In recent years there has been a rapid increase in the use of E-cigarettes as a tool to enable smoking cessation, as well as a replacement for cigarettes. Bryony Rowan, ARC NWC funded PhD researcher in Public Health, Liverpool John Moores University, presents some of the evidence around use in pregnancy and points to the need for more research and increased knowledge of health professionals.
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It is well understood that smoking combustible tobacco products is harmful for pregnant people and their unborn babies, seen by some as the biggest preventable risk factor for negative infant and maternal outcomes (Cnattingius, 2004). The use of other nicotine delivery systems such as E-cigarettes and vapes, however, is a relatively newer phenomenon, with use rising from 1.7% of Brits vaping in 2012, to 8.3% in 2022 (The Guardian, 2022). As a result of this, understanding of the potential risks and benefits associated with e-cigarette use, including during pregnancy, is less established in the general populace as well as by those in healthcare positions who may be looked to for guidance.
This lack of understanding and belief that e-cigarettes and vapes are as harmful as smoking combustible tobacco products is only being fuelled by movements within the government to prohibit the sale of disposable electronic cigarettes. The bill to ban disposable e-cigarettes was initially presented to parliament in what is known as its ‘first reading’ on 8th February, with a second reading scheduled for 24th November. While Dr. Caroline Johnson, Conservative MP for Sleaford and North Hykeham, acknowledged in her address to the House of Commons that “smoking is bad for you. E-cigarette use is possibly not as bad for you…”, mainstream media reporting of this idea has been less than accurate, with newspaper reports sensationalising ideas of childhood nicotine addiction (The Guardian, 2023) and dangers to children’s health and wellbeing (The Evening Standard, 2023). Such reports may result in people questioning the safety of e-cigarette use, ultimately leading to a reduction in their use as a smoking cessation tool.
Many researchers have shown one of the leading reasons people are hesitant to use e-cigarettes for smoking cessation is due to a lack of knowledge on the risks associated with e-cigarette use. These findings have been mirrored in both patients wishing to quit smoking, and healthcare professionals. Research such as that by Froggatt, Reissland and Covey (2021) showed that pregnant people argued that they knew more about the risks associated with smoking regular tobacco cigarettes and felt they could minimise these risks themselves by reducing the quantity of cigarettes smoked, following advice such as avoiding smoking around an infant post-birth, and recounting stories of their own, as well as family and friends’, experiences of positive birth outcomes despite still smoking. When interviewed one-month post-partum, these women consistently referenced the unknown of e-cigarettes as the main reason they were hesitant to use them – the women feared the lack of knowledge around the long-term effects of e-cigarette use, and preferred the known risks of smoking combustible tobacco cigarettes. They also acknowledged the need for further research into the effects of e-cigarette use on the brain, and proper publication of testing.
Further to this, the women interviewed were concerned about the advice they received from healthcare professionals, stating inconsistencies in advice about the safety of use as a reason they chose not to use e-cigarettes as a quitting tool. This was also found by Johnston (2020), who reported a lack of consistent, if any, advice from healthcare professionals as a significant barrier to the use of e-cigarettes for smoking cessation in pregnancy. Instead of relying on healthcare providers to inform them, pregnant and recently post-partum women relied on the use of non-scientific sources such as blogs and media articles, or misinterpreted peer reviewed scientific sources to inform themselves of the risks and benefits of e-cigarette use for smoking cessation during pregnancy. In order to ensure proper support and advice is given to those wishing to quit smoking during pregnancy, healthcare professionals need to strive to keep themselves up to date with the evidence available.
A metanalysis by Broadfield (2020) found several relevant professional bodies have been advocating for vaping as an alternative to conventional tobacco cigarette smoking during pregnancy, including suggestions of an e-cigarette starter park to promote cessation through e-cigarette use in pregnancy being suggested in NICE guidelines as early as 2018. Further to this, the NHS as early as 2019 and the Royal College of Midwives (2019) also share the view that swapping from conventional cigarettes to e-cigarettes in pregnancy should be celebrated. Despite these recommendations, research has shown that many healthcare professionals are still not comfortable bringing this advice into practice, likely due to a perceived lack of evidence on the safety of e-cigarette use in pregnancy specifically (Cooper et al., 2019).
The existing research all points to the same conclusion, that people – both healthcare professionals and laymen alike – feel there is not enough concrete evidence to support the use of e-cigarettes as a tool for smoking cessation during pregnancy, despite the fact that sufficient evidence regarding safety and efficacy does exist. With a lack of recommendations from healthcare professionals, opposition from the government and sensationalised reports in the mainstream media, it is no wonder people are reluctant to convert from smoking conventional, combustible cigarettes to e-cigarettes during pregnancy. It is because of this that it is vital to assess the existing views of people who are pregnant, and the healthcare professionals involved in their care, and develop toolkits containing up to date, evidence-based guidelines and support in order improve upon current pregnancy smoking cessation rates.
References
Broadfield, A. (2020). How do midwives’ knowledge and attitudes of all aspects of electronic cigarettes influence the recommendation for their use as a smoking cessation strategy in pregnancy? (Doctoral dissertation, University of Lincoln).
Cnattingius, S. (2004). The epidemiology of smoking during pregnancy: smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine & tobacco research, 6(Suppl_2), S125-S140.
Cooper, S., Orton, S., Campbell, K. A., Ussher, M., Coleman-Haynes, N., Whitemore, R., Dickinson, A., et al. (2019). Attitudes to E-Cigarettes and Cessation Support for Pregnant Women from English Stop Smoking Services: A Mixed Methods Study. International Journal of Environmental Research and Public Health, 16(1), 110.
Froggatt, S., Reissland, N., & Covey, J. (2021). Risk perception of cigarette and e-cigarette use during pregnancy: a qualitative postpartum perspective. Midwifery, 94, 102917.
Johnston, E. (2020). E-cigarettes: an acceptable alternative to smoking for breastfeeding mothers? (Doctoral dissertation, University of Nottingham).
Bryony Rowan, BSc (Hons), GMBPsS
ARC NWC funded PhD researcher in Public Health, Liverpool John Moores University
October 2023