Perinatal Nicotine Cessation

According to a recent review of maternal and infant wellbeing, “smoking in pregnancy constitutes the largest remediable risk factor for maternal and child health.”1 Because smoking is a risk factor that can be altered, cessation initiatives for those who are pregnant have the potential to positively impact both maternal and child health. Approximately 16% of women and birthing persons in the United States smokes tobacco2.

Obstetrical complications including placental abruption, fetal growth restriction, hemorrhage, and ectopic pregnancy are among the most common complications for birthing people during pregnancy. Pulmonary conditions such as asthma, birth defects of the mouth, increased irritability, bone fractures, breastfeeding difficulties, childhood obesity, and sudden unexpected infant death syndrome (SUIDS) are among the most common birth and health complications for children with nicotine exposure.1  Parents from lower socioeconomic backgrounds, who are unmarried or has a partner who smokes, who are heavy to moderate smokers, and who have a high school diploma or less are more likely to use nicotine during pregnancy. Those most likely to continue smoking during the postpartum period are parents who have exposure to second-hand smoke in the home, are formula feeding, did not intend to quit smoking long-term prior to pregnancy, have concerns about weight gain, and have stressors during pregnancy that worsen due to a lack of support.4

The American College of Obstetrics and Gynecology suggests that successful nicotine cessation strategies for those who are pregnant and postpartum will require providers to address these factors and the psychosocial stressors occurring during pregnancy and after birth.5 There is a myriad of stressors that can present for mothers and pregnant people that are specific to the perinatal period including circumstances of their pregnancy, risks for interpersonal violence, financial readiness to support a child, and status of parental leave benefits. Cessation programming and interventions that are specifically designed to support those who are pregnant in trying to quit nicotine must take these things into consideration.

We can improve perinatal nicotine cessation outcomes for moms, birthing people, and babies by doing the following:

  1. Engage in universal screening for nicotine and perinatal mental health conditions that co-occur in those who smoke, vape, or dip.
  2. Offer tangible resources that address psychosocial stressors.
  3. Connect parents with culturally responsive education and treatment options.

Let us work together to partner with organizations who can support this collective effort for the betterment of moms, birthing people, and babies in our community.


  1. Gould, G. S., Havard, A., Lim, L. L., & Kumar, R. (2020). Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting. International Journal of Environmental Research and Public Health, 17(6), 2034.
  2. Azagba, S., Manzione, L., Shan, L., & King, J. L. (2020). Trends in smoking during pregnancy by socioeconomic characteristics in the United States, 2010–2017. BMC Pregnancy and Childbirth, 20(1).
  3. Magee, S. R., Bublitz, M. H., Orazine, C. I., Brush, B., Salisbury, A. L., Niaura, R., & Stroud, L. R. (2014). The Relationship Between Maternal–Fetal Attachment and Cigarette Smoking Over Pregnancy. Maternal and Child Health Journal18(4), 1017–1022.
  4. Levine, M. D., Cheng, Y., Marcus, M. D., & Kalarchian, M. A. (2012). Relapse to Smoking and Postpartum Weight Retention Among Women Who Quit Smoking During Pregnancy. Obesity, 20(2), 457–459.
  5. American College of Obstetricians and Gynecologists. (2020). Tobacco and nicotine cessation during pregnancy. ACOG Committee Opinion No. 807. Obstetrical Gynecology, 135, e221–9.
2023-06-05T08:43:29-04:00June 5th, 2023|Dr. Alfred|

Maternal Mental Health and Nicotine Cessation

May is Mental Health Awareness Month and for this newsletter, we would like to highlight the importance of promoting maternal mental health for nicotine cessation. According to recent data from the Pregnancy Risk Assessment Monitoring System, about 50% of women who smoked cigarettes prior to pregnancy continued to smoke during pregnancy.1 Additionally, an estimated 1 in 10 pregnant women smoke during the last trimester of pregnancy.2 An important context to consider is that many people who are pregnant or new parents experience stressors and mental health complications, including depression, anxiety, and trauma that may contribute to unhealthy coping, including nicotine use.3 Parents with lower economic resources, and who were also depressed, are at increased risk for smoking during pregnancy and have a lower likelihood of quitting.1 For mothers and parents who experience emotional and psychological challenges and are trying to quit nicotine without adequate support and resources, the consequences can potentially impact the entire family.

