Pharmacotherapy for smoking cessation during pregnancy.

Abstract

As noted elsewhere in this issue, many pregnant women continue to smoke during pregnancy despite advice from health care providers that they should quit and/or because they have failed behavioral therapy. Continuing to smoke in the face of compelling reasons not to do so is an indication of addiction—that is, loss of control of drug use. Nicotine is responsible for addiction to cigarette smoking (Benowitz, 1999). The more severe the addiction, the harder it is to quit smoking. More highly addicted smokers obtain greater relative benefit from pharmacotherapy (vs. placebo) compared with less highly addicted smokers (Sutherland et al., 1992). Evidence also indicates that more highly addicted smokers are more likely to quit if they receive higher doses of nicotine medications, whereas less dependent smokers do as well with lower doses of nicotine (Tonnesen et al., 1988). Given that women who continue to smoke during pregnancy are likely to be highly dependent, it makes sense that pregnant smokers would benefit from pharmacotherapy to aid cessation, and that the doses of medications may need to be relatively high compared with those used in less dependent smokers. Data are scarce on the efficacy of medications to aid smoking cessation in pregnant smokers, largely because health care providers have been hesitant to expose pregnant women to medications for fear that the medications may have a negative effect on the pregnancy or the fetus. Thus, the safety of pharmacotherapy is the key question that needs to be resolved before we progress in enhancing smoking cessation during pregnancy. With respect to drug therapy, safety is not an absolute measure. Rather, safety reflects the conclusion that a drug’s benefits outweigh its risks. Because the benefits of pharmacotherapy to enhance cessation in pregnant smokers are unknown, this article focuses primarily on the question of risk, specifically, on the risks associated with cigarette smoking vs. the risks associated with medications that might result in a woman quitting.