Smoking during pregnancy remains one of the most significant preventable causes of adverse maternal and infant health outcomes worldwide. It increases the risk of miscarriage, placental complications, preterm birth, low birth weight, stillbirth, and sudden infant death syndrome, while also contributing to long-term health consequences for both mother and child.
For healthcare professionals, the objective is clear: helping pregnant women stop smoking should remain the primary goal. Clinical guidelines across the world consistently recommend behavioural support and evidence-based smoking cessation interventions as the first-line approach.
Yet clinical practice also presents a difficult reality. Many women successfully stop smoking during pregnancy, but others continue to smoke despite repeated quit attempts, counselling, and support. This raises an important question for clinicians and policymakers alike: how should healthcare systems respond when complete smoking cessation is not immediately achievable?
Smoking Cessation Remains the Gold Standard
There is broad scientific consensus that quitting smoking completely provides the greatest health benefits during pregnancy. Every effort should therefore be made to support women in achieving complete abstinence from cigarettes through behavioural interventions, professional counselling, and, where clinically appropriate, evidence-based cessation therapies.
The World Health Organization (WHO) continues to recommend comprehensive behavioural support as the cornerstone of smoking cessation during pregnancy, while recognising that evidence for pharmacological interventions remains more limited in this population.
Similarly, the American College of Obstetricians and Gynecologists (ACOG) advises clinicians to encourage cessation of all tobacco and nicotine products during pregnancy while providing compassionate, individualised care that reflects each patient’s circumstances.
These recommendations remain fundamental to good clinical practice.
Recognising the Reality of Nicotine Dependence
Although quitting smoking is the desired outcome, nicotine dependence is a chronic and relapsing condition for many people. Pregnancy often provides a strong motivation to stop smoking, but motivation alone does not eliminate addiction.
Research consistently demonstrates that many smokers require multiple quit attempts before achieving long-term abstinence. Some women continue smoking throughout pregnancy despite understanding the risks and despite receiving professional support.
Ignoring this reality does little to improve public health outcomes.
Healthcare professionals, including midwives, obstetricians, general practitioners, and smoking cessation specialists, frequently find themselves supporting women who have been unable to quit despite repeated efforts.
For these patients, clinical conversations become considerably more complex than simply advising them to stop smoking.
Distinguishing Smoking From Nicotine
One of the most important scientific principles in tobacco harm reduction is the distinction between the health risks associated with combustible tobacco smoke and those associated with nicotine itself.
Nicotine is an addictive substance and is not without risk, particularly during pregnancy, where concerns remain regarding fetal development. However, the overwhelming burden of smoking-related disease arises primarily from exposure to the thousands of toxic chemicals generated through the combustion of tobacco.
This distinction is widely recognised within toxicological and tobacco research.
Understanding the difference does not mean nicotine products should be considered safe during pregnancy. Rather, it provides important context when clinicians discuss relative risks with women who continue to smoke despite repeated cessation efforts.
Where Harm Reduction Fits
Tobacco harm reduction remains one of the more debated areas of contemporary public health policy, particularly in pregnancy.
Current evidence supporting smoke-free nicotine products, including nicotine pouches and electronic cigarettes, during pregnancy remains limited. Existing studies are insufficient to conclude that these products are safe for pregnant women or developing fetuses.
At the same time, some researchers argue that for women who are unable or unwilling to stop using nicotine completely, reducing exposure to the toxic products of combustion may warrant careful clinical consideration on an individual basis.
This is not a recommendation to initiate nicotine use during pregnancy, nor is it an endorsement of nicotine products as risk-free alternatives.
Instead, it reflects an evidence-based acknowledgement that some women continue smoking despite repeated interventions and that clinical decision-making should consider the relative risks of continued cigarette smoking alongside the available evidence.
Why Midwives Matter
Midwives are among the healthcare professionals most consistently involved in supporting women throughout pregnancy. Their role extends beyond providing clinical care, they also help women navigate difficult health decisions, address misconceptions, and access appropriate cessation support.
Evidence suggests that women are more likely to engage in smoking cessation when healthcare professionals provide non-judgmental, evidence-based advice rather than relying solely on fear-based messaging.
Open conversations allow clinicians to understand individual barriers to quitting, provide appropriate behavioural interventions, and tailor support according to each patient’s needs.
Maintaining trust is particularly important for women who have struggled repeatedly with smoking cessation.
Evidence Continues to Evolve
Research into smoke-free nicotine products continues to develop rapidly.
While nicotine pouches and electronic cigarettes have been studied extensively in adult smokers generally, considerably less evidence exists regarding their use during pregnancy.
This uncertainty reinforces the need for caution.
Rather than making categorical claims that these products are either safe or harmful during pregnancy, researchers continue to call for higher-quality prospective studies capable of evaluating maternal outcomes, fetal development, birth outcomes, and longer-term child health.
As with many areas of public health, evidence evolves over time. Clinical guidance should evolve alongside it.
Supporting Better Conversations
Effective healthcare communication requires more than simply presenting risks.
It also requires understanding individual circumstances, recognising addiction as a chronic health condition, and maintaining supportive relationships that encourage positive behavioural change.
For women who are unable to stop smoking immediately, healthcare professionals should continue providing evidence-based cessation support while discussing available options openly, honestly, and without stigma.
Maintaining trust between clinicians and patients ultimately strengthens public health objectives.
Looking Forward
Smoking during pregnancy remains a major public health priority, and complete smoking cessation should continue to be the primary goal for all pregnant women who smoke.
At the same time, healthcare systems must recognise that nicotine dependence is complex and that some women struggle to quit despite repeated support.
As evidence surrounding smoke-free nicotine products continues to develop, policymakers and clinicians should avoid both unwarranted reassurance and unnecessary alarm. Instead, public health discussions should remain grounded in the best available evidence, acknowledge uncertainty where it exists, and support further high-quality research.
For GINN, the central principle remains straightforward: effective public health policy should be guided by evidence, compassion, and proportionate risk communication. Supporting women with accurate information and evidence-based care offers the strongest foundation for improving maternal and infant health outcomes while continuing to reduce the burden of smoking-related disease.
Source
https://tobaccoharmreduction.net/article/midwives-tobacco-harm-reduction-pregnancy-alternatives/
