nicotine + smoking
In this section, when we talk about smoking we're talking about tobacco products.
Tobacco is a leafy plant that contains large amounts of nicotine, a stimulant that affects the brain.
Nicotine is found in tobacco products like cigars, cigarettes, snus, spliffs (tobacco + cannabis), and chewing tobacco. It can also be the active ingredient in gums, patches, and e-juice for vaporizers (cartridges and liquids).
How nicotine is consumed changes its effect. Nicotine reaches the bloodstream and nervous system most rapidly - and therefore has its most powerful effects in the brain - when it is inhaled. When it is chewed in gum or absorbed from a patch, the effects are more subtle.
Under the T21 law, retailers in the United States must not sell tobacco products to anyone under the age of 21 - including cigarettes, smokeless tobacco, hookah tobacco, cigars, pipe tobacco, electronic nicotine delivery systems including e-cigarettes and e-liquids.
Tobacco use is common. About 2 out of every 3 adults have tried tobacco. But tobacco use is less common than alcohol use. About 1 out of three adults has been a daily smoker at some point in their lives. Those rates are falling - especially as we understand more clearly the differences between the harms of smoking combustible tobacco and the lower risks of nicotine use.
Because of this evolving understanding, other types of nicotine delivery systems are gaining in popularity. It is generally accepted that these products are much safer than cigarette smoking.
For the purposes of this discussion, “smoking” will refer to use of combustible tobacco products, “smokeless tobacco” shall refer to chewing tobacco and snus, and “nicotine delivery systems” shall refer to patches, gum, and electronic cigarettes.
"Quitting smoking is one of the best things you can do for a healthy pregnancy and a healthy baby.
But that doesn’t make quitting easy. Whether before, during, or after baby, we have the tools and support to help you quit and stay quit."
Pharmacology is a branch of science that deals with the study of drugs and their actions on living systems - that is, the study of how drugs work in the body.
Nicotine is a naturally occurring chemical which acts on nicotinic receptors, with strongest binding capacity in the brain (1).
While nicotine dependence is thought to be the reason smokers continue to smoke, most of the problems associated with smoking are related to smoke inhalation, not nicotine (2-4).
Smoking has been associated with many health problems - primarily cancers, cardiovascular disease, and chronic lung diseases (2).
The hierarchy of risk from greatest to least is thought to be:
cigars, pipes, hookah
no tobacco/nicotine use (1-5).
Nicotine delivery systems include gum, patches, and e-cigarettes.
Use of e-cigarettes is not fully understood, but experts agree that it is likely to be safer than continuing to smoke (2, 4, 5).
There are medications which may be helpful in smoking cessation such as varenicline (6), bupropion (7), and many more.
What you vape matters.
Some vape juices have very highly concentrated nicotine. Some have less - or none.
Ideally, the medium (liquid) used in vape products to hold the active ingredients should be medical-grade.
Unregulated vape products, like those containing vitamin E acetate, large amounts of phytol, and pine resin have been associated with serious respiratory illness.
Most of the information we have about the effects of tobacco and nicotine on pregnancy comes from research about smoking during pregnancy. Most of that research is on pregnant people who smoke cigarettes.
Nicotine is a stimulant found in tobacco. The FDA places nicotine in pregnancy category D.
"Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks."
Smoking and use of nicotine products during pregnancy has been linked to:
and respiratory, gastrointestinal, and metabolic disease in offspring (8-11).
E-cigarette use is not perfectly safe for anyone, but switching from exclusive cigarette smoking to exclusive vaping is a healthier choice (17).
