Quitting smoking is a healthy choice for you and your baby.
Stopping smoking before pregnancy, or as early as possible in pregnancy, will help you and your baby.
Smoking is harmful to pregnant women and their babies. Smoking can cause complications during pregnancy. It can cause babies to be born too soon or too small. When babies are born too soon or too small, they are more likely to have serious health problems. The risk ofis greater in babies whose mothers smoked during pregnancy.
The more you smoke the greater the risk to your health and your baby‚Äôs health. Not smoking at all while you are pregnant is best for your health and your baby‚Äôs health. If you are pregnant, stop smoking if you can. If you can‚Äôt quit, consider smoking fewer cigarettes to reduce the harm to you and your baby.
Help is available if you want to quit smoking or cut down.
Quitting smoking is a healthy choice for you and your baby. It is helpful to have support when trying to quit smoking. Ask for help from family or friends. Invite them to quit with you if they smoke. If you have trouble quitting, or feel the urge to smoke again after you have quit, talk to your health care provider. There are services for women, and their families, who want to stop smoking (see the section Learn more about where to get help).
Talk to your health care provider before using nicotine replacement therapy (NRT) products.
Many products, such as lozenges, gum, inhalers, and patches contain nicotine that may help you quit smoking. Start by trying to quit smoking without nicotine products. There are groups, telephone helplines, online supports, and one-on-one services for pregnant women to help you quit smoking. If these do not work for you, your health care provider can help decide if nicotine replacement therapy is right for you.
E-cigarettes have not been tested for use during pregnancy.
E-cigarettes may cause health problems and have not been tested for during pregnancy.
Provide a smoke-free home for you and your baby.
Second-hand smoke is the smoke you breathe if you or someone else is smoking. Third-hand smoke is made up of the chemicals that remain on clothing, skin, carpets, furniture, and other items that are exposed to smoke.
Second-hand and third-hand smoke are harmful, especially for pregnant women and young children. Smoke-free spaces are the healthy choice for pregnant women, parents, babies, and children. A smoke-free home and car can decrease the risk of your baby dying from ( ). Your baby will be less likely to have ear infections and breathing problems (such as bronchitis or asthma) if you avoid second-hand smoke.
Here are some ways to lower the amount of second-hand and third-hand smoke for you and your baby:
- Make a rule that smoking is not allowed in your home or car.
- Ask people not to smoke around pregnant women, babies, and children.
- Keep doors and windows closed when someone is smoking outside.
- Ask people who smoke to wash their hands before holding your baby.
- Ask people who smoke to change their outer clothing after smoking.
Breastfeed your baby even if you smoke.
Breastfeeding is the best way to feed your baby, even if you smoke. The benefits of breastfeeding outweigh the harmful effects of tobacco on the baby‚Äôs health. Breastfeeding can also be relaxing for you.
One of the most important things you can do is breastfeed your baby. To protect your baby you can also:
- Have a smoke-free home and a smoke-free car.
- Cut down on the number of cigarettes that you smoke.
- Change your outer clothing before breastfeeding if you have smoked.
- Wash your hands before breastfeeding if you have smoked.
Learn more about where to get help.
You can find out more about smoking and how to quit from the following resources. More suggestions can be found in the Resources and Links section.
About Smoking during the Perinatal Period
Smoking during the perinatal period refers to the use of tobacco products during pregnancy and in the postpartum period. This document also deals with exposure to second-hand and third-hand smoke in this same period.
According to the Canadian Tobacco Use Monitoring Survey (CTUMS), the latest National survey, published in 2012, 22.8 percent of Canadian women age 20 ‚Äď 24 years and 4.8 percent of women age 25 ‚Äď 44 years reported smoking during their most-recent pregnancy.1
Of interest, data from the Canadian Maternity Experiences Survey (2009) reported that the proportion of women smoking daily or occasionally before pregnancy was 22.0 percent and during the last three months of pregnancy, it had reduced to 10.5 percent.2
Specific to Ontario, data from the 2010 ‚Äď 2011 Ontario‚Äôs Better Outcome Registry and Network (BORN) showed the percentage of Ontario mothers who reported smoking during pregnancy at 20 weeks‚Äô gestation or later was 9.0 percent.3
Who is at Risk?
