Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review
Introduction
Smoking is one of the most serious contemporary threats of civilization. Exposure to environmental tobacco smoke (ETS) has been linked to a number of health effects. ETS exposure is associated with adverse impacts on male and female reproduction, perinatal and postnatal manifestations of developmental toxicity, respiratory diseases, cardiovascular diseases and cancers (Haroun et al., 1999).
Over 5300 compounds have been identified in tobacco smoke. ETS or secondhand smoke, means exposure to a mixture of compounds from the smoke of burning tobacco products and smoke exhaled by the smoker. Classes of compounds include carbon and nitrogen oxides, amides, imides, lactams, lactones, aldehydes, ketones, carboxylic acids, alcohols, phenols, esters, amines, N-nitrosamines, N-heterocyclics, nitriles, nitro compounds, anhydrides, carbohydrates, ethers, hydrocarbons and metals (IARC, 2012). The principal tobacco alkaloid and major psychoactive component in smoke is nicotine. It is responsible for the addictive properties of tobacco smoke (Hukkanen et al., 2005). There are over 70 carcinogens in tobacco smoke that have been evaluated by the International Agency for Research on Cancer – IARC (IARC, 2004). Sixteen of them (among others: N′-nitrosonornicotine, 2-naphthylamine, formaldehyde, benzene, arsenic, beryllium, nickel compounds, chromium VI, cadmium, polonium-210) are classified as Group 1 - carcinogenic to humans. Moreover, there are other carcinogens in tobacco smoke that have not been evaluated by the IARC Monographs program (IARC, 2012).
In spite of documented evidence on the harmful effects of smoking on the fetus and infants, a considerable number of women continue to smoke during pregnancy and lactation. In the United States (US), 10.7% of pregnant women smoke (Centers for Disease Control and Prevention, 2012). It is estimated that in Europe this problem also affects more than 1 in 10 pregnant women (Euro-Peristat, 2013). As there is a tendency to quickly return to tobacco smoking after an interval of smoking cessation during pregnancy with 50–80% relapsing to smoking within six months after delivery. The US Surgeon General (SG), the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) have recommended exclusive breastfeeding (with the exception of infants of HIV positive mothers) during the first 6 months (Centers for Disease Control and Prevention, 2002, Butte et al., 2002, Gartner et al., 2005). Thus the number of women smoking while breastfeeding represent a significant population of women and infants at risk.
Breast milk of mothers who smoke is a significant contributor to infant exposure to ETS constituents. Women who are less educated, have lower socioeconomic status and who began smoking at a younger age may not recognize or be aware of the adverse effects of tobacco smoking on fetal development, low birth weight, premature infants and increased complications of pregnancy such as placental abruption (Centers for Disease Control and Prevention, 2012, Euro-Peristat, 2013).
This article is a review of previous reports on the impact of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, through a MEDLINE search using the terms “smoking and breastfeeding”, “smoking and lactation”, “smoking and milk composition”, “nicotine and breast milk”. Additional studies were identified through a search of the Cochrane and Scopus database, through discussions with experts, and by hand-searching of reference lists from major review articles. This review aims to describe the literature available with particular reference to the impact of tobacco smoking during breastfeeding and nicotine consumption on the lactation process, milk changes in composition and dangers/risks on the well-being and health status of children as well as to discuss the necessary future directions of research in this matter.