Those of us who work in nicotine treatment understand that the desire to quit does not always translate into immediate behavioral modification. As a psychologist who works in maternal mental health, I advocate that all moms and birthing people have access to individual or group therapy, medication as needed, peer support, and other mental health resources. There are so many life circumstances that make pregnancy and early parenting challenging and there is a need for adequate emotional support. However, mental health resources are not adequate for changing the landscape of maternal mental health, especially as it relates to nicotine treatment.

Support for new parents who have mental health complications or diagnoses and who are also trying to stop using nicotine products requires the use of a systemic approach. In addition to offering nicotine education and mental health resources, it is important for us to understand the unique basic needs of each person we treat. Where there is a lack of basic necessities (e.g., food, housing, finances), an effort must be made to meet these needs. Where there are challenges with life stressors, we must work to help parents find solutions that work for them. These considerations are essential to sustain nicotine cessation initiatives. So, our charge this month is to expand our conceptualization of effective, long-term nicotine treatment interventions, to include, but not be limited to mental health resources and support when needed.



  1. Allen, A. M., Jung, A. M., Lemieux, A., Alexander, A. C., Allen, S. S., Ward, K. D., & Al’Absi, M. (2019). Stressful life events are associated with perinatal cigarette smoking. Preventive Medicine118, 264–271.
  2. Tong, V. T., Farr, S. L., Bombard, J. M., DʼAngelo, D., Ko, J. Y., & England, L. J. (2016). Smoking Before and During Pregnancy Among Women Reporting Depression or Anxiety. Obstetrics & Gynecology128(3), 562–570.
  3. Jones, A. R., Carter-Harris, L., Stiffler, D., Macy, J. T., Staten, L. K., & Shieh, C. (2020b). Smoking Status and Symptoms of Depression During and After Pregnancy Among Low-Income Women. Journal of Obstetric, Gynecologic, & Neonatal Nursing49(4), 361–372.
2023-05-03T14:36:53-04:00May 2nd, 2023|Dr. Alfred|

Highlighting Black Maternal Health Week: Our Bodies Belong to Us

Black Maternal Health Week is April 11-17, 2023, and this this year’s theme is “Our Bodies Belong to Us: Restoring Black Autonomy and Joy.” The ability of Black moms and birthing people to make decisions about our bodies and our health is essential to how we manage all health behaviors and achieve overall wellness. With rising rates of maternal and infant mortality in the Black community, including in Ohio, there is a need to create systems of care that center Mamas’ autonomy and the right to choose care options that align with their cultural beliefs and practices.

The Black Mamas Matter Alliance highlights culturally congruent practices, including access to Black midwifery and Black-led doula care as primary needs for Black mamas and birthing people. Black midwifery and Black-led doulas center Black mothers and babies. By design, they have an inherent understanding of Black bodies and our cultural contexts, they focus on non-medicalized births when possible, and they create environments of active listening and attending to mothers’ needs during pregnancy, birth, and early parenting.

The latter tenet of care translates to other forms health promotion, including nicotine cessation. It suggests the use of comprehensive, culturally congruent models of care that consider a person’s whole life experience.  If for example, a person’s basic needs are unmet, quitting smoking or vaping will be difficult especially if stress is a trigger for use. For Black mamas and parents who are also managing racism- or other trauma-related stressors, but do not have adequate support or resources, quitting will be challenging. Whatever the factors that impact a parent’s ability to quit nicotine must be addressed if they are going to be successful at quitting. As such, we must listen to Black moms and birthing people and respond accordingly.

