Smoking

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in the second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

key message

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 of Sudden Infant Death Syndrome is greater in babies whose mothers smoked during pregnancy.

The more you smoke the greater the risk to your health and your baby’s health. Not smoking at all while you are pregnant is best for your health and your baby’s health. If you are pregnant, stop smoking if you can. If you can’t quit, consider smoking fewer cigarettes to reduce the harm to you and your baby.


key message

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).


key message

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.


key message

E-cigarettes have not been tested for use during pregnancy.

E-cigarettes may cause health problems and have not been tested for safety during pregnancy.


key message

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 Sudden Infant Death Syndrome (SIDS). 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.

Remember that the Smoke-Free Ontario Act makes it illegal to smoke with a baby or child in your car.


key message

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’s 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.


key message

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.

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Supporting Evidence



The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Smoking during the Perinatal Period

Defining smoking

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.

National and provincial statistics

According to the Canadian Tobacco Use Monitoring Survey (CTUMS), the latest National survey, published in 2012, 22.8 percent of Canadian women age 20 – 24 years and 4.8 percent of women age 25 – 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 – 2011 Ontario’s Better Outcome Registry and Network (BORN) showed the percentage of Ontario mothers who reported smoking during pregnancy at 20 weeks’ gestation or later was 9.0 percent.3

Who is at Risk?

Factors

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 misuse.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 risk factor 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

Introduction

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’s 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 dose dependent. As such, there is no safe limit within which there are no health effects for a pregnant woman and her unborn child. In other words, it cannot be claimed that if someone smokes less than a certain number of cigarettes, there is no health risk. As such, it is strongly recommended that women do not smoke at all during pregnancy.4

Consequences for women’s health

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 folate, vitamin B6, and vitamin C.8 These nutrients are essential to the pregnant woman’s health as they strengthen her immune system. Vitamin concentrations are shown to increase again in just a few days after quitting smoking.13

Consequences for the pregnancy

Compared to women who do not smoke, women who smoke during pregnancy are more likely to experience the following complications:9, 14, 15, 16

  • Spontaneous abortion.
  • Ectopic pregnancy.
  • Placenta previa.
  • Placental abruption. 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.).
  • Intrauterine growth restriction (IUGR).
  • Infant morbidity (e.g., Neonatal Intensive Care Unit (NICU) admissions) and mortality.
  • Stillbirth.

Consequences for the child

The fetus is exposed to tobacco components (including nicotine and carbon monoxide) in utero via placental transport. 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 hemoglobin, reducing the blood’s capacity to carry oxygen. This in turn reduces the concentration of oxygen in fetal tissue (intrauterine hypoxia).
  • Nicotine causes vasoconstriction 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 vasoconstriction).

Babies of mothers who smoke during pregnancy are more likely to:

  • Have a low birth weight (weigh less than 5.5 lb or 2.5 kg at birth).17 A woman who gives birth to a baby with low birth weight 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 – 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 Sudden Infant Death Syndrome. Smoking while pregnant (as well as exposure to second-hand smoke) is among the main known risk factors of Sudden Infant Death Syndrome.14, 15

Smoking during pregnancy can also affect the child’s 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’s 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

Introduction

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.

Potential health consequences

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

  • Miscarriage.
  • Intrauterine growth restriction.
  • 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

  • Low birth weight.
  • A higher risk of Sudden Infant Death Syndrome (SIDS). Exposure to second-hand smoke is one of the main known risk factors of SIDS.
  • Asthma.
  • Ear infections.
  • Upper and lower respiratory infections such as pneumonia and bronchitis.

Reducing exposure to second-hand smoke

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

Introduction

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’s 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’s 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

Harm reduction

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.

Quitting

When people quit smoking they usually experience withdrawal symptoms. 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 withdrawal are not pleasant, they are part of the quitting process and should not be a concern. Therefore, pregnant women can be reassured that quitting smoking at any point during pregnancy will not cause any harm to the pregnancy or fetus.10

Table 1: The table below lists the primary withdrawal symptoms, how long they last, and ways to get over them.32,33

Issue Duration Actions women can take
Strong desire to smoke Approximately two weeks
  • Remember that a strong desire to smoke lasts about two to three minutes.
  • React quickly. Think of something else, do something enjoyable, get away from the situation causing the strong desire, take a walk, etc.
Irritability /aggressiveness Approximately four weeks
  • Remember that it is normal to feel this way. Do enjoyable activities. As often as possible, try to do things that lead to laughter.
Fatigue Two to four weeks
  • Sleep enough to recover. Move, eat well, and drink lots of water.
Insomnia Up to three weeks
  • Avoid eating or drinking stimulants (coffee, soda, tea, chocolate, energy drinks).
  • Take a walk outside after a meal.
  • Read a book.
  • Take a bath.
  • Drink a glass of milk.
Cough Three to four weeks
  • Drink a lot of water to help expectorate the mucous.
  • Do physical activity or simple breathing exercises.
Constipation Three to four weeks
  • Drink water; eat fruits, raw vegetables, and whole grains. Do physical activity.
Increased appetite A few weeks
  • Differentiate between hunger and simply the desire to move and hold something in the mouth. If there is the desire to move and hold something in the mouth, snack often on fruits and vegetables but in small quantities.
Dizziness One to two days
  • Do slow but deep breathing exercises (such as yawning), and stretch.


Pharmacological aids

Pharmacological aids can help to mitigate withdrawal 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 their withdrawal symptoms while quitting smoking.10

NRTs contain lower amounts of nicotine than a cigarette and do not create dependence. Moreover, they do not contain any of the substances in tobacco smoke.34
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’s ability to refrain from smoking by mitigating the symptoms of withdrawal and reducing nicotine cravings. It acts on the central nervous system’s neurotransmitters, 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 withdrawal 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

E-cigarettes


Electronic cigarettes (e-cigarettes) are battery-powered devices that vaporize the liquid (e-liquid) contents of a cartridge. Companies produce e-liquids with and without nicotine in many different flavours. Propylene glycol is one of the main ingredients found in e-liquids. Propylene glycol is a known irritant when inhaled.

