Cigarette smoke increases a baby’s risk of sudden infant death syndrome (SIDS), respiratory infections, pneumonia, asthma, bronchitis, and lung cancer. And 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 in 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 without the tars, carbon monoxide, and lung irritants that come with smoking and without the “buzz.”
However, Lactmed (search: Nicotine) cautions whether enough research has been undertaken regarding using nicotine products for breastfeeding mothers. Nicotine crosses into breast milk readily; increasing a baby’s risk of SIDS and affecting their lung development. See Nicotine in Breast Milk for further information on the effects of nicotine.
Avoid using nicotine products before breastfeeding
The UK’s National Institute for Health and Care Excellence (NICE) says that nicotine products taken at intervals are preferable to those that provide a steady stream of nicotine. This allows blood levels of nicotine time to fall before the next breastfeed.
For breastfeeding woman, intermittent dosing formulations are preferable and the woman should be advised to avoid using the products for at least one hour before breastfeeding. Liquorice-flavoured NRT products are not recommended during breastfeeding.
Nicotine skin patches provide a steady level of continual nicotine which prevents timing breastfeeds so that nicotine levels are lower in breast milk. 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% 3 4 5 and removing the patch at bedtime can lower the levels of nicotine at night. Breastfeeding and medications expert Thomas Hale says nicotine patches are safer than smoking and the risk to baby is less than using formula:
Undertaking maternal smoking cessation with the nicotine patch is, therefore, a safer option than continued smoking.
the risk of using nicotine patches while breastfeeding is much less than the risk of formula feeding.
Mothers who use a nicotine patch should not smoke while using a patch as it would increase the baby’s nicotine exposure excessively and make mother ill.
A 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 (Lactmed search: nicotine).
Blood levels of nicotine from nicotine gum can vary quite widely and may be similar to smoking traditional cigarettes although no studies on breastfeeding mothers using this product have been reported (Lactmed search: nicotine). Breastfeeding mothers are advised to avoid breastfeeding for two to three hours after chewing this product 6.
Medications author Thomas Hale says levels of nicotine dispensed in an inhaler are probably too low to affect a breastfeeding baby 7. But as with all nicotine replacement products, levels will depend on useage:
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 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. 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 89. Once the European Union (EU) Tobacco Products Directive (TPD) 26 comes into effect in Member States from May 2016, electronic cigarettes containing up to 20 mg/ml of nicotine will be regulated by the TPD 10.
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 family members or colleagues. E-cigarettes have not been thoroughly evaluated in scientific studies11. Lung.org says there is no evidence to say secondhand emissions are safe:
Little is known about these emissions or the potential harm they may cause. Two initial studies have found formaldehyde, benzene and tobacco-specific nitrosamines (all carcinogens) coming from those secondhand emissions. Other studies have shown that chemicals exhaled by users also contain formaldehyde, acetaldehyde and other potential toxins. There is no evidence that shows e-cigarettes emissions (secondhand aerosol) are safe for non-users to inhale.
Meanwhile a report from Public Health England in 2015 concludes that there are no identified health risks to bystanders from e-cigarettes. This report does not mention safety with respect to a breastfeeding baby but says generally:
While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger. It has been previously estimated that [e-cigarettes] are around 95% safer than smoking. This appears to remain a reasonable estimate.
[E-cigarettes] release negligible levels of nicotine into ambient air with no identified health risks to bystanders.
More research needed
Medsmilk Online 2016, talking specifically about e-cigarettes and breastfeeding, says that more research is needed on the safety and long-term effects of vaping and breastfeeding;
the amount of nicotine that transfers into breastmilk after an acute inhalation of an e-cigarette is probably minimal, and comparable to that of a nicotine inhaler. But it is reported that an average e-cigarette user inhales up to 120 puffs/day. This could possibly amount to significantly higher blood nicotine levels. It is too early to comment on the long-term effects of chronic use of e-cigarettes and more studies are required.
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.