Scientists still need to collect more information about e-cigarette use in pregnancy, but the evidence is clear that e-cigarettes are safer than combustible cigarettes in pregnant people. (18-23) In the UK, the national health service encourages pregnant people who smoke to switch to e-cigarettes, even providing them with equipment and supplies! (24) It is unclear whether smoking and vaping is healthier for pregnancy than just continuing to smoke without vaping, even if you use fewer cigarettes (21). Most people who quit smoking with e-cigarettes are not able to switch completely right away, and many experience a period of weeks, months, or even years of using both. (23, 25) Whether or not it is healthier for you probably depends on your patterns and amount of use, but scientists aren’t sure yet. When making the decision about whether to quit smoking with a vape, it’s important to consider what it would mean for you, not just during your pregnancy, but for the rest of your life. Quitting smoking is one of the best things you can do for yourself, your pregnancy, and your future. If you have tried quitting before, but other quit methods didn’t work for you, vaping might help. The hierarchy of risk for quit methods is:
Safest: Quitting nicotine altogether
Safer: Quitting with therapies like gum, patches, or Wellbutrin
Safer: Quitting using an e-cigarette
Least safe: Continuing to smoke
There is limited evidence of a withdrawal syndrome associated with prenatal exposure to cigarettes (12, 13).
Smoking during lactation has been associated with decreased milk supply and duration of lactation, altered composition of milk, increased incidence of Sudden Infant Death Syndrome (SIDS) and asthma in offspring (10, 14).
Despite the risks, breastfeeding while smoking is considered to be safer than formula feeding while smoking, because of the proven health benefits of breastfeeding, including a 50% reduction in the incidence of SIDS (10, 15, 16).
Nicotine overdose is unlikely with smoking, but could be a concern with contact with or ingestion of e-cigarette liquid, especially for children.
Learn more at PoisonControl.org then make a plan to keep children safe.
Call 1-800-222-1222 to get help.
Nicotine withdrawal is a normal physical and emotional reaction to rapidly quitting,
or significantly reducing, your nicotine intake. It usually happens when you drastically reduce or stop smoking after you've been ingesting nicotine every day for at least several weeks. - VeryWell Mind
1. Narahashi, T., Fenster, C. P., Quick, M. W., Lester, R. A., Marszalec, W., Aistrup, G. L., Sattelle, D. B., Martin, B. R., & Levin, E. D. (2000). Symposium overview: mechanism of action of nicotine on neuronal acetylcholine receptors, from molecule to behavior. Toxicological sciences : an official journal of the Society of Toxicology, 57(2), 193–202. https://doi.org/10.1093/toxsci/57.2.193
2. Royal College of Physicians. Harm reduction in nicotine addiction: helping people who can’t quit. A report by the Tobacco Advisory Group of the Royal College of Physicians. London: RCP, 2007
3. Foulds, J., Ramstrom, L., Burke, M., & Fagerström, K. (2003). Effect of smokeless tobacco (snus) on smoking and public health in Sweden. Tobacco control, 12(4), 349–359. https://doi.org/10.1136/tc.12.4.349
4. Farsalinos, K. E., & Le Houezec, J. (2015). Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes). Risk management and healthcare policy, 8, 157–167. https://doi.org/10.2147/RMHP.S62116
5. National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems, Eaton, D. L., Kwan, L. Y., & Stratton, K. (Eds.). (2018). Public Health Consequences of E-Cigarettes. National Academies Press (US).
6. Pfizer Labs. (2016). Chantix: Highlights of prescribing information. Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021928s039s041lbl.pdf
7. GlaxoSmithKline. (2016). Zyban: Highlights of prescribing information. Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020711s044lbl.pdf
8. Committee on Underserved Women, & Committee on Obstetric Practice (2017). Committee Opinion No. 721: Smoking Cessation During Pregnancy. Obstetrics and gynecology, 130(4), e200–e204. https://doi.org/10.1097/AOG.0000000000002353
9. Einarson, A., & Riordan, S. (2009). Smoking in pregnancy and lactation: a review of risks and cessation strategies. European journal of clinical pharmacology, 65(4), 325–330. https://doi.org/10.1007/s00228-008-0609-0
10. Section on Breastfeeding (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841. https://doi.org/10.1542/peds.2011-3552
11. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Centers for Disease Control and Prevention (US).
