When a mum quits smoking, she’s making one of the biggest changes she can to improve her health, and the health of her baby. Any accurate information that those involved in breastfeeding support can give her, will support her to maintain that change. The hardest time to make or maintain behaviour changes are when one is HALT: hungry, angry, lonely or tired – and new mothers often experience some or all of these.
There is a persistent myth that abruptly quitting smoking may cause harm. In fact, while it may make symptoms such as coughing worse in the short term, this is a sign that the body’s natural responses are recovering and becoming unsuppressed by the effects of smoking. Additionally, abrupt quit is statistically the most successful way to quit smoking.
Many people believe that cutting down will provide protection for themselves and their families, but in fact most people will smoke in a compensatory way – taking more, deeper and longer held drags, thereby maintaining the levels of nicotine and other chemicals inhaled. Therefore, when wanting to quit one should use whatever method of quitting you believe will have the best chance of success in your particular case!
Will a baby be harmed by their mother quitting smoking abruptly?
No. There is evidence that nicotine exposure prenatally and through breastmilk may cause babies to undergo some symptoms of withdrawal when their mothers stop smoking. However, this must be weighed against the health risks to the baby if the mother continues to smoke. If a mother who is quitting smoking chooses to use nicotine replacement therapy while breastfeeding, her baby will receive a tapering dose of nicotine (as product strength and/or frequency of use is reduced), which could help to minimise withdrawal.
The components of cigarette smoke
There are three main problematic components in cigarette smoke: tar (the link between smoking and cancer), carbon monoxide (the link with heart disease, stroke and the main cause of damage in unborn babies) and nicotine.
Tar passes from the lungs to the bloodstream and is deposited all around the body. I have searched for information about whether tar passes into breastmilk and haven’t been able to find anything relevant. While it may be present in milk, it will certainly be present in second hand smoke. All information confirms that if a mother cannot quit smoking, then breastfeeding is protective against the chemical exposure the baby will be experiencing.
Nicotine in concentrated form is a poison – but when you have been regularly been exposed to it your body develops tolerance – the main problem with it in the form that it is in cigarettes is that it is extremely addictive.
If one chooses to use nicotine replacement therapy (NRT), one is using nicotine in a clean form, a less addictive delivery method (the more quickly it gets to your brain, the more addictive it is, and when smoked it takes less than seven seconds), and lower amounts than if smoking is continued – and with a tapering dosage.
(In the UK) all NRT is licensed for use in breastfeeding, with the recommendation that using the intermittent products (gum etc.), instead of the patches, allows mothers to minimise nicotine exposure by timing dosage. Nicotine has a half life of around 90 minutes, so smoking or using NRT just after a feed will allow mothers to minimise the nicotine transmitted to the baby. However – the exposure to a small amount of nicotine is hugely less harmful than exposure to continued smoking, so the mother should do whatever best increases her chances of success.
When choosing to use NRT, caregivers need to be aware that what is a therapeutic amount of nicotine for them would be a significant overdose for someone who is not used to it – in fact, the residue left in discarded NRT would be enough to cause harm to a baby or child. Occasionally, patches become unstuck from their original owner in bed and stuck on to other people sharing the space – apparently a part used patch or a piece of gum can make an adult feel like they are having a heart attack, so the effect on a baby would be severe. Just as smoking materials are kept out of reach, pre- and post- use NRT needs to be kept securely away from babies and children.
Electronic cigarettes (or vaping)
Public Health England has recently released an evidence summary relating to e-cigarettes. Its conclusion is that current evidence indicates that using an e-cigarette is around 95% safer than a conventional cigarette. Using an e-cigarette will not expose a baby to tar or carbon monoxide. Ambient levels of nicotine are much reduced compared with that in the air or household surfaces of a household where cigarette smoking takes place. This is because 85% of smoke released by cigarettes is sidestream smoke – the smoke that is released by a burning cigarette when it is not being smoked.
E-cigarettes are regulated by general consumer products law which is enforced by trading standards – this means it is easier for companies to bring products to market with much less testing and control than if products were regulated as medicines – it’s responsive rather than proactive. If you are going to use an e-cigarette, choose one that has a kitemark or CE mark as that gives you a guarantee that what it says on the label is what is in it, and the electrical components are safe.
The vapour itself is usually made from propylene glycol and glycerine – and as far as we know that doesn’t cause anything more serious than occasional throat irritation. There is a need for research on long term lung exposure safety.
