Smoking

Should I breastfeed if I am a smoker?

Breastfeeding helps protect the baby from some of the harmful effects of smoking. However, mothers who breastfeed and smoke are more likely to have a low milk supply and to stop breastfeeding early and the baby is more likely to have slow growth and poorer long-term development. Chemicals produced by smoking can enter a baby’s body through the placenta, through breast milk, and as smoke when breathed in. Smoking or having smokers in the household increases the risk of the baby having more frequent and severe asthma attacks, colds and pneumonia, ear infections, and sudden infant death syndrome. For the mother’s health and the health of her baby, she should stop smoking and encourage those around her to stop as well. If a mother cannot stop smoking, she should try to limit the baby’s exposure to smoke by not smoking inside the home or car.

A) The risks of smoking

Both smoking and second-hand smoke exposure increases the risk of many illnesses. 

Nicotine and other chemicals produced by smoking can enter a baby’s body (Reece-Stremtan 2015):

  • Through the placenta of their mothers.
  • Through breast milk.
  • As smoke when breathed in by the baby.

Babies are particularly vulnerable to the effects of smoke exposure. Smoking or having smokers in the household increases the risk of the baby having (CDC 2017):

  • More frequent and severe asthma attacks.
  • Respiratory infections such as colds and pneumonia.
  • Ear infections.
  • More visits to doctors and hospital stays (Dai 2020).
  • Sudden infant death syndrome (SIDS).

Even if household smokers only smoke outside, harmful chemicals can come from their clothes or bodies (Sheu 2020).

Mothers who are not smokers but who live with smokers are more likely to stop breastfeeding early and thereby increase the risk of illness for themselves and their babies (Lok 2018; Suzuki 2020).

B) Risks of smoking while breastfeeding

1) Effect of smoking on the mother

In addition to other health problems, mothers who are smokers are less likely to breastfeed (Cohen 2018; Lechosa Muñiz 2019) and more likely to develop mastitis when they stop (Napierala 2016). They are more likely to develop a particular type of breast infection (subareolar abscesses [Zuska-Atkins disease]).

2) Effects on the baby

Nicotine enters the milk of mothers who smoke while breastfeeding. The levels in milk are substantially higher than those in the mothers’ blood and it takes the baby’s body longer to get rid of it (Napierala 2016).

a) Slow growth

Smoking increases the baby’s risk of having poor growth (Hopkinson 1992; Vio 1991). This may be caused by the mother having a low milk supply brought about by (Napierala 2016):

  • Lower levels of prolactin and negative changes in other hormones (Bahadori 2013).
  • Slightly lower levels of fat, proteins, and calories in breast milk (Macchi 2021)
  • The effect of nicotine on the cells making breast milk (Kobayashi 2019).
  • A delay in the baby starting to breastfeed.
  • Poor breastfeeding ability due to neurological deficits related to smoke exposure before birth (Bertini 2020).

Slow growth may also be caused by breast milk containing:

  • Nicotine which can:
    • Reduce the baby’s appetite.
    • Cause breast milk to have an unpleasant taste thereby decreasing milk intake (Mennella 1998; Mennella 2007).
  • Higher levels of toxins such as cadmium or lead (Macchi et al. 2021).
  • Lower levels of iodine needed for making thyroid hormones (Laurberg 2004).

Babies may also grow more slowly if sick. Breast milk of mothers who smoke has less ability to fight infections as it has:

  • Lower levels of agents to help the immune system function (cytokines).
  • Lower levels of anti-oxidants (Macchi 2021).

b) Effect on sleep

Babies of mothers who smoke while breastfeeding are more likely to be unhappy and have sleep and heart rhythm abnormalities (Dahlström 2008; Mennella 2007; Reijneveld 2000).

c) Effect on long-term development

Children’s long-term development can be impaired when mothers breastfeed and smoke (Napierala 2016):

  • Children may have a reduced ability to learn and remember because of nicotine exposure.
  • Children have a higher risk of:
    • Cancer (leukemia) because of exposure to cancer-causing chemicals (Ferreira 2012).
    • Chest infections and allergies.

