GPs can be confident in prescribing nicotine replacement therapy (NRT) for pregnant women given the available evidence, according to the co-author of a narrative review published today by the MJA.

Dr Yael Bar-Zeev, a public health physician and tobacco treatment specialist at Israel’s Ben-Gurion University, and her co-authors wrote that in a recent survey of Australian GPs and obstetricians 25% of responders said that they never prescribed NRT during pregnancy.

“The most frequently cited barriers are low confidence in the ability to prescribe NRT and safety concerns,” the authors wrote.

In an exclusive podcast with MJA InSight, Dr Bar-Zeev said that because a woman’s metabolism is faster when she is pregnant, giving a dosage of NRT equivalent to her smoking levels prior to pregnancy was not sufficient to reduce her cravings for nicotine.

“That’s exactly what the research shows,” Dr Bar-Zeev said.

“Doctors are trying to give as little as possible, but she actually needs more than if she wasn’t pregnant.”

Clinicians and women were anxious in general about using any medication in pregnancy, she said. In the case of nicotine, animal studies in rats, mice and monkeys had found that nicotine was associated with problems in the development of brains and lungs in fetuses.

“But, saying that, none of this was replicated in any human studies,” Dr Bar-Zeev said.

“What the animal studies [have caused] is this fear that we don’t know enough.”

Mixed messages from guidelines were also a problem.

“Most guidelines say that you can use NRT in pregnancy, but they are very ambiguous,” Dr Bar-Zee said. “They say yes it’s safer than smoking and you can use it, but you have to make sure that you talk to the woman about risk versus benefits, and you can’t give too much, and you can only give it if the woman is really motivated to quit. They’re giving you all kinds of limitations and not really providing the confidence that it’s okay to use it.”

The Royal Australian College of GPs’ guidelines say:

“There is limited evidence of the effectiveness of NRT in helping pregnant women stop smoking. The main benefits of using NRT are the removal of the other toxins contained in tobacco smoke and the lower dose of nicotine delivered by NRT than tobacco smoke. NRT can be used by pregnant and breastfeeding mothers, but the risks and benefits should be explained carefully to the woman by a suitably qualified health professional and the clinician supervising the pregnancy should be consulted. In general, intermittent (oral) NRT should be used during pregnancy to deliver a lower total daily nicotine dose. However, larger doses or even combination therapy may be required to relieve cravings and withdrawal symptoms in pregnancy due to the faster clearance of nicotine. If patches are used by pregnant women, they should be removed before going to bed to protect the fetus from continuous exposure to nicotine. While nicotine passes from mother to child in breast milk, it is unlikely to be dangerous.”

Dr Bar-Zeev said that the strength and frequency of the woman’s cravings for nicotine were more important for determining the correct dosage of NRT than the number of cigarettes she smoked a day.

“If I have a smoker come in to my office, usually I decide on the dosage of NRT according to the number of cigarettes they smoke, and my next question would be ‘how soon do you smoke your first cigarette of the day’. The sooner you smoke that means you’re more dependent, and I would give you a higher dosage.

“But in pregnancy, those are not really good indications … for how [large a] dose of NRT I need to give.

“First of all, most [pregnant] women reduce the amount that they smoke … it doesn’t really tell me how dependent [she is].

“It’s much better to focus on her cravings for a cigarette because that’s a good indication of how she’s feeling and how she’s dealing with her addiction. So, we want to ask her ‘how strong were your urges in the past 24 hours’ and ‘how frequent were they’.

“If she has very strong urges or very frequent urges that means that no, she’s not dealing that well with her withdrawal and she may need more NRT.”

In the narrative review, the authors wrote:

“Physicians should encourage using oral NRT regularly throughout the day to substitute for cigarettes; for example, a woman smoking 10 cigarettes a day should be instructed to use one piece of gum every 1.5 hours regularly, even if she is not experiencing a strong craving at this time. In addition, physicians should encourage the use of oral NRT in anticipation of cravings; if a woman knows she is going to be in a situation where the urge to smoke will be strong (eg, going out with friends who smoke), doctors should encourage the use of oral NRT 20 minutes beforehand. Physicians should proactively review the SUTS [strength of urges to smoke scale] and FUTS [frequency of urges to smoke scale] on a weekly basis and adjust dosage as needed. Further, women should be encouraged to use NRT for at least 12 weeks, or longer if required, in order not to relapse.”

The take-home message for GPs was to be confident in prescribing NRT in pregnancy, said Dr Bar-Zeev.

“The most important message is not to be afraid of using it. Use it as much as needed to help the woman because [if she’s not confident using it], she ends up using two pieces of gum and that’s not nearly enough. Use the lowest amount you can to protect the baby, but you have to use an amount that is efficient.”

 

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