Alain Braillon: Should pregnant women be tested for smoking?

While rates of smoking are slightly decreasing in some high-income countries, worldwide more and more women smoke, and 10 to 25% of women smoke during pregnancy. Smoking remains the first avoidable cause of preterm births (ten cigarettes/day causes a 3-fold increase), lower birth weight, placental complications and perinatal mortality. However, smoking during pregnancy is too frequently overlooked and poorly treated.

The Guardian recently reported on Public Health England’s plan to give every pregnant woman a carbon monoxide test “to see if they smoke.” The plan is supported by the Royal College of Midwives. As a tobacco control advocate I commend this plan to raise the bar in a country where smoking rates among pregnant women have already fallen to an all time low.

However, the plan to reduce rates of smoking in pregnant women by using carbon monoxide monitors should be used as an adjunct to already existing care. Although using carbon monoxide breath analysers can be useful, not all women will accept the test, so it is important that healthcare professionals should also be alerted to pregnant women who smoke by asking them whether they smoke, and being able to see and smell the signs of cigarette use. Carbon monoxide testing is cheap, fast, non-invasive, and reliable. It provides an opportunity to explain to women how carbon monoxide is damaging for their babies, by reducing fetal oxygenation.

Secondly there is the issue of whether women should have the option to decline testing as with any other area of antenatal screening. The RCM have said that women should be given the option to opt out as they can with other screening interventions. Obviously, empathy and motivational interviewing, a cornerstone of care, need to be properly implemented. The problem is not the patients who refuse care, but the professionals who do not listen, share values, reassure, and explain adequately. Smoking is not the expression of the freedom of personal choices or a way of life—it is a strong addiction. Smoking is sometimes considered “as a way of helping relieve the stress of preparing to have a baby.” However many smokers are actually more stressed than non-smokers, and quitting reduces stress. Tobacco use causes stress to begin with. The temporary reduction in stressful feelings is only the satisfaction of relieving the painful craving for nicotine.

Carbon monoxide testing is missing the wood for the trees if the core issue of training and support to assist smokers to quit is missed out. Healthcare professionals need to give up brief interventions or basic counselling, as this low-cost care is almost always a programmed failure. Women are aware they should not smoke for their child’s sake, but they don’t always get adequate support for success and they fear quitting. Motivational interviewing is the key to this. It is also important to make sure that women’s partners are included in efforts to stop smoking, and that cognitive behavioural therapy is offered to help avoid recurrence.

Women who smoke during pregnancy shouldn’t be made to feel ashamed as this will preclude them looking for help, which should combine psychological support and pharmacological treatment. The system and the stakeholders need to be in place to support women. And finally why can’t we prevent adolescents from smoking, it is the most addictive behavior. Why don’t we treat women who smoke, as soon as possible, such as when they come for their first contraceptives?

Alain Braillon is a senior consultant at Amiens University Hospital, France.

Competing interests: None declared.