Medical Hypotheses 81 (2013) 582–586

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Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

Hypothesis: Smoking decreases breast feeding duration by suppressing

prolactin secretion q
Babak Bahadori a,⇑, Natalie D. Riediger b,c, Sharla M. Farrell b, Elisabeth Uitz a,
Mohammed F. Moghadasian b,c
a
State Clinic St. Poelten, Department of Internal Medicine 2, St. Poelten, Austria
b
University of Manitoba, Department of Human Nutritional Sciences, Winnipeg, Manitoba, Canada
c
Canadian Centre for Agri-food Research in Health and Medicine, St. Boniface Hospital Research Centre, Winnipeg, Manitoba, Canada

a r t i c l e i n f o a b s t r a c t

Article history: A number of studies, including new data summarized here, conclude that breast feeding duration is lower
Received 28 April 2012 in smoking mothers. Although some have suggested that this merely reflects poor health motivation in
Accepted 3 July 2013 those prone to smoke, several lines of evidence support the view that chronic smoking does indeed com-
promise breast feeding by suppressing prolactin secretion and thereby lowering breast milk volume.
Moreover, a recent clinical trial shows that an effective smoking cessation program can boost breast feed-
ing duration in smokers. An analysis of pertinent rodents studies suggests that chronic nicotine admin-
istration boosts dopaminergic activity in the tuberoinfundibular tract which functions to inhibit prolactin
release; this increase in dopaminergic activity, in turn, may reflect a nicotine-mediated suppression of
hypothalamic opioid activity.
Ó 2013 Elsevier Ltd. All rights reserved.

Breast feeding duration is low in smokers
A number of previous studies have found that duration of breast
feeding tends to be lower in women who smoke during the post-
partum period, as compared to non-smokers; our own recent
study, reported in an appendix, supports these findings [1–14]. In
China, where maternal smoking is quite rare, but paternal smoking
common, paternal smoking has recently been linked to shorter
breast feeding duration, possibly indicative of an adverse effect
of side-stream smoke [15]. A negative impact of smoking on initi-
ation of breast feeding is less consistently observed. If smoking
does indeed suppress breast feeding duration, this could be ex-
pected to have important health implications both for the infant
and the mother; prolonged breast feeding is associated with de-
creased maternal risk for breast and ovarian cancer, and possibly
metabolic syndrome, and breast-fed infants are at lower risk for
a number of types of infections [16–19].
Nevertheless, some commentators have suggested that smoking
per se does not notably influence lactation, but rather that motiva-
tional factors can account for lesser breast feeding duration in
smokers [20–24]. In other words, women who do not smoke, or
who are willing and able to quit smoking post-natally, simply have
q
The work was done in a cooperation of all the three institution mentioned
above.
⇑ Corresponding author. Address: State Clinic St. Poelten, Department of Internal
Medicine 2, Propst-Führer Straße 4, 3100 St. Poelten, Austria. Tel.: +43 6644304061;
fax: +43 274230019009.
E-mail address: b.bahadori@gmx.at (B. Bahadori).
better self-control and a more intelligent regard for their own wel-
fare and that of their infant which translates into a greater willing-
ness to commit to long-term breast feeding. By way of analogy, a
recent study has found that the chances of a mother breast feeding
for 6 months or more varied directly with the extent to which she
included fruits and vegetables in her diet; the authors of this study
argue credibly that typical variations in fruit and vegetable con-
sumption would not have such a major impact on capacity for lac-
tation as to account for these findings [24]. It does indeed seem
likely that psychological predispositions are playing some role in
the shorter breast feeding durations observed in smoking mothers.
If such predispositions were the sole reason for decreased dura-
tion of breast feeding in smokers, then it could be concluded that
post-partum smoking cessation programs would have little real
impact on breast feeding duration. But in fact there is good reason
to suspect that the physiological effects of nicotine addiction do in-
deed negatively impact capacity for lactation, and that achieving
postpartum smoking abstinence will indeed favorably influence
breast feeding duration:
1. Two studies have found that breast milk volumes are lower
in smokers than non-smokers [25,26].
2. There are several reports that maternal prolactin levels are
lower in smoking women both during pregnancy and post-
partum; low prolactin has also been noted in smoking
women outside of pregnancy [27–34]. As is well known,
prolactin is a major hormonal stimulant to breast milk pro-
duction [35,36].