There are many factors that influence smoking during pregnancy:
- Lower socioeconomic status and lower education level are associated with smoking during pregnancy.4
- Concurrent mental health issues, family violence, or past trauma.4
- Polysubstance .5
- Young women smoke more than older women during pregnancy, especially those 25 years of age or younger.6
- Having a partner who smokes is a significant for smoking during pregnancy and relapse to smoking postpartum.7
- Women are less likely to smoke during their first pregnancy than during subsequent pregnancies.8
Potential Health Consequences
Many future parents are unfamiliar with the effects of smoking, by either partner, on the health of the mother and child.9 Women and partners may know that smoking is harmful to their health and that of the fetus, but they do not always know the specific health consequences of smoking and how they occur. It is important for service providers to use a woman-centered approach by discussing risks of smoking on the woman‚Äôs health and then reviewing risks to the pregnancy, fetus, and newborn.4, 10
A women-centred approach to smoking cessation is best practise as it de-emphasizes the focus on cessation for pregnancy reasons.4 Women are thus motivated to quit for their own health and not only that of their child.11
The health consequences of smoking are
Women who smoke are susceptible to menstrual problems, difficulty with fertility, early menopause, and are at higher risk of developing cancers, depression, cardiovascular issues, rheumatoid arthritis, osteoporosis, and other health complications.12
In addition, smoking while pregnant reduces the amount of certain vitamins in the body, notably the plasma concentrations of
Compared to women who do not smoke, women who smoke during pregnancy are more likely to experience the following complications:9, 14, 15, 16
- . This risk increases in proportion to the number of cigarettes smoked.
- Prematurely ruptured membranes before the end of the pregnancy. The risk increases threefold before the 34th week of gestation.
- Deliver prematurely. Preterm birth is linked to other potential complications (e.g., difficulty with breathing, feeding, etc.).
- ( ).
- Infant morbidity (e.g., Neonatal Intensive Care Unit (NICU) admissions) and mortality.
The fetus is exposed to tobacco components (including nicotine and carbon monoxide) in utero via. This can occur through direct inhalation (when the pregnant woman smokes) or indirectly (when she is exposed to second-hand smoke).10,15
There are different explanations that demonstrate how smoking may harm the fetus:10, 15
- Carbon monoxide attaches to , reducing the blood‚Äôs capacity to carry oxygen. This in turn reduces the concentration of oxygen in fetal tissue (intrauterine ).
- Nicotine causes of the blood vessels of the uterus and placenta, reducing circulation of blood to the placenta and decreasing the amount of oxygen and nutrients that get to the fetus (arterial ).
Babies of mothers who smoke during pregnancy are more likely to:
- Have a (weigh less than 5.5 lb or 2.5 kg at birth).17 A woman who gives birth to a baby with is more likely to experience complications during delivery and the baby may be at risk of health and developmental problems.18 The babies of mothers who smoke weigh on average 200 ‚Äď 250 grams less than the babies of mothers who do not smoke.17
- Have a birth defect (e.g., cleft lip, cleft palate) and damage to lung and brain tissue.15
- Have a higher risk of . Smoking while pregnant (as well as exposure to second-hand smoke) is among the main known risk factors of .14, 15
Smoking during pregnancy can also affect the child‚Äôs behaviour in the long term. There is some evidence to suggest that children whose mothers smoked during pregnancy may be more likely to have learning difficulties and behavioural disorders.19,20,21
Smoking during pregnancy can also impact children‚Äôs health. Children may be more likely to:15, 22
- Suffer from more respiratory illnesses (e.g., asthma, pneumonia, bronchitis).
- Have childhood medical problems (e.g., ear infections).
- Experience childhood allergies.
Exposure to Second-hand and Third-hand Smoke
Second-hand smoke is a complex product of 7,000 chemical compounds that are released when a cigarette burns. At least 70 of the chemicals found in second-hand smoke are known to cause cancer.14
Tobacco smoke can be found in the home in dust and on contaminated surfaces, even if cigarettes have been smoked days or weeks before. When smoked outside, cigarette smoke can also enter the home through clothing, skin, and dust.24
This type of tobacco smoke residue is known as third-hand smoke. It is thought to react with common indoor pollutants to create a toxic mix containing cancer-causing substances. Third-hand smoke clings to furniture, drapes, bedding, carpets, dust, and other surfaces. Children are at high risk of exposure to third-hand smoke when they inhale, ingest, or touch surfaces or substances containing third-hand smoke.23
It has been documented that:25
- Cigarette smoke travels from one room to another, even if the door is closed.
