The Case for a Pregnancy-Specific Nicotine Policy

We aimed to evaluate the proposition that nicotine delivery by any means during pregnancy adversely affects the fetus and infant, review national policies on nicotine use in pregnancy across four high-income countries and propose a coherent pregnancy-specific nicotine policy framework.

Clinical guidelines, public health policy documents and evidence-based recommendations on tobacco and nicotine use in pregnancy were reviewed.

Smoking in pregnancy is strongly associated with adverse perinatal outcomes. Similar but less consistent associations are reported with snus and vaping, supporting avoidance of nicotine in all forms. National policies vary: NZ and the UK adopt harm-reduction approaches, encouraging substitution with alternative nicotine products such as vaping, whereas the US and Sweden emphasise complete nicotine cessation. We propose a precautionary framework that recognises the mother-infant dyad as the unit of care; prioritises nicotine-free pregnancy; provides personalised cessation support for all pregnant women; reserves nicotine replacement therapy with clinical caution when behavioural support is insufficient; discourages vaping; and strengthens surveillance through early carbon monoxide monitoring and systematic recording of nicotine exposure.

This framework provides a coherent pregnancy-specific nicotine policy centred on cessation as the mechanism of protection for the mother-infant dyad, with the aim of improving pregnancy outcomes.