Adults who were breastfed by a smoking mother have an increased risk of metabolic syndrome, a condition which includes increased tummy fat, high levels of unhealthy fat in the blood, diabetes, and high blood pressure (Miranda 2020). 

C) Reasons for breastfeeding if mothers cannot stop smoking

Mothers who are smokers should not stop breastfeeding as the benefits of breastfeeding for these babies outweigh the risks of infant formula use.

Breastfeeding can protect babies from some of the harmful effects of smoking, such as a particular lung infection (bronchiolitis) (Bermúdez Barrezueta 2021; Moshammer 2019). It provides this protection even if the mother doesn’t smoke but someone else in the household does (Lee 2019).

Smoking while pregnant increases the risk of the baby being born small. However, these babies have also been shown to gain weight more quickly when breastfed (Shenassa 2016).

D) Stopping smoking

For your own health and the health of the baby, consider stopping smoking and encourage those around you to stop as well.  

There are many online resources to help quit smoking. Your health-care providers may have additional information and can provide support.

Nicotine gum and patches are compatible (poses very little or no risk to the baby) with breastfeeding. Please work with your health-care providers to ensure that the amount of nicotine you take with a gum or patch does not result in higher levels of nicotine than you get by smoking.  

If you cannot stop smoking, try to limit your baby’s exposure to smoke by not smoking inside your home or car or around your baby.

E) Electronic cigarettes and vaping

While electronic cigarettes (E-cigarettes) have been promoted as safer than tobacco cigarettes, there is very little research on this topic.

Nicotine is present in both tobacco and E-cigarettes. Other known and unknown components such as toxicants, flavorings, and solvents, may also pose a risk to the baby’s growth and development and to the health of the mother (McGrath-Morrow 2015; Perrine 2019). 

References

Bahadori B, Riediger ND, Farrell SM, et al. Hypothesis: smoking decreases breast feeding duration by suppressing prolactin secretion. Med Hypotheses. 2013;81(4):582–586

Bermúdez Barrezueta L, Miñambres Rodríguez M, Palomares Cardador M, et al. Effect of prenatal and postnatal exposure to tobacco in the development of acute bronchiolitis in the first two years of life. An Pediatr (Engl Ed). 2021 Jun;94(6):385-395

Bertini G, Elia S, Lori S, et al. Abnormal neurological soft signs in babies born to smoking mothers were associated with lower breastfeeding for first three months. Acta Paediatr. 2019 Jul;108(7):1256-1261 

Centers for Disease Control and Prevention (CDC). Health Effects of Secondhand Smoke. Atlanta: Centers for Disease Control and Prevention; 2017 Jan 11 [cited 2018 Jan 11]
 
Cohen SS, Alexan der DD, Krebs NF, et al. Factors Associated with Breastfeeding Initiation and Continuation: A Meta-Analysis. J Pediatr. 2018 Oct 4. pii: S0022-3476(18)31118-1
 
Dahlström A, Ebersjö C, Lundell B. Nicotine in breast milk influences heart rate variability in the infant. Acta Paediatr. 2008;97:1075–1079

Dai S, Chan KC. Associations of household environmental tobacco smoke exposure with respiratory symptoms and utilisation of medical services in healthy young children in Hong Kong. Tob Induc Dis. 2020 Jan 10;18:02

Ferreira JD, Couto AC, Pombo-de-Oliveira MS, et al.; Brazilian Collaborative Study Group of Infant Acute Leukemia. Pregnancy, maternal tobacco smoking, and early age leukemia in Brazil. Front Oncol. 2012;2:151
 
Hopkinson JM, Schanler RJ, Fraley JK, et al. Milk production by mothers of premature infants: influence of cigarette smoking. Pediatrics. 1992;90(6):934–938pmid:1437437
  