- Opening a window in a room or in the car is not enough to get rid of the smoke. In fact, it can generate a return air current and bring the smoke back in.
- Ventilation systems (e.g., kitchen or bathroom fan) are not enough to get rid of cigarette smoke. They are designed to limit the accumulation of carbon monoxide and reduce the smell of smoke.
- Smoking in a confined space (e.g., the car) increases the concentration of harmful chemical substances produced by cigarette smoke.
Consequences for the woman
For the woman, as for the rest of the population, cigarette smoke in the environment increases the risk of:26
- Respiratory problems.
- Asthma attacks.
- Coronary problems.
- Lung cancer.
- Breast cancer.
Consequences for the pregnancy
Pregnant women exposed to cigarette smoke during pregnancy have an increased risk of:26
- Preterm birth.
Consequences for the child
The effects of second-hand smoke are more harmful for young children than adults. In fact, since their lungs are growing and are smaller than those of an adult, they breathe more rapidly and, therefore, inhale more harmful chemicals.22,23
In the first years of life, children spend more time inside the home, are in contact with dust and objects contaminated by cigarette smoke (third-hand smoke), and have repeated physical contact with their parents and relatives who smoke. They put their hands and other objects in their mouths frequently.23,26
Compared to a child who lives in a smoke-free environment, a child exposed to cigarette smoke is more likely to have:26
- A higher risk of ( ). Exposure to second-hand smoke is one of the main known risk factors of .
- Ear infections.
- Upper and lower respiratory infections such as pneumonia and bronchitis.
For the health of the woman planning pregnancy, the pregnant woman, and the unborn child, it is strongly recommended that the woman not be exposed to second-hand smoke. To reduce exposure to second-hand smoke, it is beneficial to not allow smoking in the house and car.27
House rules could include:28
- No cigarettes or tobacco products may be smoked in the home or car, either by the occupants or visitors.
- The smoking area is located far from the house.
- The doors and windows of the house and/or car are closed when someone is smoking outside.
In addition to creating a more pleasant living environment, prohibiting smoking has beneficial effects on behaviour towards smoking. A review of the studies published in 2010 showed that a full ban on smoking in the house has the greatest benefits, as compared to a partial ban.27 Adults who smoke will smoke fewer cigarettes per day and will feel a greater desire to quit smoking.29
Changing Tobacco Use: What You Need to Know
Quitting smoking is a personal challenge for each woman. For many, pregnancy is an opportunity to quit30,31 primarily because of the possible harm caused to the baby‚Äôs health. It is important to consider smoking as an addiction that needs to be treated as such not only during the pregnancy and not only for the health of the unborn baby.4.10
A pregnant woman who wants to stop smoking should do so first and foremost for herself, which will also have an effect on her baby‚Äôs health. Note that the motivation to quit smoking can change during pregnancy.10 For example, the motivation to quit can become stronger when the woman feels the fetus moving.
For other women, the process of giving up smoking can be more difficult due to unstable socioeconomic conditions or because smoking is not their only health concern during pregnancy.10
While quitting as early as possible in pregnancy is best for the health of both the pregnant woman and the fetus, it is important to recognize that there are various stages of readiness to quit. Not all women will be able to or even want to completely stop smoking during their pregnancy.4 Some women will aim for or achieve a reduction in the number of cigarettes smoked per day.
Harm reduction can mean brief periods of cessation during the pregnancy and the last month before delivery while continuing to follow other health promoting behaviour such as exercise and improved nutrition.4
Harm reduction messages should be used with caution in pregnancy.
When people quit smoking they usually experiencesymptoms. The nicotine in cigarettes causes a physical and psychological addiction, and when the body is no longer getting any nicotine, it displays symptoms or signs indicating a reduction in blood nicotine concentrations.10
Even though the symptoms of
Pharmacological aids can help to mitigate symptoms and cravings when quitting smoking.10 They are divided into two categories of drugs: 1) nicotine replacement therapies and 2) Bupropion HCL and varenicline tartrate.
Nicotine replacement therapies
Nicotine replacement therapies (NRT) are pharmacological products that release sufficient nicotine into the blood to allow people who smoke to control theirsymptoms while quitting smoking.10
NRTs contain lower amounts of nicotine than a cigarette and do not create
However, recent research has demonstrated that nicotine replacement therapy in pregnancy may not be effective nor significantly increase smoking cessation rates.12
NRTs include the following products:
- Nicotine skin patches (nicotine patches that can be affixed to the skin and that release nicotine through the skin).
- Nicotine gum.
- Nicotine lozenges.
- Nicotine inhaler (which looks like a plastic cigarette through which nicotine is absorbed in the mouth and throat).
- Nicotine spray.
Bupropion HCL and varenicline tartrate (prescription drugs)
Bupropion HCL (sold under the name Zyban¬©) is a drug initially designed to treat depression. It does not contain any nicotine and increases people‚Äôs ability to refrain from smoking by mitigating the symptoms ofand reducing nicotine cravings. It acts on the central nervous system‚Äôs , but its more specific mechanism of action is not fully understood.35
Varenicline tartrate (sold under the name of Champix¬©) acts in two ways:
- It acts like nicotine, which helps to relieve the symptoms of and reduce cravings.
- It acts against nicotine by blocking the receptor in the brain that responds to nicotine thereby reducing the pleasurable effects of smoking.35
Bupropion is not prohibited for use by pregnant women; there is no evidence of harm to the fetus. The use of bupropion should be based on an assessment of potential risk and benefits while consulting with a health care provider.34,38,39
Varenicline is not recommended while pregnant or breastfeeding as there is insufficient data about the efficacy and potential among pregnant or breastfeeding women.34,38,39
Professionals may consult Motherisk for additional information on pharmacological aids while pregnant or breastfeeding.
It is estimated that up to 50 percent to 70 percent of mothers who quit smoking while pregnant start smoking again after the baby‚Äôs birth.4,40 Some factors predispose mothers to relapse, such as having a partner who smokes, a lack of social support, and difficulties after the baby‚Äôs birth (such as stress, postpartum depression, or even weight gain).4,40
Relapse is common. The majority of people who try to quit smoking will relapse three to four times before quitting for life.
To minimize the risk of relapse, a woman can implement strategies if she finds herself stressed or craving a smoke. These strategies include:
- Seeking support from a family member.
- Finding ways to relax or make the craving pass.
- Engaging in physical activity.
- Speaking with their health care provider about developing a quit strategy and the possible use of pharmacological aids.
- Seeking help from several resources available in Ontario by contacting local public health departments to locate stop-smoking groups in their community.
Women who smoke are at higher risk for prematurely weaning their infants. Support during pregnancy and after birth in the early postpartum weeks may help women continue to breastfeed. 42
When a woman quits smoking there may be unanticipated consequences such as isolation from her social network. As well, negotiations involved in establishing a smoke-free environment may create conflict for a couple or with their friends and family.41
It must not be presumed that all women are able to discuss their tobacco use with their partner (or that it is possible for them to do so) without risking conflict.41
For some couples, shared cigarettes are moments of intimacy and are a part of the daily routine. For more information, see Addressing Smoking with Women and Their Families in the Resources and Links section.
Smoking and Breastfeeding
Breastfeeding is the optimal feeding method for all newborns, even if the mother smokes. Although tobacco residue passes into breastmilk, the protective benefits of long-term breastfeeding outweigh the harmful effects of smoking.43,44,45,46
To help reduce a newborn‚Äôs exposure to tobacco residue, in addition to the strategies mentioned above, the following precautions are suggested:
- Don‚Äôt smoke while feeding.
- Smoke after feeding and, ideally, wait two hours before the next feeding to allow your body to expel the tobacco in breastmilk. If the baby shows signs of hunger before two hours are up, the mother is encouraged to feed rather than make the baby wait.
Prenatal education providers are in an excellent position to promote smoking cessation. Any woman who wishes to stop smoking or expresses disappointment at previous attempts to quit can be referred to the services mentioned below.
