) are not safe to use during pregnancy, but 1.4% of pregnant patients report using them.2 Furthermore, recent data showed that 14% of pregnant patients enrolled in Medicaid smoke during pregnancy, which is more than 3 times higher than the rate in those enrolled in private insurance (3.6%), underscoring the need to decrease tobacco use before and during pregnancy.3
Impact on pregnancy, pregnant patient, and fetus
Tobacco use can impact both the developing fetus and pregnancy. Effects on the fetus include orofacial clefts, fetal growth restriction, low birth weight, and increased perinatal mortality.4 Pregnancy-related complications include placenta previa, abruptio placentae, preterm labor, premature rupture of membranes, ectopic pregnancy, and reduced maternal thyroid function. Pregnant smokers have a roughly 30% risk of perinatal death, and the summary relative risk increases with the number of cigarettes smoked per day.5
Pregnant smokers are more likely to experience deep vein thrombosis, pulmonary embolus, myocardial infarction, gastrointestinal ulcers, and asthma, and 3 times more likely to experience influenza or pneumonia.6 Furthermore, children born to those who smoke during pregnancy are at increased risk of respiratory infections, sudden infant death syndrome, asthma, infantile colic, bone fractures, and childhood obesity.4 Hence, clinicians should prioritize immunizations for pregnant patients, including influenza and COVID-19 vaccines.7
While pregnancy influences many women to stop smoking either before or during pregnancy, in a prospective questionnaire-based survey of 66 women, Kaur et al8 found that nearly 50% had difficulty stopping and continued smoking even though they wanted to quit.
NO SAFE TOBACCO OR NICOTINE PRODUCTS
Clinicians should be familiar with the many tobacco and nicotine products available, which include regular cigarettes, bidis (thin-rolled cigarettes), clove cigarettes (also called kreteks), hookahs, smokeless tobaccos including dips and chews, pipes, cigars, and e-cigarettes (Table 1).9,10 There is no safe level of tobacco consumption, and all tobacco products (including lozenges, patches, and gum) contain nicotine and toxic chemicals detrimental to the health of the mother, fetus, and newborn.4
The amount of nicotine in tobacco products
EVALUATION AND SCREENING
The American College of Obstetricians and Gynecologists recommends that clinicians ask about tobacco use (along with secondhand smoking) before pregnancy, throughout pregnancy, and during postpartum periods, and advise patients regarding the significant perinatal risks and the importance of quitting tobacco or nicotine use in any form, including e-cigarettes and vaping.4
THE “5 A’S”
The American College of Obstetricians and Gynecologists further recommends that clinicians use a brief counseling session based on the “5 A’s” of smoking cessation.4 Clinicians should be proactive and directly ask patients about their tobacco use at each prenatal visit and assess their smoking history, including the number of pack-years smoked. Clinicians should subsequently use the 5 A’s tobacco and nicotine cessation strategy, which includes 5 tasks: Ask, Advise, Assess, Assist, and Arrange (Figure 1).4,11
ASK the patient about all types of tobacco and nicotine being used at every visit, choosing the statement that best describes their tobacco or nicotine use, thereby reducing underreporting from asking “yes” or “no” questions4:
I have never used tobacco or nicotine or have used minimal amounts of tobacco or nicotine in my lifetime (for example, fewer than 100 cigarettes in my lifetime).
I stopped using tobacco or nicotine before I found out I was pregnant, and I am not using tobacco or nicotine now.
I stopped using tobacco or nicotine after I found out I was pregnant, and I am not using tobacco or nicotine now.
I use some tobacco or nicotine now, but I have cut down on the amount of tobacco or nicotine I use since I found out I was pregnant.
I use tobacco or nicotine regularly now, about the same as before I found out I was pregnant.
ADVISE and reinforce the decision not to use tobacco for patients who never used tobacco, and congratulate patients who quit, reinforcing their decision to quit and stay tobacco-free during this pregnancy. We advise patients still using tobacco to quit in a clear, personalized, firm but nonjudgmental tone, incorporating information gleaned from the encounter.
ASSESS patients who are still using tobacco for willingness to quit.
ASSIST patients ready to quit with various evidence-based therapies and pregnancy-specific materials and programs.
ARRANGE follow-up visits to monitor progress, reassess and adjust therapies, and congratulate the patient and support any success along the journey.
The “5 R’s”
If the pregnant patient expresses an unwillingness to quit during the Assess task, we use a motivational intervention exploring the “5 R’s”12:
Encouraging the patient to state why quitting is personally relevant to them (Relevance)
Identifying potential negative consequences of their tobacco use (Risks)
Pointing out the potential benefits of quitting (Rewards)
Identifying any potential obstacles to their quitting (Roadblocks)
Repeating this intervention at each interaction with the unmotivated patient (Repetition).
The clinician should individualize these 5 R’s at every encounter.
