Smoking and Breastfeeding
Richmond VA USA
From: LEAVEN, Vol. 40 No. 4, August-September 2004, pp. 75-78.
Should mothers who smoke cigarettes breastfeed? What overall effect does cigarette smoking have on breastfeeding mothers and their babies?
It is common knowledge that tobacco use is unhealthy. Many people still smoke, however, and many smokers are battling nicotine addiction. It has been reported that less than three percent of women who try to quit smoking each year succeed. The addictive nature of cigarettes has been compared to heroin. It’s not a simple matter to quit. Most people who quit do so only after repeated attempts. While pregnancy provides a strong incentive for women to quit, they may return to smoking once the baby is born.
According to the World Health Organization, about 250 million women in the world are daily smokers: 22 percent of women in developed countries and about nine percent of women in developing countries smoke tobacco. Many mothers who smoke choose not to breastfeed due to psychological factors or social pressure; some mothers who smoke may initiate breastfeeding and encounter physiological problems related to smoking while breastfeeding that lead to weaning; or some mothers who have given up smoking during pregnancy may choose to wean early to resume smoking because they do not believe they should smoke and breastfeed.
Studies have shown that breastfeeding offers protection against respiratory infections to babies in smoking households. Respiratory infections are much more common in babies exposed to environmental tobacco smoke, or second-hand smoke. Mothers who smoke cigarettes should be encouraged to breastfeed their babies and to try to smoke as little as possible. Many factors work against a mother who smokes and wants to breastfeed. As always, La Leche League Leaders are there to offer information and support to breastfeeding mothers who smoke.
Editor’s Note: This article is specific to tobacco cigarette smoking. It does not address marijuana or other smoking-related drugs, which are all contraindicated during breastfeeding.
AAP Rethinks Its Opinion
In 2001, The American Academy of Pediatrics (AAP) changed its official position on smoking and breastfeeding. The change was attributed to new research findings, as well as to an overall effort at the AAP to encourage an increase in US breastfeeding rates. Additionally, the committee stated, the removal of nicotine from the list of drugs of abuse not compatible with breastfeeding may afford physicians and their patients a greater opportunity to discuss cigarette smoking because: "Pregnancy and lactation are the ideal occasions for physicians to urge cessation of smoking."
The AAP report explained why doctors should discuss breastfeeding with mothers who do not wish to stop, or cannot stop smoking:
It is recognized that there are women who are unable to stop smoking cigarettes. One study reported that, among women who continue to smoke throughout breastfeeding, the incidence of acute respiratory illness is decreased among their infants, compared with infants of smoking mothers who are bottle fed. It may be that breastfeeding and smoking is less detrimental to the child than bottle feeding and smoking. The Committee on Drugs awaits more data on this issue.
Previously, nicotine was on the list of contraindicated drugs of abuse during breastfeeding due to documented decreases in milk production and infant weight gain, infant respiratory illness, and transfer of nicotine and other compounds to the babies from the milk of mothers who smoke. The 2001 report, however, stated that the committee found no evidence to document whether the amount of nicotine that passes to the infant through a mother’s milk is harmful, and it awaits further study on that issue.
The Position of LLL
"We’ve always said that, yes, mothers who smoke will have babies at greater risk for respiratory illness, but babies of mothers who smoke and breastfeed will have less," says Katy Lebbing, BS, IBCLC, RLC, and manager of the LLLI Center for Breastfeeding Information.
Lebbing comments that she has received many calls from mothers who smoke cigarettes and want to breastfeed during her tenure on the La Leche League International helpline (800-LALECHE). Discussing the information stated in THE WOMANLY ART OF BREASTFEEDING and THE BREASTFEEDING ANSWER BOOK about smoking, as well as asking questions about the related topic of stress management, is the best information and support LLL Leaders can offer.
"Smoking is something that is done to relieve stress. But there are other things that relieve stress," Lebbing says. "Going to LLL meetings or talking to an LLL Leader can help relieve a mother’s anxiety about breastfeeding-related problems."
If a mother is actively smoking,
THE WOMANLY ART OF BREASTFEEDING recommends:
- Smoke away from the baby, outdoors, or in a separate room;
- Smoke right after nursing sessions;
- Smoke as few cigarettes as possible. The risks to the baby increase if a mother smokes heavily (more than 20 cigarettes a day). Reduction in milk supply, inhibition of the let-down reflex, and physical symptoms in the baby, such as nausea, abdominal cramps, vomiting, and diarrhea, may occur.
THE BREASTFEEDING ANSWER BOOK contains a comprehensive section about nicotine use. Again, the same three guidelines are stressed: smoke away from baby, never smoke during feedings, and smoke as few cigarettes as possible per day.
THE BREASTFEEDING ANSWER BOOK also has a segment related to nicotine replacement therapy products for questions from mothers who are interested in using nicotine gum, lozenges, or patches in order to stop smoking. Mothers should use the chewing gum or lozenges right after feedings, not right before or during feedings. If mothers are using the transdermal patch, THE BREASTFEEDING ANSWER BOOK suggests mothers remove it at bedtime to allow for lower nicotine levels during night feedings. Mothers who are using the replacement products should never smoke cigarettes while using a replacement therapy as "this would produce very high nicotine levels in her blood and milk and could be a danger to her breastfeeding baby."
An additional source of information that is mother-friendly is the recently published LLLI tear-off sheet, "Smoking and Breastfeeding: The Effects of Smoking on Breastfeeding Mother and Baby."
Tobacco smoke contains at least 3,800 components. Nicotine is the most well-known and addictive ingredient. As early as 1933, it was known that nicotine was present in a smoking mother’s milk (Amir 2001). Second-hand cigarette smoke is unhealthy for babies, increasing the risk of respiratory infections, SIDS, and cancer (Ward 1999). As stated by the AAP, breastfeeding has been shown to decrease the incidence of respiratory infections in babies of smoking parents.
Mothers who smoke cigarettes and want to stop or cut back can be encouraged to find support. But if they do not stop smoking, breastfeeding is better for the baby than formula feeding. However, mothers who smoke and breastfeed may experience unique, smoking-related difficulties within the breastfeeding relationship—of both psychological and physiological natures—which may create an increased likelihood of early weaning.
Early Weaning Possible
Women who smoke are less likely to breastfeed than non-smokers, and women who smoke and breastfeed are more likely to wean early, although there does not seem to be a physiological reason for this. These statements are included in an extensive review of studies related to maternal smoking and lactation (Amir 2001).
Study author Lisa Helen Amir, MBBS, MMed, IBCLC, from the Centre for the Study of Mothers’ and Children’s Health at LaTrobe University in Australia, reviewed previously published studies from US and international databases, libraries, and medical journals to compare findings related to the topic of maternal smoking and weaning.
Amir states early weaning may be influenced more by psychological and social reasons than actual physiological breastfeeding problems:
Although there is consistent evidence that women who smoke breastfeed their infants for a shorter duration than non-smokers, the evidence for a physiological mechanism is not strong....Women who smoke seem to have significantly less motivation to breastfeed: they are less likely to intend to breastfeed and less likely to initiate breastfeeding.
Studies show a number of psychosocial factors that may play into a mother’s decision to not breastfeed or wean early if she smokes cigarettes including the number of cigarettes she smokes, if the father smokes, and a mother’s own anxiety about milk supply.
In one study, researchers found that more than 60 percent of women who gave up smoking during pregnancy resumed smoking in the months following birth; 50 percent by approximately four months postpartum. Most of those who began smoking again had a partner who smoked and most were less likely to breastfeed for more than six weeks (Mullen 1997).
Smoking is a stress-relieving mechanism for many people. New mothers who are under the inevitable stress of early parenthood may find it difficult to avoid returning to that stress-reducing habit if not given early support and alternative relaxation methods (Ward 1999).
Early weaning may also be related to physiological problems commonly attributed to smoking and breastfeeding, such as inhibited let-down and decreased milk supply. Lisa Helen Amir writes that it has been generally accepted that nicotine in the mother’s bloodstream reduces prolactin and, therefore, milk supply. However, she states, new evidence seems to second-guess the importance of prolactin on overall milk supply (Amir 2000).
"The widespread belief that smoking interferes with oxytocin release is currently unsubstantiated and research is needed to prove or refute this assertion," Amir writes.
She also concludes that early
weaning is not in the best interest of babies whose mothers smoke:
In clinical practice, all pregnant and lactating women should be encouraged and given help to stop smoking. However, women who continue to smoke should be encouraged to breastfeed as the health risks of the combination of parental smoking and artificial feeding outweigh the potential risks of smoking and breastfeeding.
Smoking reduces the body’s ability to absorb some vitamins and minerals. A recent study showed that mothers who smoke cigarettes may have reduced ability to transport iodine, which can also cause the same deficiency in the breastfed baby (Laurberg 2004). The study was conducted in Denmark, a country where iodized salt was not regularly used at the time of the study. Iodine deficiency is of particular interest because it is the main cause of preventable brain damage and mental retardation worldwide.
According to the study by Dr. Peter Laurberg, smoking reduces the transport of iodine into breast milk, increasing the risk of developmental brain issues. "During the period of breastfeeding, thyroid function of the infant depends on iodine in maternal milk," indicates Laurberg. The study did not make specific suggestions for iodine supplementation in breastfeeding mothers who smoke.
Iodized salt provides 400 mcg of iodine per teaspoon. The dose of iodine recommended for breastfeeding mothers by the US is 290 mcg. The breastfeeding mother who smokes should consult with her health care provider about supplementation of iodine or other vitamins and minerals.
Key Information for LLL Leaders
When giving information and support to a mother who is smoking and breastfeeding, an LLL Leader may need to set aside personal biases about smoking. It is important to offer breastfeeding information and support, and to not mix the separate cause of smoking cessation.