Because of the high rate of relapse after birth for women who do quit smoking and the association with smoking and premature weaning, discuss the need for ongoing support after the baby is born.
Ontario has a network of resources to support people in their attempts to quit smoking. These services include a counselling helpline and various resources. For individual and/or group support, please check with your local public health unit for more information.
Professionals are encouraged to refer pregnant women who want to quit smoking to specialized resources, where they may be offered an assessment and appropriate followup.
To learn about various smoking cessation resources for both clients and professionals, professionals are encouraged to consult the Resources and Links section where they will find additional reading, as well as the Appendix, which outlines an approach for treating a pregnant woman.
Resources & Links
- Society of Obstetricians and Gynaecologists of Canada (SOGC)
- World Health Organization (WHO)
Websites: Smoking Cessation Resources for Women and Families
Websites: Smoking Cessation Resources for Professionals
- Action on Women‚Äôs Addictions ‚Äď Research & Education
- Registered Nurses’ Association of Ontario (RNAO)
Prenatal Education Provider Tools
- Best Start Resource Centre (BSRC)
- CAN-ADAPPT Canadian Smoking Cessation Guideline
Client Resources and Handouts
- Best Start Resource Centre (BSRC)
- Canadian Cancer Society
- Centers for Disease Control and Prevention (CDC)
- Families Controlling & Eliminating Tobacco (FACET)
- Health Canada
- The Lung Association
- Registered Nurses’ Association of Ontario (RNAO)
- Best Start Resource Centre (BSRC)
Brief individual smoking cessation intervention.
There are several approaches to helping individuals who would like to quit smoking. Proposed interventions can be viewed in the suggested readings in the Resources and Links section.
- Canadian Tobacco Use Monitoring Survey (CTUMS). (2012). Retrieved from¬†www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2012/ann_summary-sommaire-eng.php
- Public Health Agency of Canada, Canadian Maternity Experiences Survey, (2009). Retrieved from www.phac-aspc.gc.ca/rhs-ssg/survey-enquete/mes-eem-1-eng.php
- BORN Ontario. (2013). 2011-2012 BORN: Better Outcomes Registry & Network program report. Ottawa, ON: Author. Retrieved from www.bornontario.ca/assets/documents/BORN%202011-2012%20Program%20Report.pdf
- Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S., & Aboussafy, D. (2003). Expecting to quit: A best practices review of smoking cessation interventions for pregnant and post-partum girls and women. Vancouver: British Columbia Centre of Excellence for Women’s Health.
- Massey, S. H., Lieberman, D. Z., Reiss, D., Leve, L. D., Shaw, D. S., & Niederhiser, J. M. (2010). Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy. The American Journal on Addictions, 20(2), 143-150. doi: 10.1111/j.1521-0391.2010.00110.x
- Millar, W. J., & Hill, G. (2004, July). Pregnancy and smoking. Health Reports, 15(4), 53-56. Retrieved from http://www.statcan.gc.ca/pub/82-003-x/2003004/article/6981-eng.pdf
- Penn, G., & Owen, L. (2002). Factors associated with continued smoking during pregnancy: Analysis of sociodemographic, pregnancy and smoking related factors. Drug and Alcohol Review, 21(1), 17-25.
- Klesges, L. M., Johnson, K. C., Ward, K. D., & Barnard, M. (2001). Smoking cessation in pregnant women. Obstetrics and Gyneocological Clinics of North America, 28(2), 269-282. DOI: 10.1016/S0889-8545(05)70200-X
- Cnattingius, S. (2004). The epidemiology of smoking during pregnancy: smoking , maternal characteristics, and pregnancy outcomes. Nicotine & Tobacco Research, 6(Suppl 2), S125-S140. Retrieved from http://ntr.oxfordjournals.org/
- CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Pregnant and Breastfeeding Women. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health, 2011. www.nicotinedependenceclinic.com/English/CANADAPTT/Pages/Home.aspx
- Chamberlain et al. (2013). Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Review Issue 10. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24154953
- Best Start Resource Centre. Addressing Smoking with Women and their Families. (2015). Toronto, ON: Author.
