3.8 Child health and maternal smoking before and after birth

Last updated: March 2015 
Suggested citation: Ford, C, Greenhalgh, EM & Winstanley, MH. 3.8 Child health and maternal smoking before and after birth. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-8-chid-health-and-maternal-smoking

There are several possible routes by which the effects of tobacco smoke may compromise infant health. Before birth, paternal active smoking may alter chromosomes or damage DNA in sperm, and the foetus may be exposed to maternal active smoking or maternal exposure to secondhand smoke during pregnancy.
1,2 Following birth, infants may be exposed to parental secondhand smoke in the home,2 to thirdhand smoke in household dust and indoor surfaces,3 and to an increased bacterial load carried by a parent or carer who smokes.4,5,6 Both prenatal and postnatal exposure have been found to contribute to several health conditions in children.1,2 Maternal smoking also has negative effects on the quality and quantity of breast milk.7,8 Delineating the impact of each route of exposure in the causation of disease can sometimes be difficult, particularly for rarer conditions such as birth defects and childhood cancers.

Exposure to secondhand smoke during pregnancy is also a cause of reduced infant birthweight, and is associated with other health problems for the developing foetus.9,10 See Chapter 4, Section 4.11 for further information.

3.8.1 Foetal size and growth Birthweight

Smoking in pregnancy causes restricted growth and low birthweight in the infant. Intrauterine growth retardation is reduced foetal growth during gestation. Babies born with low birthweight have a higher risk of subsequent illness, death and longer-term poor health outcomes through childhood and adult life.9 Low birthweight is associated with heart disease, type 2 diabetes, high blood pressure and being overweight in adulthood.11,12,13

Babies born to smokers weigh, on average, about 150 g to 200 g less than babies born to non-smokers.9 Australian data show that babies of women who smoke during pregnancy are twice as likely to be of low birthweight (defined as weighing less than 2500 g) compared to babies whose mothers are non-smokers. They are also more likely to be admitted to special care nurseries or neonatal intensive care units.14,15 In Australia in 2004–5, it is estimated that about 14% of all deaths due to low birthweight were attributable to tobacco use in pregnancy.16

The effect of maternal smoking on low birthweight is largely due to intrauterine growth retardation and to a lesser extent shortened gestation. Growth retardation is likely to be caused by chronic mild oxygen deprivation in the foetus from exposure to carbon monoxide, with a more minor role played by the effects of smoking on the placenta leading to nutritional deficiency of the foetus.1 The effects of smoking on birthweight appear to be stronger among older mothers and in mothers who have particular genotypes for drug-metabolising enzymes. The risk for low birthweight increases with the number of cigarettes the mother smokes per day.1 However, some research indicates that birthweight declines far more sharply at low levels of exposure, such as that experienced by women exposed to secondhand smoke and possibly by women who smoke a low number of cigarettes per day.17,18,19,20,21 This may help account for the observation that the benefits of cutting down the number of cigarettes smoked per day on birthweight are considerably smaller than for complete smoking cessation.7,22,20

Mothers who stop smoking early in their pregnancy have babies with similar birthweights to babies of non-smokers. Even mothers who stop before their third trimester can avoid much of the effect of smoking on birthweight.9 Respiratory health

Maternal smoking during pregnancy causes reduced lung function in infants, and may also cause an increase in the number of lower respiratory tract illnesses, including wheezing, during infancy.23,1 The effects of maternal smoking in utero may also be related to an increased risk of impaired lung function in childhood and adulthood.9 Australian research suggests that infants born to women who have smoked during pregnancy have weakened innate immune defences, and develop their acquired immune system more slowly than infants of non-smoking mothers. This may explain why infants of smokers are more prone to be asthmatic and to develop respiratory infections.24 In Australia in 2004–05, it is estimated that about 13% of all deaths due to lower respiratory tract infections in babies less than one year of age were attributable to exposure to maternal tobacco smoking before and/or after pregnancy.16

Infants living with smokers are also more likely to experience a range of respiratory symptoms and chest illnesses.2 These findings are discussed in greater detail in Chapter 4, Section 4 .9.