E-cigarettes come in a range of flavours including menthol – peppermint oil is sometimes associated with reduced milk supply. If you are concerned you might check your preferred brand to see if it actually contains peppermint oil or a synthetic. Menthol cigarettes are linked to higher rates of lung cancer, but that is because the mint numbs the throat, enabling smoke to be drawn in deeper/ held longer. That wouldn’t be an issue with e-cigarettes.
ASH (Action on Smoking and Health) have a good online factsheet giving an introduction to e-cigarettes: http://ash.org.uk/search/?q=e%20cigarette&x=0&y=0
NICE (National Institute for Health and Care Excellence) now takes a harm reduction approach to e-cigarettes – they cannot recommend an unlicensed product, but are clear that they are less harmful than smoking. We know that many women quit smoking when pregnant and lapse after their baby has been born. If a mum who has quit smoking conventional cigarettes and is now using an e-cigarette, her baby isn’t being exposed to the chemicals in smoke – she has to weigh up how she feels about maintaining her successful quit versus risk of lapse if she stops using it.
Co-sleeping and smoking or vaping
Maternal (and to a lesser extent paternal or other parent present in the bed) smoking has long been clearly linked to increased risk of SIDS. Exposure to nicotine damages babies’ ability to develop normal robust neurological processes to protect their breathing and respond if it is compromised. It also decreases lung function and increases sleep related respiratory problems. According to evidence examined by the WHO, it is unclear how much of this risk is down to tobacco smoking during pregnancy damaging the foetus’s development, and how much is down to exposure to second hand smoke after birth.
This has implications for where babies sleep when their mothers smoked during pregnancy, even if the mother quit smoking at (or before) birth and is not now smoking. Additionally, sleep changes related to smoking such as apnoeas may take time to resolve after quitting smoking, and these may make the mother less responsive to her baby.
Cannabis and breastfeeding
Most times, cannabis is smoked together with tobacco – this means that all the health impact of tobacco is present, only with the additional effect that when joints are smoked, each inhalation is usually taken deeper and held for longer. This increases the lung exposure to harm. Because of the higher levels of oil in cannabis, it is usually estimated that each joint smoked is the equivalent of 5-7 cigarettes.
The effects of cannabis in breastmilk on babies’ development are controversial. Some studies indicate that there is no impact on babies’ long term development, others find that motor development at the age of one is slightly reduced in babies who were regularly exposed. Additionally, most babies who are exposed to THC (see below) via breastmilk will also have been exposed foetally, making it difficult to determine what changes have occurred when.
The active intoxicant in cannabis is delta-9-tetrahydrocannabinol (THC) – this is fat soluble, is stored in the body’s fat reserves and transfers into breastmilk. The immediate effects on babies can be sedation, weakness and poor feeding pattern. Because THC is stored and released slowly, among heavy, regular cannabis users the levels of THC in breastmilk can be eight times the levels in blood serum.
A mother who is intoxicated by cannabis use will sleep more deeply – plus her baby will also face the raised SIDS risk factors relating to tobacco use. Therefore co-sleeping would be clearly contraindicated.
Cannabis suppresses prolactin production, which may affect milk production. There is some evidence of this in animal studies, however human studies have found no difference in weaning age between cannabis using and non-cannabis using mothers. 
If breastfeeding is well established, then prolactin suppression may not affect breastmilk production.
Researchers are divided on whether the risks to the baby of cannabis exposure – including currently unidentified long-term developmental risks – are outweighed by the protective effects of breastmilk. Effects are dose-related, meaning that the risks to an infant of occasional exposure are very different to those who are regularly and chronically exposed.
Shisha or waterpipe smoking involves flavoured tobacco being placed on a disk of charcoal which is then lit. The smoke is drawn through water and into the mouth. Sometimes tobacco free preparations are smoked via a waterpipe. The burning of charcoal produces a dense smoke containing a lot of carbon monoxide. Additionally, sessions are often long. These effects combined mean that in one shisha session you can absorb the equivalent amount of smoke as in 100 cigarettes.
Anyone wanting to decide whether their shisha smoking was affecting their baby via breastmilk would need to consider whether the exposure was one-off or long term. With occasional use, mothers would need to think about whether their co-sleeping risk was temporarily increased while they were affected by carbon monoxide.
Written by Rebecca Coyle, edited by Ruth Lewis
Originally published in LLLGB’s Leader publication FEEDBACK
Copyright LLLGB 2016
Smoking and breastfeeding https://www.laleche.org.uk/smoking-breastfeeding/
Marijuana and breastfeeding http://breastfeeding.support/smoking-weed-while-breastfeeding/