- Ulvik, A., Ebbing, M., Hustad, S., Midttun, √ė., Nyg√•rd, O., Vollset, S. E., ‚Ä¶ Ueland, P. M. (2010). Long-and short-term effects of tobacco smoking on circulating concentrations of B vitamins. Clinical Chemistry, 56(5), 755. doi: 10.1373/clinchem.2009.137513
- S. Department of Health and Human Services. (2010). How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. Retrieved from http://www.cdc.gov/tobacco/data_statistics/sgr/2010/index.htm
- U.S. Department of Health and Human Services. (2014). The health consequences of smoking ‚Äď 50 years of progress: A report of the Surgeon General. Atlanta, GA: U.S. 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. Retrieved from http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf
- Al‚ÄźSahab, B., Saqib, M., Hauser, G., & Tamim, H. (2010). of smoking during pregnancy and associated risk factors among Canadian women: A national survey. BMC Pregnancy and Childbirth, 10(24), doi:10.1186/1471-2393-10-24
- Centers for Disease Control and Prevention, Department of Health and Human Services. (2007, July). Preventing smoking and exposure to second-hand smoke before, during, and after pregnancy. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/nccdphp/publications/factsheets/prevention/pdf/smoking.pdf
- Matsuo, H. (2005, April ). The health consequences of http://www.uclouvain.be/6913.html : Literature review and critique (Working Document No. 23). Louvain-la-Neuve, Belgium: Universit√© Catholique de Louvain, D√©partement des sciences de la population et du d√©veloppement (SPED). Retrieved from
- Braun, J. M., Kahn, R. S., Froehlich, T., Auinger, P., & Lanphear, B. P. (2006). Exposures to environmental toxicants and attention deficit hyperactivity disorder in US children. Environmental Health Perspectives, 114(12), 1904-1909. Retrieved from http://ehp.niehs.nih.gov/
- Indredavik, M. S., Brubakk, A., Romundstad, P., & Vik, T. (2007). Prenatal smoking exposure and psychiatric symptoms in adolescence. Acta Paediatrica, 96, 377-382. DOI: 10.1111/j.1651-2227.2006.00148.x
- Pickett, K. E., Wood, C., Adamson, J., D‚ÄôSouza, L., & Wakschlag, L. S. (2008). Meaningful differences in maternal smoking behaviour during pregnancy: Implications for infant behavioural vulnerability. Journal of Epidemiology and Community Health, 62(4), 318-324. doi: 10.1136/jech.2006.058768
- Best, D., The Committee on Environmental Health, The Committee on Native American Child Health, & The Committee on Adolescence. (2009). Technical report ‚Äď Second hand and prenatal tobacco smoke exposure. Pediatrics, 124(5), e1017-e1044. doi: 10.1542/peds.2009-2120
- Health Canada. (2015). Dangers of second-hand smoke. Retrieved from http://healthycanadians.gc.ca/healthy-living-vie-saine/tobacco-tabac/dangers-eng.php
- Matt, G. E., Quintana, P. J. E., Destaillats, H., Gundel, L. A., Sleiman, M., Singer, B. C., ‚Ä¶ Melbourne, F. H. (2011). Thirdhand tobacco smoke: Emerging evidence and arguments for a multidisciplinary research agenda. Environmental Health Perspectives, 119(9), 1218-1226. Retrieved from http://www.medscape.com/viewpublication/1084
- Singer, B. C., Guevarra, K. S., Hawley, E. L., & Nazaroff, W.W. (2002). Gas-phase organics in environmental tobacco smoke. 1. Effects of smoking rate, ventilation, and furnishing level on emission factors. Environmental Science & Technology, 36(5), 846-853
- US Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
- Emory, K., Saquib, N., Gilpin, E. A., & Pierce, J. P. (2010). The association between home smoking restrictions and youth smoking behaviour: A review. Tobacco Control, 19(6), 495-506. doi: 10.1136/tc.2010.035998
- Johansson, A. K., Hermansson, G., & Ludvigsson, J. (2004). How should parents protect their children from environmental tobacco-smoke exposure in the home? Pediatrics, 113, e291-e295. Retrieved from http://pediatrics.aappublications.org/