3.8.2 Perinatal and infant death Stillbirth

Maternal smoking is associated with an increased risk of stillbirth (foetal death after 28 weeks' gestation) and neonatal mortality (death of an infant within the first 28 days of life).9 Data from the Australian Institute of Health and Welfare's National Perinatal Statistics Unit show that in 2003, babies born to mothers who smoked during pregnancy had a 50% greater risk of perinatal deathi than babies of non-smoking women.14

Proposed mechanisms by which smoking increases perinatal mortality include complications of pregnancy (abruption, placenta previa), preterm delivery, premature and prolonged rupture of the membranes (“water breaking”), and through physiologic responses of the foetus and newborn to stress.25 Sudden infant death syndrome

Sudden infant death syndrome (SIDS) is the sudden, unexplained, unexpected death of a child before one year of age.9 Smoking has been established as a cause of SIDS, whether the baby has been exposed to smoking before birth or in the home following birth.9 The biological pathway remains uncertain, but may be due to the effects of chronic oxygen deficiency on the development of the central nervous system and other neurotoxic effects of tobacco smoke on the foetal brain.9 Neurochemical changes to the cardiorespiratory control centres of the brainstem can result in changes in the development of respiratory control. Several studies have linked smoking during pregnancy to alterations in breathing patterns, ventilatory responses, and arousal responses in infants.9,25 Almost one in five deaths from SIDS in Australia (19%) is thought to be caused by maternal tobacco use.16

For information on secondhand smoke and SIDS see Chapter 4, Sub-section 4.9.2.

3.8.3 Birth defects

A large meta-analysis of studies published between 1959 and 2010 found that maternal smoking is associated with an increased risk for limb reduction defects; oral clefts; clubfoot; defects of the eyes; and defects of the gastrointestinal system, especially gastroschisis and abdominal hernia. More modest associations were found for digit anomalies (abnormal number or formation of fingers); cryptorchidism (undescended testes); and defects of the heart and musculoskeletal system, including craniosynostosis (premature fusing of the skull bones).27

The US Surgeon General’s report (2014) concluded that maternal smoking in early pregnancy causes orofacial clefts, and that maternal smoking is associated with other defects such as clubfoot, gastroschisis (the guts protruding through an opening in the abdominal wall), and atrial septal heart defects.25 Proposed mechanisms for oral clefts include the alteration of embryonic movements in early pregnancy that are important to the development of the organ systems, reduced supply of essential nutrients (such as vitamins and folate) for embryonic tissues, oxygen deficiency, and DNA damage. Mothers and babies with certain genotypes may be more susceptible to damage from tobacco smoke. Further work is needed to establish the mechanism. Studies also support an increased risk of oral clefts with paternal smoking, although it is not clear whether this is due to exposure of the mother to secondhand smoke or if it is due to the effects of tobacco smoke on sperm.1

3.8.4 Health complaints in infancy

A few studies have reported an association between maternal smoking, both during and after pregnancy, and infantile colic or excessive crying.28,29 Infantile colic is characterised by the frequent sudden fits of irritability, inconsolable crying and screaming accompanied by clenched fists, drawn-up legs and a red face. It occurs in the first weeks after birth and usually resolves by four months of age.28 One study suggests that maternal smoking may be linked to colic through gastrointestinal tract dysregulation. More research is needed to confirm this theory.28

The evidence is uncertain regarding the effect maternal smoking during pregnancy on risk of allergic sensitisation and atopic disease, including allergic symptoms, eczema, rhinitis and dermatitis. More studies addressing potential genetic determinants of susceptibility are needed.2 While smoking during pregnancy may increase the risk of wheezing illnesses in infants,9 the potential role of prenatal tobacco exposure as an independent cause of asthma is still unclear.2