12. Law, K. L., Stroud, L. R., LaGasse, L. L., Niaura, R., Liu, J., & Lester, B. M. (2003). Smoking during pregnancy and newborn neurobehavior. Pediatrics, 111(6 Pt 1), 1318–1323. https://doi.org/10.1542/peds.111.6.1318
13. Stroud, L. R., Paster, R. L., Papandonatos, G. D., Niaura, R., Salisbury, A. L., Battle, C., Lagasse, L. L., & Lester, B. (2009). Maternal smoking during pregnancy and newborn neurobehavior: effects at 10 to 27 days. The Journal of pediatrics, 154(1), 10–16. https://doi.org/10.1016/j.jpeds.2008.07.048
14. Napierala, M., Mazela, J., Merritt, T. A., & Florek, E. (2016). Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review. Environmental research, 151, 321–338. https://doi.org/10.1016/j.envres.2016.08.002
15. Dorea J. G. (2007). Maternal smoking and infant feeding: breastfeeding is better and safer. Maternal and child health journal, 11(3), 287–291. https://doi.org/10.1007/s10995-006-0172-1
16. Vennemann, M. M., Bajanowski, T., Brinkmann, B., Jorch, G., Yücesan, K., Sauerland, C., Mitchell, E. A., & GeSID Study Group (2009). Does breastfeeding reduce the risk of sudden infant death syndrome?. Pediatrics, 123(3), e406–e410. https://doi.org/10.1542/peds.2008-2145
17. Grana, R., Benowitz, N., & Glantz, S. A. (2014). E-cigarettes: a scientific review. Circulation, 129(19), 1972–1986. https://doi.org/10.1161/CIRCULATIONAHA.114.007667
18. Centers for Disease Control and Prevention. E-cigarettes and pregnancy. Atlanta, GA: CDC; 2019. Available at:
19. Spindel, E. R., & McEvoy, C. T. (2016). The Role of Nicotine in the Effects of Maternal Smoking during Pregnancy on Lung Development and Childhood Respiratory Disease. Implications for Dangers of E-Cigarettes. American journal of respiratory and critical care medicine, 193(5), 486–494. https://doi.org/10.1164/rccm.201510-2013PP
20. Whittington, J. R., Simmons, P. M., Phillips, A. M., Gammill, S. K., Cen, R., Magann, E. F., & Cardenas, V. M. (2018). The Use of Electronic Cigarettes in Pregnancy: A Review of the Literature. Obstetrical & gynecological survey, 73(9), 544–549. https://doi.org/10.1097/OGX.0000000000000595
21. McDonnell, B. P., Dicker, P., & Regan, C. L. (2020). Electronic cigarettes and obstetric outcomes: a prospective observational study. BJOG : an international journal of obstetrics and gynaecology, 127(6), 750–756. https://doi.org/10.1111/1471-0528.16110
22. Wang, X., Lee, N. L., & Burstyn, I. (2020). Smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a 2016 U.S. national sample. Preventive medicine, 134, 106041. https://doi.org/10.1016/j.ypmed.2020.106041
23. Shittu, A., Kumar, B. P., Okafor, U., Berkelhamer, S., Goniewicz, M. L., & Wen, X. (2021). Changes in e-cigarette and cigarette use during pregnancy and their association with small-for-gestational-age birth. American journal of obstetrics and gynecology, S0002-9378(21)02583-7. Advance online publication. https://doi.org/10.1016/j.ajog.2021.11.1354
24. Bowker, K., Ussher, M., Cooper, S., Orton, S., Coleman, T., & Campbell, K. A. (2020). Addressing and Overcoming Barriers to E-Cigarette Use for Smoking Cessation in Pregnancy: A Qualitative Study. International journal of environmental research and public health, 17(13), 4823. https://doi.org/10.3390/ijerph17134823
25. DeVito, E. E., Fagle, T., Allen, A. M., Pang, R. D., Petersen, N., Smith, P. H., & Weinberger, A. H. (2021). Electronic Nicotine Delivery Systems (ENDS) Use and Pregnancy I: ENDS Use Behavior During Pregnancy. Current addiction reports, 8(3), 347–365. https://doi.org/10.1007/s40429-021-00380-w