Kobayashi K, Tsugami Y, Suzuki N, et al. Nicotine directly affects milk production in lactating mammary epithelial cells concurrently with inactivation of STAT5 and glucocorticoid receptor in vitro. Toxicol In Vitro. 2019 Nov 27;63:104741
 
Laurberg P, Nøhr SB, Pedersen KM. Iodine nutrition in breastfed infants is impaired by maternal smoking. JClin Endocrinol Metab. 2004;89:181– 187

Lechosa Muñiz C, Paz-Zulueta M, Del Río EC, et al. Impact of Maternal Smoking on the Onset of Breastfeeding versus Formula Feeding: A Cross-Sectional Study. Int J Environ Res Public Health. 2019;16(24):4888. Published 2019 Dec 4 

Lee M, Ha M, Hong YC, et al. Exposure to prenatal secondhand smoke and early neurodevelopment: Mothers and Children's Environmental Health (MOCEH) study. Environ Health. 2019 Mar 20;18(1):22
 
Lok KYW, Wang MP, Chan VHS, et al. Effect of Secondary Cigarette Smoke from Household Members on Breastfeeding Duration: A Prospective Cohort Study. Breastfeed Med. 2018 Jul/Aug;13(6):412-417

Macchi M, Bambini L, Franceschini S, et al. The effect of tobacco smoking during pregnancy and breastfeeding on human milk composition-a systematic review. Eur J Clin Nutr. 2021 May;75(5):736-747

McGrath-Morrow SA, Hayashi M, Aherrera A, et al. The effects of electronic cigarette emissions on systemic cotinine levels, weight and postnatal lung growth in neonatal mice. PLoS One. 2015;10(2):e0118344
 
Mennella JA, Beauchamp GK. Smoking and the flavor of breast milk. N Engl J Med. 1998 Nov 19;339(21):1559-60
 
Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short term effects on infant feeding and sleep. Pediatrics. 2007;120:497– 502

Miranda RA, Gaspar de Moura E, Lisboa PC. TOBACCO SMOKING DURING BREASTFEEDING INCREASES THE RISK OF DEVELOPING METABOLIC SYNDROME IN ADULTHOOD: LESSONS FROM EXPERIMENTAL MODELS. Food Chem Toxicol. 2020 Jul 29:111623
 
Moshammer H, Hutter HP. Breast-Feeding Protects Children from Adverse Effects of Environmental Tobacco Smoke. Int J Environ Res Public Health. 2019 Jan 23;16(3). pii: E304
 
Napierala M, Merritt T, Maxela J, et al. Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review. Toxicology Letters 2016; 258:S197
 
Perrine CG, Pickens CM, Boehmer TK, et al.; Lung Injury Response Epidemiology/Surveillance Group. Characteristics of a Multistate Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping - United States, 2019. MMWR Morb Mortal Wkly Rep. 2019 Oct 4;68(39):860-864
 
Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015 Apr;10(3):135-41
 
Reijneveld SA, Brugman E, Hirasing RA. Infantile colic: maternal smoking as potential risk factor. Arch Dis Child. 2000 Oct;83(4):302-3
 
Shenassa ED, Wen X, Braid S. Exposure to Tobacco Metabolites via Breast Milk and Infant Weight Gain: A Population-Based Study. J Hum Lact. 2016 Aug;32(3):462-71

Sheu R, Stönner C, Ditto JC, et al. Human transport of thirdhand tobacco smoke: A prominent source of hazardous air pollutants into indoor nonsmoking environments. Sci Adv. 2020 Mar 4;6(10):eaay4109

Suzuki D, Wariki WMV, Suto M, et al. Secondhand Smoke Exposure During Pregnancy and Mothers' Subsequent Breastfeeding Outcomes: A Systematic Review and Meta-Analysis. Sci Rep. 2019 Jun 12;9(1):8535

Vio F, Salazar G, Infante C. Smoking during pregnancy and lactation and its effects on breast-milk volume. Am J Clin Nutr. 1991;54(6):1011–1016