Section snippets
Nicotine and cotinine in breast milk
Simultaneous maternal smoking and breastfeeding significantly increases absorption of nicotine by the infant compared to this only being exposed to tobacco smoke (Luck and Nau, 1985, Dahlström et al., 1990, Schulte-Hobein et al., 1992). Studies of pharmacokinetics of nicotine have shown that its half-life in milk (t1/2=97±20 min) is longer than the half-life in serum (t1/2=81±9 min); however, the difference between these two values was not statistically significant (Luck and Nau, 1985). When
Effect of smoking on the lactation process
Among women who smoke reduced production of milk and shorter lactation periods are observed (Clements et al., 1997, Scott and Binns, 1999, Horta et al., 2001, Knudsen et al., 2001, Letson et al., 2002). Hopkinson et al. (1992) have shown that the daily amount of milk up to 2 weeks after birth was 406±262 mL/day in smoking mothers, while in the control group of non-smoking mothers 514±338 mL/day. Between weeks 2 and 4 after initiation of lactation, the amount of milk produced by non-smoking women
Tobacco smoke impair breast milk taste and composition
Infants of mothers smoking during pregnancy are usually born with lower birth weights by 150–250 g than infants of non-smoking women (Fried, 1993). The results of studies on weight gain of breastfed babies of smoking mothers are varied (Schulte-Hobein et al., 1992, Schwartz-Bickenbach et al., 1987, Little et al., 1994, Nafstad et al., 1997, Boshuizen et al., 1998, Visscher et al., 2003, Shenassa et al., 2015). Nevertheless, there are reports indicating that nicotine in breast milk may suppress
Exposure to tobacco smoke through breast milk and the infant development
Infants exposed to the harmful effect of smoking by their mothers run a higher probability of suffering from otitis media, and from lower and upper respiratory tract infections – 2.9, 8.2 and 15.3 times higher, respectively. However, it has been shown in the case of SHS exposure that breastfeeding may reduce this risk (Yilmaz et al., 2009).
Nicotine in breast milk may affect the infants' heart rate variability. Power values of frequency domains (HRV) in male infants of mothers who smoke have
Discussion
ETS is a complex mixture of chemicals generated during burning of tobacco products. Chemicals present in ETS, among others, include mutagens, carcinogens and reproductive toxicants (Haroun et al., 1999). To date, over 70 compounds in tobacco smoke have been identified by IARC as carcinogens. 16 of them are listed as carcinogenic to humans (Group I) (IARC, 2012). There are reports about the transfer of some of them (for example tobacco-specific nitrosamines: NNN, NNK, BaP) into milk (LaVoie et
Conflict of interest statement
The authors declare that there is no conflict of interest.
References (144)
- et al.
Hypothesis: smoking decreases breast feeding duration by suppressing prolactin secretion
Med. Hypotheses
(2013) - et al.
Arsenic, cadmium, lead, and aluminium concentrations in human milk at early stages of lactation
Pediatr. Neonatol.
(2014) - et al.
Breast-feeding and the prevalence of asthma and wheeze in children: Analyses from the Third National Health and Nutrition Examination Survey, 1988–1994
J. Allergy Clin. Immunol.
(2003) - et al.
Late emerging effects of prenatal and early postnatal nicotine exposure on the cholinergic system and anxiety-like behavior
Neurotoxicol. Teratol.
(2010) - et al.
Validation of a screening questionnaire for a human milk bank to determine the presence of illegal drugs, nicotine, and caffeine
J. Pediatr.
(2014) - et al.
Mercury, lead and cadmium in human milk in relation to diet, lifestyle habits and sociodemographic variables in Madrid (Spain)
Chemosphere
(2011) - et al.
Hormonal effects of smoking: II Effects on plasma cortisol, growth hormone, and prolactin
Am. J. Med. Sci.
(1986) - et al.
Determination of tobacco-specific nitrosamines in replacement liquids of electronic cigarettes by liquid chromatography-tandem mass spectrometry
J. Chromatogr. A
(2013) - et al.
Nicotine and cotinine concentrations in serum and urine of infants exposed via passive smoking or milk from smoking mothers
J. Pediatr.
(1985) - et al.
The influence of maternal nicotine exposure on neonatal lung carbohydrate metabolism
Cell Biol. Int. Rep.
(1992)
Chronic maternal nicotine exposure during gestation and lactation and the development of the lung parenchyma in the offspring. Response to nicotine withdrawal
Pathophysiology
Early postnatal nicotine exposure causes hippocampus-dependent memory impairments in adolescent mice: association with altered nicotinic cholinergic modulation of LTP, but not impaired LTP
Neurobiol. Learn Mem.
Earlier smoking habits are associated with higher serum lipids and lower milk fat and polyunsaturated fatty acid content in the first 6 months of lactation
Eur. J. Clin. Nutr.
The transfer of drugs and other chemicals into human milk
Pediatrics
Suppressed prolactin but normal neurophysin levels in cigarette smoking breast-feeding women
Clin. Endocrinol.
Assessing secondhand smoke using biological markers
Tob. Control.