Although e-cigarettes containing nicotine are illegal in Canada, they are sold on the internet and in many e-cigarette specialty stores.

Health Canada warns people not to buy or use e-cigarettes as they may cause health risks. E-cigarettes have not been fully tested for safety.36,37 Ontario created the Electronic Cigarettes Act in 2015 in response to the lack of federal regulation.


Quit-smoking supports available for pregnant or breastfeeding woman

Table 2: The table below lists the different options available to women who are pregnant or breastfeeding to help them quit smoking.34,38,39

Recommendations Comments
First choice Psychosocial interventions to stop smoking without drug therapy. Behavioural therapy and patient education should be recommended as first-line therapy for smoking cessation.39
Second choice For pregnant women who are not able to quit smoking with support and counselling alone NRT may be considered. A prescription is not necessary to purchase NRT, however, it is advised that pregnant women discuss the use of NRT with their health care provider.39
A patch or gum can also be used while breastfeeding.
Since NRTs already supply a certain amount of nicotine to the body, women who use it are advised to:

  • Refrain from smoking cigarettes since they would then be consuming a higher dose of nicotine.
  • Use intermittent dosing NRT (e.g., Nicotine gum) preferably over continuous dosing products (nicotine patch).
  • Remove the nicotine patch at night (16-hour application).39
  • Continue discussion and updates on women’s use of NRT with health care providers.39

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 teratogenic potential among pregnant or breastfeeding women.34,38,39

Professionals may consult Motherisk for additional information on pharmacological aids while pregnant or breastfeeding.

Relapsing

It is estimated that up to 50 percent to 70 percent of mothers who quit smoking while pregnant start smoking again after the baby’s 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’s 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

Social environment

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

Recommendations

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’s exposure to tobacco residue, in addition to the strategies mentioned above, the following precautions are suggested:

  • Don’t smoke while feeding.
  • Smoke after feeding and, ideally, wait two hours before the next feeding to allow your body to expel the tobacco metabolites 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.

Referrals

When to refer

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.

Where to refer

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.

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Resources & Links



Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practise guideline.

Professional Guidelines

Websites: Smoking Cessation Resources for Women and Families

Websites: Smoking Cessation Resources for Professionals

Helplines

  • Motherisk Helpline
    1-877-439-2744 (Toll-free)
    416-813-6780 (Toronto and GTA)

    Alcohol and Substance Use Helpline
    1-877-327-4636

  • Smokers’ Helpline (Canadian Cancer Society) 1-877-513-5333

Prenatal Education Provider Tools

Client Resources and Handouts

Videos

Apps

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Appendix

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.

The table below gives one example of a brief intervention, taken from the scientific literature and clinical practise. These steps are a suggested route; at all times, the professional's clinical judgment is key to assessing a pregnant woman's needs, and to adjusting the intervention.

Steps in individual intervention Ideal strategies and information to convey
  • Inquire as to the status of smoking.
  • Use proposed scenarios instead of closed yes/no questions.
  • Congratulate women who do not smoke or have stopped smoking.
  • Acknowledge and affirm efforts, as it is hard to quit smoking.
  • Motivate pregnant women to make the decision to quit smoking as quickly as possible.
Discuss:

  • The effects of tobacco on the health of the mother and of the fetus as well as the complications that could arise during pregnancy.
  • The benefits of quitting smoking, while not excluding the potential disadvantages.
  • That it is ideal to stop smoking at the start or early on in the pregnancy. Quitting smoking, regardless at what point, is always beneficial.
  • Discuss strategies that can help women stop smoking.
  • Establish the steps required to take action: list the needs that cigarettes fulfill, identify the situations associated with the act of smoking, develop strategies to deal with these situations, and set a time to quit.
  • Help the woman to identify the rituals and automatic behaviours related to cigarettes, and to change her habits to resist the urge to smoke.
  • Make the woman aware of the importance of support from her social network and from her partner.
  • Support the efforts of pregnant women who are quitting smoking throughout the pregnancy and postpartum period.
  • Discuss the advantages of quitting smoking.
  • Discuss the disadvantages associated with withdrawal.
  • Make women aware of the increased risk of starting to smoke again after the baby’s birth, particularly between the 6th and 12th week.
  • Value efforts and progress made.

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References

  1. 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
  2. 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
  3. 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
  4. 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.
  5. 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
  6. 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
  7. 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.
  8. 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
  9. Cnattingius, S. (2004). The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine & Tobacco Research, 6(Suppl 2), S125-S140. Retrieved from http://ntr.oxfordjournals.org/
  10. 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
  11. 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
  12. Best Start Resource Centre. Addressing Smoking with Women and their Families. (2015). Toronto, ON: Author.
  13. Ulvik, A., Ebbing, M., Hustad, S., Midttun, Ø., Nygård, O., Vollset, S. E., … 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
  14. 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
  15. U.S. Department of Health and Human Services. (2014). The health consequences of smoking – 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
  16. Al‐Sahab, B., Saqib, M., Hauser, G., & Tamim, H. (2010). Prevalence 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
  17. 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
  18. Matsuo, H. (2005, April ). The health consequences of low birth weight: Literature review and critique (Working Document No. 23). Louvain-la-Neuve, Belgium: Université Catholique de Louvain, Département des sciences de la population et du développement (SPED). Retrieved from http://www.uclouvain.be/6913.html
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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood