Smoking Before, During and After Pregnancy in 2021 — and How Often Doctors Asked

Smoking in pregnancy raises the risk of placenta previa, placental abruption and premature rupture of membranes, and of harm to the baby: cleft lip and palate, stillbirth, preterm birth, restricted growth, infant death and sudden infant death syndrome (SIDS). Smoking before pregnancy can impair fertility; smoking after it raises the risk of SIDS and childhood respiratory infections. The U.S. Preventive Services Task Force recommends that providers ask every adult, pregnant women included, about tobacco, advise them to quit, and support them in doing so.

CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) surveys women by mail or phone 2–6 months after they give birth. This analysis covers 36,493 women in 37 jurisdictions in 2021.

How many smoked

56.1% of women who smoked before pregnancy quit while pregnant — from 35.9% in Wyoming to 87.9% in Puerto Rico.

Smoking during pregnancy was more common among non-Hispanic American Indian or Alaska Native women, women whose prenatal care was paid for by Medicaid, women with 12 years of education or less, and women with a history of depression before pregnancy.

How often providers asked

CDC

Among women who had a visit in each period:

Even among women who had smoked before pregnancy, only 69.7% were asked about smoking after the birth. Being asked at the postpartum checkup was less common for women 35 or older, women with more than 12 years of education, women without a history of depression, and women who hadn't smoked before pregnancy.

That postpartum gap matters. Asking is the first step toward quitting — a chance to follow up on readiness and connect people to help — and guidance for the postpartum visit includes screening for tobacco and counseling about relapse for women who quit while pregnant.

What works

• Counseling and medication. Both help people quit. For adults who aren't pregnant, FDA-approved quit-smoking medicines raise the odds of success, especially with counseling. They are not recommended in pregnancy, because there isn't enough evidence that nicotine replacement doesn't affect birth outcomes.
• Coverage. Comprehensive, barrier-free insurance coverage for cessation is cost-effective, and since 2010 Medicaid has had to cover tobacco cessation for pregnant women without cost sharing.
• Quitlines. Providers can refer patients to the free national quitline numbers; studies show quitlines and public health campaigns help pregnant women.
• Population measures — tobacco taxes, campaigns and smoke-free laws.

Comprehensive state and local tobacco control has been shown to reduce smoking. For example, New York City and Puerto Rico were the only PRAMS jurisdictions to meet the Healthy People 2020 goal of cutting smoking in pregnancy to 1.4%; both had cigarette taxes above $4 a pack and comprehensive smoke-free indoor air laws. Maine, West Virginia and Wyoming, with the most smoking in pregnancy, had taxes of $2 a pack or less, and West Virginia and Wyoming had no statewide comprehensive smoke-free law.

The bigger picture

Smoking around pregnancy has declined: PRAMS data show less smoking before, during and after pregnancy, and more quitting, from 2000 to 2020. Other sources measure differently — the 2020 National Survey on Drug Use and Health found 8.4% of pregnant women used tobacco products, and 2021 birth certificates recorded 4.6% smoking in pregnancy — but they agree that smoking in pregnancy is higher among younger women and AI/AN women, and varies by place.

Limits

Women may under-report smoking and over-report quitting; answers given months later may be misremembered; e-cigarettes and other tobacco weren't counted; "during pregnancy" covers only the last 3 months; only women who had a visit could be asked; and the results apply only to the jurisdictions included.

Sources

Based on Kipling L, Bombard J, Wang X, Cox S, "Cigarette Smoking Among Pregnant Women During the Perinatal Period: Prevalence and Health Care Provider Inquiries — Pregnancy Risk Assessment Monitoring System, United States, 2021," MMWR volume 73, number 17, Centers for Disease Control and Prevention; a work of the United States government in the public domain.