Tips for safely treating tobacco use and supporting lactation during postpartum
In honor of National Breastfeeding Month (August), we decided to highlight a common clinical question faced by those of us working at the intersection of women’s health and tobacco treatment. “Is it safe to use tobacco cessation medications, such as nicotine replacement, while breastfeeding?” And closely related, “What recommendations can I give mothers and other family members who are still smoking?”
To answer these questions, I sat down with an expert on the topic. Jaimie Lea, IBCLC, MPH, is an International Board Certified Lactation Consultant and holds a MPH with a focus on maternal and child health. She is a trainer and implementation specialist with YouQuitTwoQuit, a program of the UNC Collaborative for Maternal and Infant Health that supports comprehensive tobacco use screening and cessation counseling for women of reproductive age, before, between and beyond pregnancy.
One of the biggest takeaways from our conversation is that this group desperately needs tobacco treatment support services. Of the women who quit smoking during pregnancy, 90% relapse after 1 year. Pregnancy and early-postpartum is a key time to help many women capitalize on increased motivation for change by supporting them with evidence-based treatment. Supporting cessation can also help women be more successful with breastfeeding. The American Academy of Pediatrics notes that continued smoking and use of other tobacco/nicotine products is associated with reduced milk production and a shorter duration of lactation.
How does nicotine affect breastfeeding, and how can women limit nicotine exposure while using Nicotine Replacement Therapy (NRT)?
Nicotine lowers serum prolactin. You need that hormone to fuel milk production. Treatment with nicotine replacement therapy is designed to step down in nicotine dose, but with continued tobacco use there usually isn’t that same gradual decrease in use. Nicotine is a water-soluble molecule, so the concentration of nicotine in breast milk really mirrors the mom’s serum nicotine concentration. Individuals can minimize exposure to nicotine by using short-acting NRT, such as nicotine gum or lozenges, and using the product right after nursing or pumping; that way, the level of nicotine is lowest by the time it’s time to feed or pump again in a couple of hours.
“I view a parent’s desire to breastfeed/chestfeed as one way to help motivate them to stay tobacco free during the postpartum period,” says Jaimie Lea, IBCLC, MPH
If a postpartum person needs to use a nicotine patch, removing the patch at night, if they are able to do so without returning to tobacco use, can help not disrupt the surge of prolactin at night that helps fuel milk production. Using the lowest effective dose of patch is also helpful. Another piece of information to share with parents is that cigarette smoke and nicotine can change the taste of the milk for the baby, and they may develop an aversion to feeding due to an unpleasant taste.
Are tobacco cessation medications safe during lactation?
Medications are graded on safety during lactation based on their potential impact on the baby and the mother’s milk supply. These ratings are based on a book written by perinatal pharmacologist Thomas Hale, PhD, called Medications and Mother’s Milk. Information on the effect of medications on human milk can also be found in the Drug and Lactation Database (LactMed). Nicotine replacement therapy and bupropion fall into risk category L3 – “probably compatible” – which means limited controlled studies are available on risk, but the potential risk to the infant is minimal or non-life threatening. With drugs in this category, the benefits of using these medications need to outweigh the risks. When the risk is continued tobacco use, these cessation medications are a better option if they help mothers stay tobacco free.
There is anecdotal evidence that bupropion may reduce milk supply. When considering bupropion - and any medication - it is important to have a shared-decision-making conversation with the nursing parent to discuss their priorities and goals around lactation and the possible effects of the medication. It may be beneficial to wait until the milk supply and nursing relationship with the baby is well established before starting bupropion. Another consideration is that bupropion can lower the seizure threshold, but typically not at the doses used for tobacco cessation. If the nursing parent or infant are prone to seizures, bupropion may not be the best option.
Varenicline (formerly known by the brand name Chantix) has an L4 rating, meaning it is potentially hazardous. There is no data on varenicline in human lactation, but animal models have shown some concerning things. One is that the molecular structure of varenicline easily moves into the breast milk compartment and doesn’t move easily out. In addition, varenicline has a long half-life (24 hours), so it stays in the lactating person’s system longer than many medications. In animal models, the drug was detectable in nursing mouse pups.
How do you support postpartum women in quitting tobacco use?