COUNSELING
Studies have shown that motivational interviewing helps the patient explore their ambivalence about quitting, thereby fostering self-responsibility by identifying their reason to quit. Along with cognitive behavioral therapy, motivational interviewing helps pregnant patients to feel they are equipped with tools to manage their emotions and thoughts and any stressful situations that readily trigger the urge to smoke or use other tobacco products.4
Providing patients with self-help materials and access to support groups increases quit rates.13 Smoking cessation is increased with the use of pregnancy-specific tobacco and nicotine cessation materials such as self-help manuals and posters.4 Programs like “You Quit, Two Quit” (youquittwoquit.org) offer screening and cessation counseling targeting pregnant and postpartum women, while the Medicaid and Children’s Health Insurance Program offers videos that explain the adverse effects of smoking and tobacco use to pregnant patients (youtube.com/watch?v=VWY-y-2npS4).3,14,15
In one program, adding vouchers to routine care (which included nicotine replacement therapy for 10 weeks and 4 weekly support telephone calls) more than doubled tobacco cessation rates during pregnancy.16 Tobacco cessation vouchers are available through some health-insurance and state quit telephone lines. Use of state 1-800-QUIT-NOW lines with pregnancy-specific extensions should be encouraged.14
PHARMACOTHERAPY
Patients motivated to quit but unsuccessful with behavioral therapy alone might achieve success from the addition of pharmacologic treatment such as nicotine replacement therapies (eg, transdermal patch, gum, lozenges). The risks of nicotine replacement therapy for the fetus include possible neurobehavioral and neurodevelopmental complications, and shared decision-making and education about such therapies are critical in pregnant patients who want to quit using tobacco.17,18
Bupropion is an antidepressant that works by inhibiting the reuptake of norepinephrine and dopamine and stimulating their release; hence, it targets the brain reward and mood pathways that are heavily involved in nicotine addiction.4,16 By increasing neurotransmitter levels, it mimics the effect of nicotine and alleviates withdrawal symptoms. Bupropion may be a reasonable treatment option for pregnant patients with depression who require pharmacotherapy, especially those who are also attempting to quit tobacco use during pregnancy.4
Varenicline is a partial agonist of nicotine receptors with no US Food and Drug Administration pregnancy category.19 It has not shown teratogenicity in limited studies.4
CONCLUSION
A shared decision-making discussion with the pregnant patient about the risks and benefits of pharmacologic treatments used to help with quitting and the risks of continued tobacco or nicotine use is necessary, and treatment must be done under close supervision or referral to specialty care. Half of patients who quit smoking during pregnancy relapse; rescreening and continual support throughout the pregnancy and during the postpartum period are vital to reduce this relapse rate.4,20 Finally, smoking counseling should be a key component of routine postpartum care and prioritized during the transition from the obstetrician back to the primary care clinician.20
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.
REFERENCES
- 1↵Martin JA, Osterman MJK, Driscoll AK. Declines in cigarette smoking during pregnancy in the United States, 2016–2021. NCHS Data Brief 2023; 1(458):1–8. pmid:36723453
- 2↵Kapaya M, D’Angelo DV, Tong VT, et al. Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth—Oklahoma and Texas, 2015. MMWR Morb Mortal Wkly Rep 2019; 68(8):189–194. doi:10.15585/mmwr.mm6808a1
- 3↵Centers for Medicare & Medicaid Services. Call to action: tobacco use and cessation efforts among pregnant individuals enrolled in Medicaid and CHIP transcript. www.medicaid.gov/media/152511. Accessed August 15, 2025.
- 4↵Tobacco and nicotine cessation during pregnancy: ACOG Committee Opinion, Number 807. Obstet Gynecol 2020; 135(5):e221–e229. doi:10.1097/AOG.0000000000003822
- 5↵Pineles BL, Hsu S, Park E, Samet JM. Systematic review and meta-analyses of perinatal death and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol 2016; 184(2):87–97. doi:10.1093/aje/kwv301
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- 7↵US Centers for Disease Control and Prevention (CDC). Vaccine recommendations before, during, and after pregnancy. June 24, 2024. www.cdc.gov/vaccines-pregnancy/recommended-vaccines/index.html. Accessed August 15, 2025.
- 8↵Kaur S, Manhungira W, Sankar A, Sarkar R. Women’s perspectives on smoking during pregnancy and factors influencing their willingness to quit smoking in pregnancy: a study from the United Kingdom. Cureus 2023; 15(5):e38890. doi:10.7759/cureus.38890
- 9↵Tobacco Settlement Endowment Trust. Tobacco stops with me. How much nicotine is in tobacco products? October 24, 2023. stopswithme.com/how-much-nicotine-is-in-tobacco-products. Accessed August 15, 2025.
- 10↵Van Thomme G. What to know about nicotine pouches. The University of Texas MD Anderson Cancer Center. January 16, 2025. www.mdanderson.org/cancerwise/what-to-know-about-nicotine-pouches.h00-159773289.html. Accessed August 15, 2025.
- 11↵US Department of Health and Human Services Agency for Healthcare Research and Policy. Five major steps to intervention (The “5 A’s”). December 2012. www.ahrq.gov/prevention/guidelines/tobacco/5steps.html. Accessed August 15, 2025.
- 12↵Agency for Healthcare Research and Quality. Patients not ready to make a quit attempt now (The “5 R’s”). December 2012. www.ahrq.gov/prevention/guidelines/tobacco/5rs.html. Accessed August 15, 2025.
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- 15↵National Institute on Drug Abuse. Tobacco, nicotine, and e-cigarettes research report: what are treatments for tobacco dependence? January 2020. nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-are-treatments-tobacco-dependence. Accessed August 15, 2025.
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