WHO recommendation on tobacco use in pregnancy

WHO recommendation on tobacco use in pregnancy



Health-care providers should ask all pregnant women about their tobacco use (past and present) and exposure to second-hand smoke as early as possible in pregnancy and at every antenatal care visit.



Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016



  • This strong recommendation based on low-quality evidence has been integrated from the 2013 WHO recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy (1). Related recommendations from this guideline include the following:

–– Health-care providers should routinely offer advice and psychosocial interventions for tobacco cessation to all pregnant women who are either current tobacco users or recent tobacco quitters (strong recommendation based on moderate quality evidence).

–– All health-care facilities should be smoke-free to protect the health of all staff, patients and visitors, including pregnant women (strong recommendation based on low-quality evidence).

–– Health-care providers should provide pregnant women, their partners and other household members with advice and information about the risks of second-hand smoke (SHS) exposure from all forms of smoked tobacco, as well as strategies to reduce SHS in the home (strong recommendation based on low-quality evidence).

–– Health-care providers should, wherever possible, engage directly with partners and other household members to inform them of all the risks of SHS exposure to pregnant women from all forms of tobacco, and to promote reduction of exposure and offer smoking cessation support (strong recommendation based on low-quality evidence).



Exposure to tobacco smoke affects all stages of human reproduction. Tobacco smoking affects both male and female fecundity. Maternal cigarette smoking is associated with increased risks for ectopic pregnancy, premature rupture of membranes, abruptio placentae, placenta previa, miscarriage, stillbirth, preterm birth, low birth weight, small for gestational age, and congenital anomalies such as cleft lip. After birth, the risk for sudden infant death syndrome (SIDS) is increased among the offspring of women who smoked during or after pregnancy. The harms of tobacco use in pregnancy are not limited to smoked tobacco products only. Evidence suggests that infants born to women who use smokeless tobacco in pregnancy have a higher risk of several adverse outcomes such as stillbirth, preterm birth, and low birth weight. Additionally, maternal exposure to secondhand smoke (SHS) in pregnancy has also been associated with a modest reduction in birth weight, and can increase the risk of low birth weight (<2500 g) by 22%.



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)  (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does screening women for tobacco use at ANC visits (I) compared with not screening (C) improve health outcomes (O)?


Evidence summary

Further information and considerations related to this recommendation can be found in the 2013 WHO guideline, available at: http://www.who.int/tobacco/publications/pregnancy/guidelinestobaccosmokeexposure/en/


Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG did not identify any priority question related to this recommendation


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Health Topics: Tobacco

WHO Tobacco Free Initiative (TFI)



  1. WHO recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy. Geneva: World Health Organization; 2013 (http:// www.who.int/tobacco/publications/pregnancy/ guidelinestobaccosmokeexposure/en/, accessed 29 September 2016).
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016). 17. DECIDE [website].
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).


Citation: WHO Reproductive Health Library. WHO recommendation on tobacco use in pregnancy. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.