As providers, we have a wealth of knowledge in regard to our respective disciplines. Many of us have licenses, certifications, and advanced training in our fields. Despite the knowledge we have about health behavior, risks, benefits, and the most effective treatment options, Black women and birthing people are the experts on our bodies and lived experience. As care providers we need to honor that, understand that, and prioritize care that is centered on that. Our bodies belong to us, and we will care for them based on our values, beliefs, and the knowledge we acquire from our providers in making informed decisions.

As you ponder changes you will make in your practice to re-empower Black moms and birthing people to practice autonomy with their health decisions, consider supporting and uplifting Black-owned and led organizations in our community that support birth equity, reproductive justice, and maternal mental health awareness for Black moms and birthing people. The organizations listed below are both local and national organizations that focus on Black maternal health. Support them.


2023-03-28T08:22:56-04:00March 28th, 2023|Dr. Alfred|

Postpartum Psychosis: Education, Screening, and Treatment for Maternal and Infant Vitality

This month, we want to spotlight a perinatal mental health complication that is often misunderstood and has recently received media attention. Perinatal or postpartum psychosis is a mental health condition that occurs during pregnancy and the first year following birth. This condition is deemed a mental health emergency due to the risk for harm to self and others, including infants and children. Timely screening and treatment are critical for optimal recovery.

Postpartum psychosis is characterized by the mom, pregnant woman, or birthing person losing touch with reality. Specifically, they may experience auditory or visual hallucinations where they hear or see things others do not see or hear. They may also experience delusions, characterized by strange or inaccurate beliefs, which can be associated with perinatal suicide and infanticide. Other symptoms include cognitive impairment, irritability, difficulty sleeping, paranoia, mood swings, and persistent thoughts about death or lack of safety1.

Approximately 1-2 moms or birthing people per 1,000 births experience postpartum psychosis2. Those who have been diagnosed with or have unmanaged symptoms of bipolar disorder may be at greater risk for this perinatal mental health complication. Although psychosis is a serious mental health condition, it can be treated.  Treatment typically includes hospitalization, medication, and therapy. For those who experience postpartum psychosis to receive necessary treatment, there is a need for health care providers and birthworkers to receive adequate training on the breadth of perinatal mental health complications, as well as screening and referral processes. Additionally, there is a need for parents and family members to receive accurate education about all perinatal mental health complications and available resources. We have included resources for providers and families in this newsletter.


  3. Psychosis Symptom Checklist (PSC) and Overview
2023-03-28T14:29:12-04:00February 22nd, 2023|Dr. Alfred, Uncategorized|

Partnering with Parents for Improved Nicotine Cessation Outcomes

Many parents who use nicotine products recognize that there are risks to their health and the wellbeing of their baby. However, efforts to quit are complicated by a myriad of factors, especially for those who Black, Indigenous and People of Color. For instance, in addition to having higher rates of tobacco-related morbidity and mortality, research suggests that smokers who identify as African American also experience disparities in tobacco cessation counseling despite best practices for universal screening and counseling.1,2,4 As providers, we can positively impact the experiences of parents trying to quit using nicotine, especially those for whom health inequities exist. Below are some suggestions for becoming better partners with parents in tobacco treatment settings:

  • Listen to parents. We all know that quitting can be difficult. As providers, it is essential for us to understand the unique challenges of each parent, as well as their available resources if we are going to develop a quit plan that is realistic and attainable for them. If we are not collaborating with clients on strategies that meet their unique needs, quit attempts may not be as successful.
  • Practice cultural humility. A lack of awareness of cultural practices and rituals that are important to parents of diverse backgrounds may give the perception that these things are not valued or relevant to their quit attempts. It is important for us to recognize that culture matters in health care decision-making and behavior change. As such, it is imperative that we are intentional about understanding the lived experiences of those we serve and not imposing our values upon them.
  • Explore implicit biases. Implicit bias occurs when attitudes and perceptions unconsciously affect our behaviors. For providers offering nicotine cessation treatment, it is essential that we explore our implicit biases in working with specific populations and individuals and make appropriate corrections to behaviors that negatively impact care (e.g., decisions about who we offer services and what those services entail, confronting assumptions about treatment adherence). This may be difficult to discern without direct feedback from our clients. However, regular consultation and collaboration with colleagues from diverse backgrounds can support our efforts to be more aware of and reduce bias.
  • Address structural racism within our organizations. If we are to address the impact of structural racism in our organizational policies and practices, we must first acknowledge the systems of racism that exist. Prioritizing continuing education that focuses on anti-racism and cultural humility is an important first step. Ensuring that stakeholders are part of the process in creating nicotine cessation programs and services is also paramount. We should be developing programs with those who are seeking our services, not for