3.8.5 Long-term development Neurodevelopment

Investigating the impact of maternal smoking on the cognitive and behavioural development in infants and children is difficult as many factors affect the outcomes, including genetic and environmental effects.1 This has produced mixed results in the research. So while various studies have found an association between smoking during pregnancy and poorer outcomes in children, including for impaired learning and memory, lowered IQ, cognitive dysfunction, later childhood conduct problems, substance use, and early adult criminality, their findings are called into question by other studies reporting no association and the problems of inadequate study design.30

Recently, the US Surgeon General concluded that maternal prenatal smoking increases the risk of disruptive behavioural disorders, particularly attention deficit hyperactivity disorder, among children. However, there is insufficient evidence to infer a relationship between maternal prenatal smoking and anxiety, depression, Tourette syndrome, schizophrenia, and intellectual disability among children.25

General assessments of children's cognition and intelligence have been mixed. However, studies of children's general verbal skills and specific language and auditory tests have found a more consistent association between smoking during pregnancy and children's poorer performance on these tests.1

More comprehensively designed studies that take into account the many confounding factors on child development are needed.30 Nicotine dependence

Evidence is emerging that suggests that exposure to nicotine in utero predisposes an individual to a greater likelihood of nicotine dependence later in life, independent of socio-economic and other factors that influence uptake of smoking.31 It is possible that this may occur by nicotine having a direct effect on the developing foetal brain, causing permanent abnormalities in neurotransmitter regulation.31, 32 Other research, while confirming that offspring of women who smoked during pregnancy are more likely to become smokers in early adolescence, suggests that environmental influences on smoking uptake such as the mother's current smoking status and peer group behaviour are stronger predictors.33 This is an area requiring further study. Physical development

Studies into the possible effects of smoking during pregnancy on subsequent physical growth of children have been mixed. Where differences have been found between children of smokers and non-smokers, they have generally been small. More research is needed.9,1 Cardiovascular disease risk

Several studies have examined the link between smoking during pregnancy and the development of cardiovascular risk factors in the child. Among other risk factors, maternal smoking during pregnancy is associated being overweight or obese in childhood. This effect appears to be independent of the effects of smoking on foetal growth, and is likely to be an effect of smoking in early pregnancy.34–37 Two possible mechanisms are the effects of smoking on hypothalamic function affecting food intake and energy expenditure, or abnormalities in fat cells.35,36 Breastfeeding for more than six months may reduce the risk of child obesity associated with smoking in pregnancy.37

The evidence is unclear as to whether there is an increased risk of higher blood pressure in children born to women who smoked during pregnancy.38 However, limited research indicates that maternal smoking in pregnancy leads to impaired blood pressure regulation in infants39 and adverse lipid (cholesterol) profiles in adult offspring.40–42 Smoking throughout pregnancy is a risk factor for cardiovascular developmental changes, including aortic narrowing, in early childhood and adolescence.43,44 One study found that the foetuses of smoking mothers are more likely to have lesions in the walls of the foetal artery and adjoining vessels, which are the initial stages of atherosclerosis (narrowing of the arteries by fatty deposits).45 Other long-term consequences

A few studies suggest that smoking during pregnancy may affect the reproductive development of male offspring, increasing the risk for lower sperm counts and quality, lower fertility, smaller testicles, undescended testes and hypospadias (a penis abnormality).46–50,26,1 Limited research suggests that smoking during pregnancy may also affect reproduction in female offspring. It is associated with a smaller uterus, a reduced number of somatic cells (which are necessary for egg survival), and slightly lower fertility in female offspring.52–53,1 More research is required to confirm these findings.