0306-9877/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.mehy.2013.07.007
 B. Bahadori et al. / Medical Hypotheses 81 (2013) 582–586 583

3. Passive smoking by non-smoking women, as assessed by
blood cotinine levels at delivery, was associated with lesser
duration of breast feeding in one recent study [37]. This
finding is evidently consistent with a negative impact of
nicotine or other tobacco toxins on breast feeding duration
and it accords well with recent evidence that paternal
smoking adversely influences breast feeding duration [15].
4. A recent study provides cogent evidence that smoking ces-
sation per se can improve breast feeding duration [11].
Post-partum women were randomized to an incentive pro-
gram which provided reward vouchers for demonstrable
abstinence from smoking, or to a control program that pro-
vided the these vouchers without requirements. Breast
feeding was found to be greater at 8 and 12 weeks post-
partum in the first group, as opposed to the latter. Since
there is no reason to suspect that women randomized to
the first group had greater motivation for breast feeding,
the results suggest that smoking cessation per se was ben-
eficial for breast feeding duration. Moreover, analysis of the
data from both groups combined showed that those
women in either group who achieved smoking cessation
tended to achieve greater breast feeding duration; and a
multiple regression analysis showed that, within the first
group, smoking cessation entirely explained the observed
increase in breast feeding duration.
Of related interest is a recent controlled study which encour-
aged postpartum smoking abstinence indirectly by instruction in
infant bonding [13]. Smoking mothers who had ceased smoking
during pregnancy all received postpartum advice regarding the
importance of continuing smoking abstinence, but some were ran-
domly selected to receive various books, handouts, and DVDs in-
tended to encourage bonding with their infants. On follow-up
evaluation 8 weeks postpartum, 81% of the bonding-instructed
mothers were smoking abstinent and 86% were still breast feeding;
in the control group, 46% were smoking abstinent and 21% still
breast feeding at this time. Although in contrast to the previously
cited study it is not clear to what extent smoking abstinence per
se was responsible for longer breast feeding duration in the inter-
vention group, this study offers suggestive evidence that child-
bonding instruction soon after birth may be quite useful for pro-
moting both smoking abstinence and prolonged breast feeding.
We therefore suggest that smoking does indeed impair breast
feeding duration in the post-partum period, most probably by sup-
pressing prolactin secretion, and that effective smoking cessation
programs following childbirth, particularly those which stress in-
Dopamine secreted by hypothalamic tuberoinfundibular dopa-
minergic neurons is known to suppress pituitary secretion of
prolactin, and indeed is one of the major determinants of prolactin
activity [46]. Whereas an acute administration of nicotine is re-
ported to suppress this dopaminergic activity, chronic administra-
tion boosts it, resulting in a suppression of prolactin release
[45,47–49]. There is reason to suspect as postulated by Rasmussen
[45] that this chronic up-regulation tuberoinfundibular dopami-
nergic activity might be attributable, at least in part, to a concur-
rent suppression of opioid activity in the mediobasal
hypothalamus (MBH), as has been observed in rodents treated
chronically with nicotine [45,50]. Chronic nicotine administration
in rats leads to a reduction in expression of proopiomelanocortin
mRNA in the MBH (presumably a marker for opioid activity),
accompanied by an up-regulation of tyrosine hydroxylase expres-
sion in this region [45]. Tuberoinfundibular dopaminergic activity
is suppressed by opioids [47,51]; indeed, the acute stimulatory ef-
fect of a single dose of nicotine on prolactin release appears to be
mediated by an increase in opioid activity that inhibits hypotha-
lamic dopamine release [47]. Hence, the suppression of hypotha-
lamic opioid production associated with nicotine addiction an
effect which likely motivates the addiction, as nicotine acutely
boosts opioid activity [45,52] may be largely responsible for the in-
creased dopaminergic tone which inhibits prolactin release in
smokers.
However, this model is difficult to square with a recent clinical
study in which the impact of naltrexone administration on prolac-
tin levels was assessed in smokers and non-smokers [53]. While
the smokers showed less responsiveness to naltrexone than non-
smokers – as would be expected from a predicted down-regulation
of opioid activity in smokers prolactin rose in response to the nal-
trexone, a response opposite in direction to that predicted from the
model. Perhaps this reflects an impact of naltrexone on some part
of the brain other than the hypothalamus or perhaps rodent
models of nicotine addiction are less than perfect guides to the
Table 1
Characteristics of study cohort of Canadian women who gave birth (n = 3485).
Characteristic Proportion of sample sizea
Age
15-19 1.9
20-24 11.6
25-29 26.1
30-34 32.7
35-39 21.2
40-44 5.7
45-49 0.8

