Fifty years ago, NRT, Chantix, Zyban, e-cigarettes, telephone quit lines and the Internet didn't exist. Nearly all pregnant smokers who quit smoking did so unassisted by going cold turkey. What about today?

Surprisingly, little has changed.

"Our findings highlight the opportunity for presenting the positive message about unassisted cessation as the most common and successful quitting method to pregnant smokers who are ready to try to quit."

Those are the closing 32 words from a study of 3,154 pregnant smokers published on April 2, 2023 in BMC Pregnancy and Childbirth.

The study analyzed 2016–2018 Pregnancy Risk Assessment Monitoring System (PRAMS) survey responses from 7 states (Arkansas, Georgia, Iowa, Utah, Virginia, Vermont, or West Virginia ) asking standardized CDC-generated postpartum smoking and quitting questions.

Pregnancy Attempts

Selecting from a list of 10 stop smoking methods, paths, and support sources, women were asked to select all that they had used during their pregnancy. A separate question asked about e-cigarette use.

Among the 78% or 2,477 who indicated that they'd made a quitting attempt, 71.5% (1,856) selected "Try to quit on my own (e.g., cold turkey)." Only 6.3% selected "Use a nicotine patch, gum, lozenge, nasal spray or inhaler," 6.9% used e-cigarettes, 2.7% visited a quitting website or telephoned a quit line, 1.3% used bupropion (Zyban/Wellbutrin) and 0.8% used varenicline (Chantix).

But trying is different from succeeding. Which method was most effective?

Method Effectiveness

The survey asked, "In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day?" The last of 7 available answers was, "I didn't smoke then."

Overall, 1,414 (55.3%) of pre-pregnancy smokers self-reported being smoking abstinent during late pregnancy.

As for quitting method effectiveness, 64.8% who quit cold turkey reported not smoking during the final 3 months of pregnancy. That's roughly twice the effectiveness of women who turned to vaping e-cigarettes (31.3%) or for a pooled group of all remaining quitting methods, including NRT and prescription medications (35.7%).

Method Productivity

As for which method generated the most success stories, unassisted cold turkey produced 1,203 of 1,414 third-trimester quitters, a whopping 85% of all cigarette-free women.

The most chosen method, the most effective, and the most productive, given quitting product marketing claims, while you may be thinking that unaided cold turkey's success is limited to pregnancy, the authors cite a number of studies suggesting otherwise, including Doran 2006.

There, an Australian study of 2002-2003 smoking family practice patients found that cold turkey was the most chosen method (80.3%), the most productive method (generating 88% or 1,942 of 2,207 of all successful quitters), and roughly twice as effective as NRT or bupropion. Sound similar?

That was 20 years ago. Transfer to vaping e-cigs has altered basic "quitting" math. While cold turkey's share in most recent real-world observational studies is significantly less, when considering nicotine dependency recovery, not just smoking cessation, it continues to produce the vast majority of successful quitters.

Staying Quit

What about staying smoke-free after giving birth? The new study examined that too.

The study's three most disturbing findings are that roughly 1 in 5 women who smoked prior to pregnancy didn't attempt quitting (21.4% or 677 of 3,154 smokers), that 41.9% who attempted quitting failed (1,037 of 2,477), and, while 1,440 succeeded in quitting, only 955 reported being smoke-free shortly after giving birth.

That means that roughly 70% of newborns were forced to bond to the 7,000+ chemicals that cigarette smoke deposits on their mother's hair, skin, clothing, and breath, instead of her natural scent.

As for those who relapsed, 44.6% who attempted quitting cold turkey remained smoke-free (828 of 1,856), 31.2% who vaped were not smoking, and just 18.9% of all other pooled quitting methods remained abstinent.

Why 70% Still Smoking

Non-quitters (21%), failed quitters (33%), and postpartum relapses (18%), the burning question is, why are the vast majority of women who smoked prior to pregnancy, smoking shortly after giving birth?

