Introduction

Nicotine poisoning refers to the toxic effects caused by an excessive amount of nicotine entering the body. In recent years, nicotine poisoning is more common and is usually due to the use of nicotine as an insecticide, accidental ingestion/inhalation of tobacco, ingestion of nicotine-containing plants, and using cigarettes, vapes/e-cigarettes and pure liquid nicotine. Notably, liquid products have a greater concentration of nicotine compared to other tobacco products.¹  

Sources and scenarios of poisoning

Smoking/vaping during pregnancy

Smoking or being exposed to nicotine in other ways is significantly warned against during pregnancy. This is because the toxic chemical is extremely harmful to both maternal and foetal health. Approximately 15 - 25% of birth parents still smoke during this period, and for the portion of women who cease smoking, they often start again after giving birth.^2,3

smokeless tobacco, nicotine replacement therapy (NRT)

Smokeless tobacco is extensively used among pregnant birth parents as a way to reduce smoking while pregnant, while still experiencing the required effects of nicotine. Smokeless tobacco products are popular in countries like India. However, smokeless tobacco still delivers a high dose of nicotine and poses a risk. Nicotine replacement therapy (NRT) is available in formats like gums, patches, inhalers, nasal spray, mouth spray, oral strips, lozenges and microtabs. NRT is known to increase successful smoking cessation in non-pregnant persons by 1.5 to 2-fold. However, this hasn’t been proven in pregnant birth parents. NRT is considered to be safer than smoking during pregnancy, but sufficient evidence is not available.^2,3

Environmental/secondhand exposure

Secondhand smoke can still have significant effects on foetal health, and so this should be avoided while pregnant. Passive exposure can still result in nicotine and other toxins entering the bloodstream of the pregnant individual.²

Mechanism of nicotine toxicity

An individual is exposed to the effects of nicotine when it enters the body. It is absorbed through the skin in the liquid form, rapidly absorbed into the lungs, and absorbed by the mucous membrane of the mouth and the intestines. Nicotine crosses the placenta quickly and easily, and the concentration usually peaks in about 15-30 minutes. It can also accumulate in breast milk as well as the foetal brain.^1,3 

Nicotine binds to nicotinic acetylcholinergic receptors (nAChRs), located in the brain and peripheral nervous system, and produces its effects. Studies have shown that nicotine is metabolised faster in pregnancy due to physiological changes in liver enzyme activity. ³

Maternal health risks

Currently, there are no cases reported detailing nicotine poisoning during pregnancy in a person assigned female at birth (AFAB). However, considering the usual symptoms of nicotine poisoning, it is expected that an expectant parent’s health can be affected negatively.^1,3  

Common nicotine poisoning symptoms

• Nausea
• Vomiting
• Dizziness
• Headache
• High blood pressure* – research has shown that smoking cigarettes during pregnancy reduces the risk of gestational hypertension and preeclampsia
• Abdominal pain
• Tremors
• Seizures 
• Muscle weakness/paralysis
• Respiratory failure

Reported symptoms/complications due to nicotine exposure 

• Low maternal weight following chronic exposure
• Cardiovascular effects
• Preterm labour and delivery

Foetal risks

The developing foetus is particularly vulnerable to the toxic effects of nicotine, which can cross the placenta and directly affect foetal tissues, including the brain. The adverse effects of nicotine on the foetus are well documented and may be multifactorial, linked to the nutritional status of the birth parent, restricted placental blood flow and direct nAChRs activity in the foetal brain. There are multiple ways that the foetus can be affected.^2,3,4  

Developmental issues

• Uteroplacental insufficiency (reduced placental blood flow)
• Low birth weight – not seen in NRT pregnant birth parents 
• Premature birth
• Stillbirth
• Increased susceptibility to injections and respiratory-related disorders
• Sudden infant death syndrome (SIDS)

Neurodevelopmental impact

• Impaired brain development – motor, sensory and cognitive deficits
• Behavioural issues – aggression, hyperactivity, oppositional behaviours
• These effects can progress into late childhood and adolescence, increasing the risk of mental health disorders like attention-deficit/hyperactivity disorder (ADHD)³

Toxic effects

• Direct fetal nicotine dependence – there is an increased risk of neonates developing nicotine dependence later due to early neurochemical imprinting 

Prevention and management

Avoidance

Staying away from nicotine products during pregnancy is the best prevention option for birth parents. This will produce numerous benefits, as it will reduce the risk of pregnancy complications and improve maternal and foetal health, leading to an overall healthier pregnancy.²

Education

By learning about the effects of nicotine on pregnancy, expectant parents can make informed decisions for the betterment of their health and unborn children through awareness campaigns and antenatal education. It is also important that families, friends, carers and other persons educate themselves as well to support birth parents and to avoid nicotine exposure.²

Medical response

Treating for nicotine poisoning includes activated charcoal to reduce nicotine absorption in the intestines. Other supportive treatments may be used for specific symptoms, like antiseizure medications, intravenous (IV) fluids and oxygen ventilation. Close monitoring of maternal and foetal status.¹

Summary

Nicotine poisoning during pregnancy poses serious health risks for both the mother and fetus, largely due to nicotine’s rapid absorption and ability to cross the placenta. While commonly linked to smoking and vaping, exposure can also come from smokeless tobacco, nicotine replacement therapy (NRT), or secondhand smoke. These sources deliver nicotine into the bloodstream, where it affects maternal health and foetal development. Although direct cases of nicotine poisoning in pregnant individuals haven’t been widely reported, known symptoms include nausea, dizziness, seizures, and cardiovascular complications. Chronic exposure can also lead to preterm labour and reduced maternal weight.

The foetus is especially vulnerable. Nicotine reduces placental blood flow and directly affects foetal brain development, potentially leading to low birth weight, premature birth, stillbirth, neurodevelopmental disorders, and increased risk for sudden infant death syndrome (SIDS). These effects can persist into childhood and adolescence, contributing to behavioural issues and mental health challenges. Long-term developmental and behavioural issues, such as ADHD and cognitive impairments, may also arise.

Preventing nicotine exposure during pregnancy is essential. Avoiding all nicotine products, promoting education, and ensuring timely medical intervention in cases of suspected poisoning can significantly reduce the associated risks and support healthier outcomes for both mother and child.