The link between parental smoking and development of childhood cancers is discussed in Chapter 4, Section 4.9.9. Possible effects of paternal smoking

[Content in development] Possible effects smoking by grandparents

[Content in development] 

3.8.6 Breastfeeding and smoking

Breastfeeding has wide-ranging health benefits for both baby and mother. These include well-recognised benefits such as reduced risk of diarrhoeal illness, reduced risk of developing allergies to cow's milk and possible reduced risk of obesity later in childhood. They also include less well-recognised benefits such as improved sight and psycho-motor development, reduced incidence of orthodontic problems resulting from under-development of the jaw and other facial bones, and possibly reduced risk of autoimmune diseases such as diabetes and inflammatory bowel disease.54

Babies who are breastfed gain better levels of immunity to infectious disease, particularly against respiratory and ear infections associated with secondhand smoke exposure.7,55–58 Women who have breastfed have a reduced risk of developing breast cancer and possibly ovarian cancer,59 as well as possible improvements in bone mineralisation.54

There is consistent evidence that women who smoke are less likely to breastfeed their infant and are more likely to wean their child earlier than mothers who do not smoke. This effect persists even after adjusting for other influences on the decision to breastfeed, such as socio-economic factors.7,8

Tobacco smoke appears to have a direct negative effect on milk quality, as well as the quantity produced. It is thought that nicotine may affect the activity of prolactin, a hormone essential for milk production.7,8 Nicotine is found in the breast milk of mothers who smoke. Cotinine, one of the main metabolites of nicotine, is found in the urine of breastfed infants of smokers, as well as in the urine of infants who are exposed to secondhand smoke.60 Nicotine absorbed by infants through breast milk can produce short-term symptoms such as restlessness, insomnia, nausea, vomiting, diarrhea and rapid pulse, and may affect infants' autonomic cardiovascular control and sleeping patterns.60,61 However, as nicotine has a short half-life in milk of about two hours, breastfeeding mothers who cannot quit can minimise the exposure of their baby to nicotine by prolonging the time between their last cigarette and breastfeeding.60 Although smoking and breastfeeding is not ideal, the benefits of breastfeeding outweigh the risks associated with smoking and not breastfeeding.58

Recent news and research

For recent news items and research on this topic, click here (Last updated March 2018) 

i Perinatal death is defined as 'a fetal or neonatal death of at least 20 weeks gestation or at least 400 grams birthweight', Laws et al (2006) (p42).


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2. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2006/index.htm

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4. Arcavi L and Benowitz NL. Cigarette smoking and infection. Archives of Internal Medicine 2004;164(20):2206-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15534156

5. Brook I and Gober A. Recovery of potential pathogens in the nasopharynx of healthy and otitis media-prone children and their smoking and nonsmoking parents. Annals of Otology, Rhinology, and Laryngology 2008;117(10):727–30. Available from: http://www.annals.com/toc/auto_abstract.php?id=15299

6. Robinson P, Taylor K and Nolan T. Risk-factors for meningococcal disease in Victoria, Australia, in 1997. Epidemiology and Infection 2001;127(2):261-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11693503

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8. British Medical Association Board of Science and Education and Tobacco Control Resource Centre. Smoking and reproductive life. The impact of smoking on sexual, reproductive and child health. London: British Medical Association, 2004. Available from: http://www.bma.org.uk/images/smoking_tcm41-21289.pdf

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14. Laws P, Grayson N and Sullivan E. Smoking and pregnancy. AIHW cat. no. PER 33. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2006. Available from: http://www.npsu.unsw.edu.au/NPSUweb.nsf/resources/AMB_2004_2008/$file/Smoking+and+pregnancy+for+web.pdf

15. Laws P, Li Z and Sullivan E. Australia's mothers and babies 2008. Perinatal statistics series no. 24, AIHW cat. no. PER 50. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2010. Available from: http://www.aihw.gov.au/publication-detail/?id=6442472399&tab=2

16. Collins D and Lapsley H. The costs of tobacco, alcohol and illicit drug abuse to Australian society in 2004-05. P3 2625. Canberra: Department of Health and Ageing, 2008. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/mono64/$File/mono64.pdf

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20. Secker-Walker RH and Vacek PM. Infant birth weight as a measure of harm reduction during smoking cessation trials in pregnancy. Health Education & Behavior 2002;29(5):557-69. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12238700

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