Leaders may encounter breastfeeding mothers who want to stop smoking and who ask for information. In those cases, they can offer information from THE BREASTFEEDING ANSWER BOOK about nicotine replacement therapies and their effects on breastfeeding. They can offer alternative methods of stress relief, including attending LLL meetings. They can refer mothers desiring to stop smoking to related treatment organizations (see resources at end of article).
Leaders may also encounter mothers who don’t want to stop smoking. In those instances, they can offer the recommended guidelines from THE BREASTFEEDING ANSWER BOOK and THE WOMANLY ART OF BREASTFEEDING. Leaders can provide mothers with the information that babies who are exposed to cigarette smoke have a higher incidence of respiratory infections, and that breastfeeding offers some protection against those illnesses. Leaders may also want to ask open-ended questions about how the mother is handling the stress associated with new motherhood.
- Breastfed babies of mothers who smoke cigarettes have fewer respiratory infections than formula-fed babies of mothers who smoke.
- Breastfeeding mothers who smoke should smoke as few cigarettes as possible each day.
- Mothers who smoke should smoke away from the baby, outdoors, or in a separate, well-ventilated area to reduce amount of second-hand smoke and particulate matter the baby is exposed to.
- Mothers who smoke should do so after feedings to allow time for the level of nicotine in the milk to decrease before the next feeding.
- Mothers who smoke and breastfeed may discuss iodine and other vitamin and mineral supplementation with their health care provider.
- Smoking may reduce the protection against SIDS that breastfeeding offers.
- If a mother who is breastfeeding uses nicotine replacement products, she should not smoke any cigarettes while using the products.
- Mothers who want to quit smoking should seek support to do so.
- Smoking is often an anxiety-related activity. Encourage the mother to find other ways to reduce stress.
Dealing with Biases About Smoking
Do you have mixed feelings about encouraging a breastfeeding mother who smokes to continue breastfeeding? If so, you’re not alone. For a variety of reasons, many in the LLL community have strong feelings about the risks of smoking. A Leader can best help a mother who smokes by offering clear and objective information about the relationship between breastfeeding and smoking.
A breastfeeding mother who smokes may conjure up unconscious concerns about mother’s milk being "good enough" for babies. This is a fear that baby milk manufacturers have played upon subtly over the years.
As a demographic group, LLL Leaders are probably less likely to smoke than the general population. However, we may have family members who smoke. Or we may have a spouse, parent, or friend suffering from a smoking-related illness. Our concerns for loved ones may magnify any concern we have for the breastfeeding mothers we are helping.
Many of us have heard or read about unfavorable comparisons between how the health care community treats smoking by a pregnant mother verses how the health care community treats a pregnant mother’s "feeding choice." Health care professionals may strongly condemn smoking during pregnancy and lactation, while downplaying the health risks of not breastfeeding. Our unconscious or conscious awareness of such contrasts may affect our language on a subtle level.
The history of smoking being targeted as a public health issue also affects our attitudes. Some of us are old enough to remember times before smoking was banned on airplanes and in many public buildings in the US. The drastic change in attitudes may make us feel more militant about offering advice about quitting smoking, thus straying from our primary responsibility to help mothers with breastfeeding.
LLL Leaders tend to be more health-conscious than the general public. They are more aware of nutrition, and tend to do lots of reading about pregnancy, birth, nutrition, and childcare. Smoking is not the only health issue that may be of concern, but it’s a highly sensitive one. When a mother asks for input on her decision about smoking, both the mother and the Leader are put in a very delicate situation. Health care providers, family members, or friends have likely criticized the mother for her smoking. The Leader needs to be especially compassionate.
It is not our job to get mothers to quit smoking, or even to cut down on smoking. We can offer a mother information about the effects of smoking, including that the half-life of nicotine in the mother’s blood and milk is 95 minutes (Steldinger and Luck 1988), to help the mother make her own decisions. Leaders can feel confident encouraging the mother who smokes to continue breastfeeding for the positive health benefits to her baby and herself.
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Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK, 3rd Edition. Schaumburg, IL: La Leche League International, 2003.
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Smoking and Breastfeeding. LLLI, 2004. Publication No. 1487-27.
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Ward, S. Addressing nicotine addiction in women. J Nurse Midwifery 1999; 44(1): 3-18.
Widstrom, A.M. et al. Somatostatin levels in plasma in non-smoking and smoking breastfeeding women. Acta Paediatrica Scandinavica 1991; 80:13-21.
THE WOMANLY ART OF BREASTFEEDING, 7th Edition. Schaumburg, IL: La Leche League International, 2004.
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Helpful Web sites
La Leche League International
World Health Organization
The International Cancer
American Lung Association
Freedom From Smoking
American Cancer Society
Dana Villamagna, MSJ, is a freelance journalist and LLL Leader on Leader Reserve in Richmond, Virginia, USA where she lives with her husband, Drew, and two daughters, Olivia (6) and Elena (2)..