As we’ve given ever-deeper thought to our nation’s distressingly high infant morality rate, we’ve started to wonder how best to address the problem. Everything we’ve read in recent days seems to indicate that the rate could be dramatically lowered if more expectant mothers took better care of their bodies—specifically by quitting smoking, which pretty clearly results in low birth weights (and thus increased risk of death in the first year of life).
But we realize those cancer sticks can be mighty tough to give up, especially when a smoker feels unduly stressed—say, by the imminent arrival of a young’un and all the attendant madness that entails. So how about prescribing nicotine replacement therapies (NRTs) to pregnant women, instead of insisting that they go cold turkey?
The argument against this is pretty easy to discern: Nicorette and similar products contain a healthy dollop of nicotine, and so may still pose a threat to fetal health. But how much of a threat? We could only dig up one study on the topic, from Denmark, and it came down pretty clearly on the side of NRTs:
Of the 2% of women who had used NRT during pregnancy, 56% had continued to smoke during pregnancy, while 30% had stopped smoking for the duration of the pregnancy and 14% had quit smoking. A total of 495 of the 87,032 pregnancies (5.7 per 1000 births) ended in stillbirth. Among NRT users, the rate of stillbirth was 4.2 in 1000 births. Compared to nonusers, women using NRT had an unadjusted HR of 0.75 (95% CI 0.37-1.15) for stillbirth. The risk of stillbirth was not affected by the type of NRT used (patches only, chewing gum only, inhaling substances only, and various combinations of NRT products). Adjustment for smoking habits during pregnancy lowered the estimated risk, while adjustment for household socio-occupational status and maternal age did not change the estimate. Consistent with previous studies, the risk of stillbirth was increased during pregnancy among smokers who did not use NRT (HR 1.46, 95% CI 1.17-1.82). Women who both smoked and used NRT during pregnancy had a HR of 0.83 (95% CI 0.34-2.00).
While such a study only serves to get the research ball rolling, it does make us wonder about the potential for using NRTs to lower the American IM rate. The stumbling block, of course, will be the objections of idealists, who insist on cold turkey as the only truly safe means. But would a harm reduction strategy here really be immoral? The cold-turkey effectiveness rate is just so low, we almost feel as if more lives could be saved by going the pragmatic route. Yet we fear that such a thing can never come to pass, simply because of the all-or-nothing mindset that so many health practitioners favor.
When in doubt, we favor the policy that can save the maximum number of lives. But we also understand how such pragmatism might strike our more idealistic counterparts as cold-hearted. Who here is truly on the side of the angels? And how do we convince the opposing team of the righteousness of our views?