- Norman, G. J., Ribisl, K. M., Howard-Pitney, B., & Howard, K. A. (1999). Smoking bans in the home and car: Do those who really need them have them? Preventive Medicine, 29(6), 581-589. DOI:10.1006/pmed.1999.0574
- French, G. M., Groner, J. A., Wewers, M. E., & Ahijevych, K. (2007). Staying smoke free: An intervention to prevent post-partum relapse. Nicotine and Tobacco Research, 9(6), 663-670. doi: 10.1080/14622200701365277
- Reitzel, L. R., Vidrine, J. I., Li, Y., Mullen, P. D., Velasquez, M. M., Cinciripini, P. M., ‚Ä¶ Wetter, D. W. (2007). The influence of subjective social status on vulnerability to post-partum smoking among young pregnant women. American Journal of Public Health, 97(8), 1476-1482.doi: 10.2105/AJPH.2006.101295
- The Lung Association. (2014). Manage your symptoms. Retrieved from http://www.lung.ca/lung-health/smoking-and-tobacco/manage-your- -symptoms
- Canadian Cancer Society. (2014). http://www.cancer.ca/en/cancer-information/cancer-101/what-is-a-risk-factor/tobacco/-symptoms/?region=on symptoms. Retrieved from
- Ontario Medical Association. (2008, January). Rethinking stop-smoking medications: Treatment myths and medical realities. Retrieved from https://www.oma.org/Resources/Pages/PositionPapers.aspx
- Centre for Addiction and Mental Health. (2009). Other medications for smoking cessation. Retrieved from https://www.porticonetwork.ca/web/smoking-toolkit/treatment/other-medications-smoking-cessation
- Health Canada. (2009). Health Canada advises Canadians not to use electronic cigarettes. Retrieved from http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2009/13373a-eng.php?_ga=1.232584346.445389004.1414262660#media-medias
- Reed, J. L., Gervais, A. A., & Reid, R. D. (2013). Five things to know about‚Ä¶electronic cigarettes. Canadian Medical Association Journal. DOI:10.1503/cmaj.130806
- Cressman, A. M., Pupco, A., Kim, E., Koren, G., & Bozzo, P. (2012). Smoking cessation therapy during pregnancy. Canadian Family Physician, 58(5), 525-527. Retrieved from http://www.cfp.ca/
- Wong S, Ordean A, Kahan M, (2011).Society of Obstetricians and Gynaecologists of Canada. Substance use in pregnancy: no. 256, Int J Gynaecol Obstet 2011;114(2):190-202
- Mullen, P. D. (2004). How can more smoking suspension during pregnancy become lifelong abstinence? Lessons learned about predictors, interventions, and gaps in our accumulated knowledge. Nicotine & Tobacco Research, 6(S2), S217-S238. doi: 10.1080/14622200410001669150
- Bottorff, J. L., Kalaw, C., Johnson, J. L., Stewart, M., Greaves, L., & Carey, J. (2006). Couple dynamics during women’s tobacco reduction in pregnancy and post-partum. Nicotine & Tobacco Research, 8(4), 499-509. doi: 10.1080/14622200600789551
- Kendzor, DE, Businelle, MS, Costello, TJ, Castro, Y, Reitzel, LR, Vidrine, JI, Li, Y. Mullen, PD,Velasquez, MM Cinciripini, PM Cofta-Woerpel, LM & x Wetter, WD. (2010). Breast feeding is associated with postpartum smoking abstinence among women who quit smoking due to pregnancy. Nicotine & Tobacco Research, 12(10): 983‚Äď988
- Best Start Resource Centre. (2013). Breastfeeding matters: An important guide to breastfeeding for women and their families. Toronto, ON: Author. Retrieved from http://www.beststart.org/resources/breastfeeding/breastfeeding_matters_EN_LR.pdf
- Batstra L, Neeleman J, Hadders-Algra M. Can breast feeding modify the adverse effects of smoking during pregnancy on the child‚Äôs cognitive development? Journal of Epidemiology and Community Health 2003;57:403‚Äď4
- American Academy of Pediatrics. Policy statement: Breastfeeding and the use of human milk. Pediatrics 2005;15(2):496‚Äď506.
- CPS Position Statement 2012. The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding. CM Pound, SL Unger; Canadian Paediatric Society , Paediatric Child Health 2012;17(6):317-21