Cigarette smoke increases a baby’s risk of sudden infant death syndrome (SIDS), respiratory infections, pneumonia, asthma, bronchitis, and lung cancer. While babies exposed to nicotine—one of the highly addictive substances found in tobacco smoke—can be fussier, have more colic, disturbed sleep, nausea, and are more likely to become smokers themselves (see Nicotine in Breast Milk). Nicotine replacement therapy (NRT) by patch, gum, spray or inhaler will at least avoid some of the harmful effects of passive smoking for mother and baby. However nicotine does still pass into the breast milk of a mother using these products.
Are nicotine replacement products recommended for breastfeeding mothers? What about e-cigarettes, vaping and breastfeeding? This article looks at the recommendations for breastfeeding mothers who are considering alternatives to traditional cigarettes.
Nicotine replacement therapy and breastfeeding
Although there has not been much research on NRT it is thought that the small amount of nicotine excreted into breast milk from nicotine therapy products is less dangerous for the baby than smoke inhalation from smoking traditional tobacco products.1 Nicotine absorption from NRTs (including nicotine gum, transdermal patch, nasal spray, inhaler, sublingual tablets, and lozenges) is slower than from smoking and blood levels of nicotine rise more slowly.2 Breastfeeding author Nancy Mohrbacher explains:
Nicotine replacement products provide blood nicotine levels high enough to prevent or reduce withdrawal symptoms but without the “buzz” of cigarettes. They are also missing the tars, carbon monoxide, and lung irritants that come with smoking.
However, Lactmed3 cautions that nicotine crosses into breast milk readily; and based on animal studies it may increase a baby’s risk of SIDS and may interfere with normal lung development. Lactmed says no studies have been undertaken to resolve concerns around using nicotine products for breastfeeding mothers. See Nicotine in Breast Milk for further information on the effects of nicotine.
Nicotine and colic
One study found that babies exposed to nicotine replacement therapy in pregnancy had a higher risk of getting infant colic to the same degree as babies of mothers who smoke regular tobacco—suggesting nicotine may be the ingredient in smoking that causes colic.4
The UK’s National Institute for Health and Care Excellence (NICE) says that nicotine products taken at intervals (intermittent therapy) are preferred in breastfeeding women as opposed to products that provide a steady stream of nicotine (such as a nicotine patch, see next section). This allows blood levels of nicotine time to fall before the next breastfeed.5
Nicotine skin patches provide a steady level of continual nicotine. This prevents the possibility of timing breastfeeds so that nicotine levels are lower in breast milk at the time of a breastfeed. However, using the lowest strength patch available e.g. 7 mg is said to reduce a baby’s exposure to nicotine by as much as 70% compared to smoking or using a high strength patch.67 Removing the patch at bedtime can lower the levels of nicotine at night.8 Following a clinical trial, breastfeeding and medications expert Thomas Hale and colleagues say nicotine patches are safer than smoking:
Undertaking maternal smoking cessation with the nicotine patch is, therefore, a safer option than continued smoking.
A nicotine nasal spray delivers nicotine to the blood more rapidly compared to other NRT products and is closer to the rate of nicotine delivery of cigarette smoking (Benowitz et al, 2009). Even so Lactmed says that a nicotine spray reduces blood and probably breast milk levels of nicotine by two thirds compared with smoking a cigarette although no studies on breastfeeding mothers have been reported.
Blood levels of nicotine from nicotine gum can vary quite widely and may be similar to smoking traditional cigarettes however there aren’t any studies on breastfeeding mothers using this product (Lactmed, 2018). Hale says levels of blood nicotine from chewing gum may be 30-60% of the levels of blood nicotine found in cigarette smokers. Hale also states however that if the gum is chewed rapidly the levels of nicotine may be similar to smoking itself. Breastfeeding mothers are advised to avoid breastfeeding for two to three hours after chewing this product (Halesmeds.com. 2018)
Medications author Thomas Hale says levels of nicotine dispensed in an inhaler are probably too low to affect a breastfeeding baby (Halesmeds.com. 2018) . But as with all nicotine replacement products, levels will depend on how used:
Habitual smokeless tobacco users will receive 130-250 mg of nicotine per day compared to 180 mg per day for 1 pack of cigarettes.
E-cigarettes, vaping and breastfeeding
Electronic cigarettes or e-cigarettes (electronic nicotine delivery systems) are battery powered fake cigarettes consisting of a mouth piece, a cartridge with nicotine and other chemicals, and an atomiser that converts the liquid into a vapour. Some look like a traditional cigarette and some look more like a pen and are called vaporisers. In the UK e-cigarettes are regulated under the UK Tobacco and Related Products Regulations 2016 which translates the European Union Tobacco Products Directive (2014/40/EU) into UK law.9 In America different brands are not safety regulated by the U.S. Food and Drug Administration (FDA) and contain various chemicals and flavourings with varying amounts of nicotine 1011.
The e-cigarette user inhales nicotine vapour from the cartridge. When the smoker breathes out again, a mix of nicotine and chemical vapour is released into the air potentially exposing your baby and others to secondhand emissions. Opinions differ on how harmful this could be to the user, family members or colleagues. E-cigarettes have not been thoroughly evaluated in scientific studies and more research is needed12. Lung.org says it is concerned about the health consequences of these products:
In 2016, the Surgeon General concluded that secondhand emissions contain, “nicotine; ultrafine particles; flavorings such as diacetyl, a chemical linked to serious lung disease; volatile organic compounds such as benzene, which is found in car exhaust; and heavy metals, such as nickel, tin, and lead.”
The mid-to-long-term consequences of e-cigarettes are not yet known, as it’s a new product and has been sold for less than a decade in the U.S. While much remains to be determined about these lasting health consequences of these products, we are very troubled by what we see so far. The inhalation of harmful chemicals can cause irreversible lung damage and lung diseases.
Meanwhile a report from Public Health England in 2020 concludes:
vaping regulated nicotine products has a small fraction of the risks of smoking, but this does not mean it is safe
This report does not mention safety with respect to a breastfeeding baby but links to the following document to guide health professionals:
Can I use an e-cigarette if I’m breastfeeding?
Based on the available evidence on e-cigarette safety there is no reason to believe that using an e-cigarette would compromise breastfeeding. If vaping is helping you to quit smoking and stay smokefree, you should carry on with it, including while breastfeeding.
The UK’s National Health Service website says:
While using an e-cigarette (vaping) is a lot safer than smoking, it isn’t completely risk free. As well as nicotine, e-cigarette liquid and vapour can contain toxic substances, although these are mostly at much lower levels than in cigarette smoke.
At the moment there are no e-cigarettes licensed as medicines. New mums are advised to use licensed NRT products for help with quitting smoking and staying smokefree.
However, if you do choose to use an e-cigarette to help you stay smokefree, it’s still better to carry on breastfeeding as the benefits will outweigh any potential harm.
More research needed
Thomas Hale talking specifically about e-cigarettes and breastfeeding, says that more research is needed on the safety and long-term effects of vaping and breastfeeding (Halesmeds 2018)
Nicotine replacement products, including e-cigarettes and vaping are relatively new products and there is conflicting research about their safety record and very little information about their safety for the breastfed baby whose mother uses them. Generally nicotine replacement therapy is thought to be less dangerous to the breastfed baby than traditional cigarettes but little is known about the consequences of e-cigarettes. Nicotine can affect the breastfed baby via breast milk and the effects will be greater the more heavily nicotine products are used.
If you are considering nicotine replacement therapy while breastfeeding, contact your health professional or stop smoking service to discuss which product is recommended for your situation.