After 23 years of daily working with smokers, I hypothesize that it's due to a multitude of factors, including the obvious, that smoked nicotine is highly addictive, that it's real drug addiction in every sense, a mental illness as permanent as alcoholism.

As for the 21% who failed to attempt quitting, should primary blame fall upon those best positioned to offer meaningful help, their family physicians and prenatal care providers? Before them stood a golden opportunity to help the expectant woman leave the office super excited about breaking smoked nicotine's grip upon her mind and life, in helping prepare her for smoke-free motherhood.

A 2006 study found that although 98% of surveyed Ohio obstetricians and gynecologists asked patients about smoking, 34% failed to offer advice, 71% failed to assist with quitting, and 94% failed to make a cessation-related follow-up visit or referral.

As for the new study's 33% of failed pregnancy quitters, what percentage attempted to quit for the baby? Why does it matter? Because quitting for others, including the unborn, roots her attempt in self-deprivation and sacrifice, a recipe for relapse.

As yet, there is no motivation-shifting research investigating the consequences of helping pregnant women accelerate their own dream of someday quitting, instead of the natural tendency to quit out of fear of harming the fetus.

Otherwise, she can only remain afraid for so long before growing numb to it. If quitting for herself, while allowing her unborn to inherit freedom's fruits, embracing feeling her healing while coming home will likely melt quitting fears and dread into like (or even love) of being free within just 2 to 3 weeks.

As for postpartum relapses, what percentage of those women also "quit for the baby"? Again, there is no data because there's been no research.

Whether relapse occurs during pregnancy or soon after birth, what are the consequences of CDC and NCI websites having for decades taught medical students, physicians, smokers, and quitters that "slips happen," suggesting that smoking lapse is normal, expected, and easily survivable when lapse/relapse studies suggest that nearly all lapses end in relapse?

More neglected research, how hard would it be for one study arm to teach that "slips happen, it's no big deal," while the other arm teaches that lapse equals relapse, that one puff would be too many, while thousands won't be enough, that the key to lasting freedom is to Never Take Another Puff?

Tail Still Wagging the Dog

The new pregnancy study's authors express concern "that overmedicalizing smoking cessation may disempower smokers and create artificial barriers to quitting."

Why do the CDC and NCI minimize lapse? Because pharmaceutical industry financial influence was allowed to author U.S. cessation policy. Because gradual nicotine weaning via NRT normally takes weeks or months and isn't nearly as easy or effective as gum, patch, and lozenge advertising suggests.

Try this. Imagine finding out you're pregnant and then searching for "cold turkey" on the government's SmokeFree.gov website.

To the authors' point about disempowering smokers and contrary to their findings, the only "cold turkey" resource returned discourages smokers from quitting cold turkey.

Pregnant women are told that "It is difficult to quit smoking on your own, but quitting cold turkey is not your only choice. In fact, choosing another option may improve your chances of success."

Type "quitting methods" into the SmokeFree.gov search engine. The top result returned is entitled "Explore Quit Methods."

There, pregnant women will find web pages devoted to 13 different quitting methods. Guess which method is missing? Need a hint? It's the one the U.S. Surgeon General's 2020 "Smoking Cessation" report acknowledged as helping more smokers quit each year than all others combined.

#NicotineFree2023 Yes you can!

---

John R. Polito received his JD from the University of South Carolina School of Law in 1985, where he graduated Wig & Robe. He is a former 3-pack-a-day thirty-year smoker and the 1999 founder of WhyQuit. A nicotine cessation educator since 2000, John mentored under Joel Spitzer for two decades, presenting more than 100 live nicotine dependency recovery programs modeled after Joel's programs. He is the author of "Freedom from Nicotine - The Journey Home," "Smart Turkey," 6 peer-reviewed journal articles, and founder and director of Turkeyville, a 15,000-member Facebook support group exclusively for cold turkey quitters. Email: johnpolito54@gmail.com

---

---