By becoming better partners to parents, especially those for whom health inequities exist, we can positively impact their well-being and the health of their babies. What commitment will you make to become a better partner?


2023-03-28T15:41:09-04:00January 23rd, 2023|Dr. Alfred, Uncategorized|

Vaping is the new smoking

While tobacco products, combustibles as well as dip and chew, continue to be utilized by more than thirty million adults in the United States1, vaping seems to be the new smoking. Research shows that vaping is one of the most popular substances use trends, especially among young adults and teens. Flavors that are enticing to young people, including sweet, fruity flavors and menthol have led to their popularity. Additionally, vaping devices come in forms that are appealing and discreet, making them more accessible than other forms of nicotine.

Vaping has also become popularized as a strategy for tobacco cessation. There is a perception that vaping is a healthier option than smoking. However, despite its popularity, vaping does not come without risks. We share a few myths and misconceptions to help clarify the dangers of using vaping devices and e-cigarettes.

Myth #1 Vaping is safe. While those who vape avoid exposure to tar, carbon monoxide and harmful chemicals that are associated with combustible tobacco, studies show that there are still thousands of toxins, metals, and ultrafine particles that people who vape are exposed to2. Further, the substance that is released from vaping is not a water vapor. The substance released is an aerosol, which over time can result in cardiovascular and respiratory problems. Additionally, it has been estimated that more than 90% of vaping cartridges and liquids sold in the United States contain nicotine, which can be harmful to adolescent brain development and lead to nicotine dependence3. Vaping also presents risks for those who are pregnant. Vaping during pregnancy can result in low birth weight, and problems with lung and brain development in babies4,5. In essence, vaping is not free from health risks for adults, youth, or those who are pregnant.

Myth #2 Vaping can help with tobacco cessation. While some have had success with quitting tobacco after initiating vaping, many who vape also continue to smoke in some capacity. Most American public health agencies discourage vaping and e-cigarettes as a tool for tobacco cessation because there are known, and unknown health risks associated with their use. Certified nicotine treatment specialists can assist those trying to quit in exploring safer options.

Myth #3 Vaping is not addictive. As noted earlier, most vapes contain nicotine, a substance that is highly addictive. Both physiological and psychological addiction are possible consequences of vaping. Working with a nicotine treatment specialist can help with developing strategies for managing cravings and other symptoms associated with nicotine addiction. They can also assist with nicotine replacement therapies that are deemed safe for those who are trying to quit.

In summary, vaping has become a popularized form of smoking, but it is not risk-free. Learn more about the risks of vaping and the impact it can have on you and those around you, especially if you are pregnant.


2023-03-28T15:43:52-04:00January 10th, 2023|Dr. Alfred, Uncategorized|

Be A Quitter: Supporting Nicotine Cessation for Infant Vitality

In Ohio, and other states throughout the country, there is an effort to enhance infant vitality and maternal health outcomes. Although rates of infant mortality in Ohio dropped from 2019 to 2020, the current overall rate of 6.7 deaths per 1,000 live births; 13.6 deaths per 1,000 live births for Black infants in Ohio suggests that there are still far too many infant deaths in our state1. There are multifaceted and complex factors that contribute to these statistics, including drivers of health inequity (e.g., racism, implicit bias, poverty), which we cannot ignore if we are going to positively impact the outcomes. While we work to address these issues on a systemic level, we know that on an individual level, helping those who are pregnant or postpartum to quit nicotine can have a positive impact on infant vitality.

