Gillian S. Gould, Ling Li Lim, Joerg Mattes

Tobacco smoking during pregnancy is the most important modifiable risk factor for adverse pregnancy outcomes and long-term health complications for mother and bab(ies). Tobacco use during pregnancy has reduced in high-income countries; but not for Indigenous women in Australia, New Zealand, the United States, and Canada. This evidence-based review focusses on tobacco use among Indigenous pregnant women in high-income countries, who share a history of European colonisation. Indigenous women are more likely to use tobacco because of socio-economic disadvantage, social norms, and poor access to culturally-appropriate tobacco cessation support. Complications arising from tobacco-smoking during pregnancy such as low birth weight, prematurity, perinatal death, and sudden infant death syndrome are much higher in Indigenous populations. Effective approaches to cessation in pregnant non-Indigenous women involves behavioral counselling with or without nicotine replacement therapy (NRT). Higher nicotine metabolism during pregnancy, and poor adherence, may affect therapeutic levels of NRT. Only two randomized trials were conducted among Indigenous women: neither found a statistically significant difference in cessation rates between the treatment and comparison arms. Considerations should be given to: a) whole life course approaches to reduce tobacco use in Indigenous women; b) prohibiting tobacco promotion, and reducing access to alcohol for minors to prevent smoking initiation in Indigenous youth, c) training healthcare professionals in culturally-appropriate smoking cessation care to improve services access. It is critical to ensure acceptability and feasibility of study designs, consult with the relevant Indigenous communities and pre-empt implementation challenges. Research is needed into the effect of reducing or stopping smoking during pregnancy when using NRT, on subsequent maternal and infant outcomes.