fant bonding, can be expected to have a favorable impact on breast Income

feeding duration. <$15000 9.9
$15000-$29999 14.5
$30000-$49999 21.5
$50000-$79999 29.2
>$80000 25.0
Nicotine addiction suppresses prolactin by up-regulating Education
tuberoinfundibular dopamine Less than secondary school graduation 7.8
Secondary school graduation 13.0
Some post-secondary education 6.6
How then does smoking suppress prolactin secretion? In rats, a
Post-secondary graduation 72.6
single dose of nicotine typically provokes prolactin secretion; how-
Marital status
ever, this response is substantially blunted if subsequent doses are
Married 62.2
given [38–42]. Studies in rats chronically treated with nicotine Common-law 17.5
show a decrease in blood prolactin levels [43–45]. In one provoca- Single (never married) 13.2
tive study, pregnant rats were injected with 2 mg nicotine daily Widowed/divorced/separated 7.1
from day 5 of gestation until the pups were weaned. Although their Racial origin
litter sizes and weights were near–normal at birth, the pups failed White 84.4
to gain weight normally, and about 70% died prior to weaning; the Visible minorityb 15.6

nicotine had blocked the normal post-partum rise in maternal pro- a

Percentages may not add up to 100% due to rounding; participants who did not
lactin, milk volumes were grossly subnormal, and most of the pups respond to a question were not included in the analysis of that question.
b
died from starvation [43]. In Canada, ‘‘visible minority’’ is defined as non-Caucasian people.
584 B. Bahadori et al. / Medical Hypotheses 81 (2013) 582–586

physiology of smoking humans. Further research will be required
to clarify the role of hypothalamic opioids in the chronic up-regu-
lation of MBH dopaminergic activity that characterizes nicotine
addiction.
Also of interest is a report that nicotine can act directly on pro-
lactin-secreting GH3 cells to inhibit transcription of the prolactin
gene; if valid, this effect evidently could complement the suppres-
sive impact of increased dopaminergic activity on prolactin secre-
tion [54].
Conflict of interest statement
None.
Appendix A. An observational study on breast feeding duration
in smokers
A.1. Data source
Data source for the present study was the Canadian Community
Health Survey cycle 2.1 Public Use File, conducted by Statistics
Canada (2003). The use of the data obtained from this survey
was approved by the University of Manitoba and Statistics Canada.
The survey provides cross-sectional estimates of health status,
health system utilization and health determinants and was con-
ducted from January 2003 to December 2003. The survey was
established by using three frames: (1) an area frame (48% of
respondents), (2) a telephone number frame (50% of respondents)
and a random digit–dialing frame (2% of respondents). The survey
was distributed to 1,30,000 people aged above 12 years in all prov-
inces and territories in Canada, excluding Canadian Forces Bases
and aboriginal reserves/Crown Lands. From this survey a sub-sam-
ple of women aged 15–49 years old who gave birth in the past five
years was analyzed in the present study.
A.2. Variables
The main outcome measure was the duration of breastfeeding.
The participants reported duration of breastfeeding for their last
child as either up to 12 weeks (3 months) or greater than 3 months.
Fifteen questions were examined concerning information on the
use and frequency of cigarettes, alcohol and illicit drugs. The ques-
tions pertaining to cigarette smoking habits aimed to determine
the frequency of smoking as daily, occasional or never during preg-
nancy and lactation. For both daily and occasional smokers, the fre-
quency of smoking during pregnancy and lactation was further
assessed.
A.3. Statistical analysis
Data were analyzed using SPSS version 11.5 for windows. Meth-
ods described by Riediger et al., were used to partially account for

Table 2
Association of smoking status and duration of breastfeeding.

Duration of breastfeeding (% sample size)

Adverse behaviour (n) < 3 months 3 months to > 1 year p-valuea p-valueb Odds Ratio (95% CI)b
Type of smoker (n = 2451) 46.7 53.3 p <0.001 p <0.05 1.229 (1.002, 1.508)
Daily 36.2 63.8
Occasional 29.6 70.4
Not at all