While many women and birthing people attempt to quit during pregnancy, statistics show that smoking during pregnancy is not uncommon. The National Vital Statistics System showed that in 2016 about 7.2% of women who gave birth reported smoking during pregnancy. Smoking was most common amongst American Indian and Alaska natives and women ages 20-242. Quitting nicotine during pregnancy may seem intuitive, because of the health benefits for mom and baby. However, we know that systemic health inequities and pregnancy-related stressors may make it difficult for those who use nicotine to quit, especially if their use is triggered by toxic stressors. It is imperative that we find ways to support those who are pregnant in their health goals, and address health care inequities that contribute to their overall wellbeing. In today’s edition, we offer suggestions to those who are trying to quit. In future newsletters, we will discuss systemic and provider-related strategies for improving infant vitality.

So, what are some ways for you to better manage your stress if you are pregnant while trying to quit?

  • Practice deep breathing. Diaphragmatic or deep breathing gives you time to pause and regulate your emotional state in a moment of stress.
  • Set healthy boundaries. Sometimes we take on more than we can handle and need to practice saying “no” or “not right now” to improve our stress level.
  • Increase your activity. The natural hormones released from exercise or activity can help counteract the effects of cumulative stress.
  • Find a trusted, culturally aware provider to support you during your health journey. For people who are pregnant, having a safe environment where you feel seen and heard can make the difference in your care experience. Working with providers you trust and feel safe with is essential for discussing challenges, including nicotine cessation, and getting the support you need to quit.
  • Join our Infant Vitality Program. We will help you to better understand the risks of smoking to you and your baby and help you with strategies for quitting.
  • Join a free support group. The Perinatal Outreach and Engagement for Moms (POEM) Program in central Ohio has support groups for mothers and birthing people that are led by peer facilitators. These groups can help with developing healthy new coping strategies and knowing you are not alone in your struggles.
  • Initiate therapy. Sometimes unmanaged anxiety and depressive symptoms may make it more difficult to manage stress. Find a qualified, culturally aware therapist to help you navigate life stressors that make it challenging for you to quit.

The risks of smoking and using nicotine are too great for you, and for your baby. Be a quitter for you and for your baby. You are both worth the effort.


2023-01-23T11:10:32-05:00November 29th, 2022|Dr. Alfred, Uncategorized|

Quit is Best for All

Pregnancy represents a time of change. In addition to the physical changes in your body, the most notable adjustment that you will make during pregnancy is the attention and focus that you give to your health. Starting a regimen of prenatal vitamins and other supplements will be a focus of initial appointments. This is in addition to continuing treatment that you are already engaged in to manage health issues you had prior to pregnancy. Depending on your health profile, you may require more appointments than you expected, which means changes to your schedule and routine. Most likely, you will also be asked to consider modifications to your diet and possibly your activity level.

Out of all of the things that you will be asked to make, one of the best things you can do during your pregnancy is quit smoking and/or vaping nicotine. Each of the aforementioned health goals are important but quitting smoking can help save lives and improve the overall health of you and your baby. Now we know pregnancy can also be a time of great stress, and for some smoking is a coping strategy. In future postings, we will share more about strategies and tips, but for now, let us consider some of the health benefits for you and your baby if you quit.

  • You gain a sense of accomplishment and empowerment that you have taken an important step in improving your overall health.
  • You can increase your life expectancy by as much as 10 years.
  • You decrease your risk for certain cancers, lung diseases, and heart diseases.
  • You lower your baby’s risk for preterm birth. Complications experienced from a preterm birth can result in significant health issues in your baby and create undue stress for you as a parent. Emotional, financial, and employment stress are common for those who have babies with complications during and after birth.
  • You decrease the risk for sudden infant death syndrome (SIDS). This condition is more prevalent in babies whose parents were smokers
  • You lower your baby’s risk for asthma and other respiratory conditions.

We know it may not be an easy thing to accomplish, but we will support you along the way. As you consider what it might take for you to start this process, remember that no matter how difficult, quit is best for all. Start your journey today by accessing free resources at



2023-03-28T15:51:53-04:00November 4th, 2022|Dr. Alfred, Uncategorized|
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