It is important to frame everything in a positive manner. Instead of discussing all the negatives of continued tobacco use, highlight benefits of quitting. ‘If you quit smoking/vaping, your baby is less likely to have ear infections and respiratory infections.’ There is so much shame and stigma around continued tobacco use that being positive can be an effective way to shift the conversation. Let them know you are on their side. You are not judging them for their tobacco use. Acknowledge that tobacco is really hard to quit. Show empathy for the many challenges of parenting an infant and the increased stresses of the postpartum period. Highlight what they are doing well and their previous successes. Be a cheerleader, providing social support and encouraging them to find support among their family, friends, and larger community.
What about vaping and e-cigarette use?
The risks are the same as smoking in terms of the effect of nicotine on lactation and the baby. In some cases, these devices are providing higher levels of nicotine than conventional cigarettes. Just the fact that we don’t know what chemicals you are being exposed to at this point is another concern. (There is a lack of long-term research on the health impacts of e-cigarette use, and the e-cigarette market is largely unregulated.) There are so many products out there that trying to make generalizations is impossible. Looking at poison control data, there has been a big increase in reports of nicotine poisoning. Just 1 teaspoon of nicotine can be fatal to a 20-pound toddler. The vegetable glycerin and propylene glycol used in e-cigarette liquid is sweet, and many products have flavoring and brightly colored, attractive packaging. It is easy for kids to mistake them for candy. For this reason, parents using these products should keep them stored safely out of reach.
3 Takeaways for Tobacco Treatment Specialists
Encourage human milk feeding despite tobacco use status. Even if the patient continues to use tobacco, it is not a contraindication to breast/chestfeeding. Human milk has qualities that are protective for the risks associated with environmental tobacco exposure, including sleep-related deaths and infections. Studies show that human milk also helps prevent asthma. Immunoglobulins in milk are protective. The risks of exposure to tobacco smoke or nicotine are mitigated by exposure to human milk. Artificial human milk substitutes (aka formula) do not contain the biological factors that are protective against the harmful effects of environmental tobacco exposure.
Be really understanding and compassionate. During the postpartum period, people have so much going on. Quitting tobacco may not be a top priority. Breastfeeding itself can be stressful for both the nursing parent and baby. When tobacco use has been a coping mechanism for increased stress, it makes sense that women want to continue to use tobacco. Recognize that staying tobacco-free can be more challenging when paired with the demands, increased stress, and fatigue that comes with caring for a new baby.
Work on minimizing risks. Help families minimize risks if individuals in the household continue to smoke or vape. Advise them to nurse or pump, then use the tobacco product and try not to use again until after the next time nursing or pumping. Never smoke or vape in a room or space where the infant or small children will be. Infants are really susceptible to secondhand (smoke/vape inhaled from a nearby lit tobacco product) and thirdhand (smoke/vape residue left on walls, clothes, or hands). They put their hands on everything and then in their mouth. Infants have higher respiratory rates and are exposed more to chemicals in the air. If adults go outside to smoke or vape, they should completely change clothes and wash their face and hands before touching the baby. These routines are a little burdensome and sometimes a motivator to help people work on quitting.
Continued tobacco use is not a contraindication to breastfeeding due to the known benefits of human milk for babies, according to the American Academy of Pediatrics. AAP also states that nicotine cessation products may be used while breastfeeding. To help reduce secondhand and thirdhand exposure to tobacco smoke/vape, caregivers should be counseled to:
Never smoke or vape while feeding their baby
Never smoke or vape indoors or in the car
If they are going to continue to smoke or vape, suggest using tobacco immediately after breastfeeding or pumping to reduce harm
After smoking or vaping, wash hands and face and change their clothes before touching the baby
If you are looking for more resources on this topic, You Quit, Two Quit has some excellent pregnancy, postpartum, and parenting-specific materials for both patients and healthcare providers. Visit https://youquittwoquit.org/ to access these.
Duke-UNC TTS offers a range of trainings in evidence-based tobacco treatment for all healthcare professionals. Visit www.dukeunctts.com to learn about or register for an upcoming tobacco treatment training.
About the Author
Rachael Joyner, DNP, FNP-BC, APRN, is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.