Effects of smoking, mother’s age, body mass index, and parity number on lipid, protein, and secretory immunoglobulin A concentrations of human milk
Breast. Med
The effects of maternal passive smoking on maternal milk lipid
Acta Med. Iran.
Nicotine chemistry, metabolism, kinetics and biomarkers
Handb. Exp. Pharmacol.
Nicotine blocks the suckling-induced rise in circulating prolactin in lactating rats
Science
Maternal smoking during lactation: relation to growth during the first year of life in a Dutch birth cohort
Am. J. Epidemiol.
Fetal and neonatal nicotine exposure and postnatal glucose homeostasis: identifying critical windows of exposure
J. Endocrinol.
Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life
WHO Report Geneva
US Public Health Service Women and Smoking: A Report of the Surgeon General
The effect of acute and chronic administration of nicotine on lipoprotein lipase activity
Int. Angiol.
Maternal nicotine exposure during gestation and lactation induces kidney injury and fibrosis in rat offspring
Pediatr. Res.
Environmental tobacco smoke exposure during infancy
Am. J. Public Health
Association between exposure to environmental tobacco smoke (ETS) and breastfeeding behavior
Influences on breastfeeding in southeast England
Acta Paediatr.
The hypothalamus and the mechanism of sympathetic-adrenal inhibition of milk ejection
J. Endocrinol.
The influence of radioiodine therapy on ocular changes and their relation to urine cotinine level in patients with Graves' Ophthalmopathy
Neuro. Endocrinol. Lett.
Nicotine exposure in breastfed infants
Acta Paediatr.
Nicotine in breast milk influences heart rate variability in the infant
Acta Paediatr.
Nicotine and cotinine concentrations in the nursing mother and her infant
Acta Paediatr. Scand.
Accelerated metabolism of nicotine and cotinine in pregnant smokers
J. Pharmacol. Exp. Ther.
Nicotine metabolism and elimination kinetics in newborns
Clin. Pharmacol. Ther.
CYP2A6 genotype but not age determines cotinine half-life in infants and children
Clin. Pharmacol. Ther.
Maternal smoking and infant feeding: breastfeeding is better and safer
Matern. Child Health J.
Influence of smoking on human milk tumor necrosis factor-α, interleukin-1β, and soluble vascular cell adhesion molecule-1 levels at postpartum seventh day
Pediatr. Int.
Effect of maternal smoking on colostrum and breast milk cytokines
Eur. Cytokine Netw.
Nicotine dependence in women
J. Am. Med. Women’s. Assoc.
Tobacco-specific nitrosamines in electronic cigarettes
Comp. Liq. Aerosol Lev.
Determination of nicotine concentrations in human milk
Am. J. Dis. Child.
Pregnancy, maternal tobacco smoking, and early age leukemia in Brazil
Front. Oncol.
Prenatal exposure to tobacco and marijuana: effects during pregnancy, infancy, and early childhood
Clin. Obstet. Gynecol.
Adverse effects of nicotine and interleukin-1beta on autoresuscitation after apnea in piglets: implications for sudden infant death syndrome
Pediatrics
Postnatal expression of cytochrome P450 1A1, 2A3, and 2B1 mRNA in neonatal rat lung: influence of maternal nicotine exposure
Exp. Lung Res.
Breastfeeding and the use of human milk
Pediatrics
Cited by (139)
Tobacco use in currently married pregnant & lactating women in India; key findings from the National Family Health Survey-5
2024, The Lancet Regional Health - Southeast AsiaCauses of Low Milk Supply: The Roles of Estrogens, Progesterone, and Related External Factors
2024, Advances in NutritionWhat risk factors for Developmental Language Disorder can tell us about the neurobiological mechanisms of language development
2023, Neuroscience and Biobehavioral ReviewsThe heterogeneous associations of universal cash-payouts with breastfeeding initiation and continuation
2023, SSM - Population HealthDespite intention to breastfeed, smoking during pregnancy is associated with shorter breastfeeding duration
2023, Journal of Neonatal NursingCitation Excerpt :Therefore, it is difficult to address whether the association between smoking and BF prevalence is socio-cultural and/or physiological. Notably, evidence has been published from both perspectives (Amir and Donath, 2012; Napierala et al., 2016). However, no consensus has been reached regarding this relationship to date.