Type of smoker while pregnant (n=1601) 52.7 47.3 p <0.001 p <0.01 1.638 (1.232, 2.178)
Daily 44.9 55.1
Occasionally 30.7 69.3
Not at all
Number of cigarettes smoked daily while pregnant
(daily smokers) (n = 224)
1 to 5 40.9 59.1 0.568 (0.369, 0.874)4
6 to 10 53.9 46.1 p = 0.245 p=0.558
>10 62.2 37.8
Number of cigarettes smoked daily while pregnant
(occasional smokers) (n = 212)
61 52.1 47.9 p = 0.697 p = 0.558 0.909 (0.659, 1.252)
2 to 4 39.4 60.6
>4 50.9 49.1

Type of smoker while breastfeeding(n=1601)

Daily 47.1 52.9 p <0.001 p <0.05 1.439 (1.075, 1.926)
Occasionally 34.9 65.1
Not at all 33.9 66.1

Number of cigarettes smoked daily while breastfeeding

of daily smokers (n=224)
2 to 5 41.1 58.9 p = 0.341 p = 0.115 0.718 (0.475, 1.084)
6 to 10 42.7 57.3
>10 55.8 44.2
Number of cigarettes smoked daily while breastfeeding
of occasional smokers (n = 187)

61 31.4 68.6 p = 0.156 p = 0.057 0.652 (0.420, 1.012)

2 to 4 29.9 70.1
>4 48.9 51.1
a
p-value according to chi-square test to detect differences in duration of breastfeeding among different types of smokers and their frequency of smoking
b
p-value and odds ratio according to binary logistic regression after adjusting for age, total household income, education, province of residency, marital status, and
ethnicity
 B. Bahadori et al. / Medical Hypotheses 81 (2013) 582–586
survey design when conducting statistical analysis.[55] Chi-square
test was used to determine significance of test variables. P-values
<0.05 were considered statistically significant. Binary logistic
regression was used to generate odds ratios (OR) and 95% confi-
dence intervals (CI). Binary logistic regression analyses were ad-
justed for age, total household income, educational level,
geographic location, marital status and ethnic origin.
A.4. Results
Characteristics of study participants, including age, income,
educational level, marital status and racial origin are given in Ta-
ble 1. In detail, 3485 women reported a birth between 1998 and
2003 and were included in the presented study. Of these 3485 wo-
men, 33.5% reported breastfeeding up to 3 months and 66.5% re-
ported to breastfed over 3 months.
A.5. Associations between duration of breastfeeding and smoking
Smoking behavior of study participants is given in Table 2. In
detail, 20.4% of the women who gave birth reported themselves
as daily smokers, while 6.2% were occasional smokers, and 73.4%
reported not smoking at all. During pregnancy, 14.9% of women
were self-reported daily smokers, 13.5% occasional smokers, and
71.6% reported not to smoke at all. Similarly, 14.1% of lactating
mothers reported daily smoking, 11.8% were occasional smokers,
and 74.1% non-smokers. Of those women who reported daily
smoking during pregnancy, 27.8% claimed to smoke 1–5 ciga-
rettes/day, 37.6% smoked 6–10 cigarettes/day, and 34.6% smoked
more than 10 cigarettes/day. Of the women that were self-reported
occasional smokers during pregnancy, 22.6% smoked one or less
cigarettes/day, 51.4% smoked 2–4 cigarettes/day, and 25.9%
smoked greater than four cigarettes/day. Of those women that re-
ported daily smoking during breastfeeding, 25% smoked between
2–5 cigarettes/day, 36.6% smoked 6–10 cigarettes/day, and 38.4%
smoked more than 10 cigarettes/day. Of the women that reported
occasional smoking during breastfeeding, 18.7% reported having
less than or equal to one cigarette/day, 57.2% had 2–4 cigarettes/
day, and 24.1% smoked more than 4 cigarettes/day.
Analyses of smoking status and frequency of smoking during
pregnancy and breastfeeding are outlined in Table 2. In detail,
the type of smoker (p < 0.001), type of smoker while pregnant
(p < 0.001) and type of smoker while breastfeeding (p < 0.001)
were all significantly associated with duration of breastfeeding.
Occasional and daily smokers were less likely to breastfeed greater
than 3 months compared to women that never smoked. Associa-
tions remained significant in binary logistic regression analyses
after adjustment for various socio-demographic factors listed
above with odds ratios of 1.229 (95%CI: 1.002–1.508) for type of
smoker, 1.638 (95%CI: 1.232, 2.178) for type of smoker while preg-
nant and 1.439 (95%CI 1.075, 1.926) for type of smoker while
breastfeeding. The number of cigarettes smoked during pregnancy
and breastfeeding did not show a significant association with dura-
tion of breastfeeding.
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