The use of electronic cigarettes has been continuing to rise globally. The impact on pregnancy is less known. In this article Amy Broadfield MRes BSc explores the evidence around their use in pregnancy to help midwives provide the best information.
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Electronic cigarettes as a smoking cessation strategy in pregnancy
There has been rising popularity in the use of electronic cigarettes to aid smoking cessation in adults in the UK, and quit attempts linked with electronic cigarettes were associated with the highest success rates of cessation (McNeill et al., 2022). It is generally accepted that whilst electronic cigarettes (e-cigarettes) are not completely risk-free, due to less toxins they are considerably less risky than conventional cigarettes (McNeill et al., 2022).
The Royal College of Midwives released a position statement regarding support in quitting smoking during pregnancy. This echoes the above statement that e-cigarettes contain less toxins than a conventional cigarette, and that support should be given to pregnant women who express the wish to quit smoking by using an e-cigarette (Royal College of Midwives, 2019). Although the statement was published in 2019, it was recently reviewed in May 2022 and remains unchanged. The NHS take a similar stance; they state that current evidence indicates that e-cigarettes are less risky to the fetus than conventional cigarettes. Whilst the vapour in e-cigarettes contains some of the harmful chemicals found in cigarette smoke, including nicotine, the levels of these chemicals are much lower and are less harmful to both expectant mother and baby (National Health Service, 2019a). The NHS long-term plan highlights the importance of a smoke-free pregnancy and home, and wishes to implement focused sessions and treatment for both expectant woman and their partner in order to achieve this (National Health Service, 2019b).
The National Institute for Health and Care Excellence (NICE) suggest that pregnant women could be provided with ‘starter packs’ by smoking cessation services. This would contain an e-cigarette device in the hopes that pregnant women would continue to use this by themselves after pregnancy (National Institute for Health and Care Excellence, 2018). This highlights the duty of healthcare professionals to introduce smokers to e-cigarettes as a smoking cessation strategy in pregnancy, as this could continue postpartum.
Despite the high quit attempts associated with e-cigarettes, the current NICE guidelines state that pregnant women should stop smoking without the use of nicotine replacement therapies such as patches or e-cigarettes (NICE, 2021a). E-cigarettes are not currently licensed for use as a smoking cessation strategy in pregnancy due to the lack of evidence regarding their safety and effectiveness (NICE, 2021b). The Royal College of Midwives believe that there is strong reasoning to test the efficacy of e-cigarettes as a cessation strategy in pregnancy (Royal College of Midwives, 2019). There is also research showing that there is a perceived lack of evidence amongst professionals who work in smoking cessation services, which leads to a reluctance to recommend e-cigarette use during pregnancy (Cooper et al., 2019, Mann & Faflik, 2018). Almost 70% of stop smoking services view the use of e-cigarettes during pregnancy as a personal choice, favouring this over following guidance and promoting the practice of using e-cigarettes in the place of conventional cigarettes, and 60% do not follow a specific policy on the e-cigarette advice they give to pregnant women (Mann & Faflik, 2018).
The Nursing and Midwifery Council (NMC) state that midwives should be practising in line with the best evidence available and advice should be evidence-based. However, some have expressed reluctance to advise pregnant women due to the perceived lack of evidence available (Nursing and Midwifery Council, 2020). A recent qualitative study that used focus groups to interview midwives about smoking cessation care found that midwives experienced their ‘midwife-woman’ relationship jeopardised when discussing smoking cessation during pregnancy (Kalamkarian et al., 2023). They thought that it added stress to the pregnant woman and increased the likelihood of non-attendance. Midwives felt they were perceived as judgemental and that there is a fine balance between having an informed conversation about smoking cessation and overwhelming the woman, thus risking non-attendance. The study concluded that additional training and support for midwives could increase their understanding and motivation of smoking cessation strategies and allow for more informed discussions with pregnant women (Kalamkarian et al., 2023).
Therefore, it could be argued that training involving case studies and success stories could influence a midwives’ recommendation of e-cigarette use in pregnancy. This type of training has been effective. It was found that healthcare professionals, when questioned about their beliefs on the use of e-cigarettes as a smoking cessation strategy, remembered positive experiences of pregnant women using e-cigarettes and then removing nicotine from their lifestyle completely. (Hunter et al., 2020).
Much uncertainty remains in the form of lack of evidence surrounding effects and safety of e-cigarette use on both mother and fetus. More studies are required to confirm the effect e-cigarettes have as a smoking cessation strategy compared to no smoking cessation treatment. Despite current guidelines, due to this lack of evidence, smoking cessation professionals have expressed a reluctance to recommend e-cigarettes. There is a clear need to improve knowledge surrounding e-cigarettes to allow health professionals, such as midwives, to feel better informed. This could be done by introducing more readily available resources, study days or online courses regarding the safety of e-cigarettes in pregnancy. This would allow midwives to increase their knowledge on the subject and therefore improve their conversation with pregnant women on the use of e-cigarettes. Therefore, increased knowledge would be translated into personal practice. Midwives are in constant contact with pregnant women, so it is vital that they are supplied with up-to-date information and materials to allow for more informed discussions in practice.
References
Cooper, S., Orton, S., Campbell, K. 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. https://doi.org/10.3390/ijerph16010110
Hunter, A., Yargawa, J., Notley, C., et al (2020). Healthcare Professionals’ Beliefs, Attitudes, Knowledge, and Behavior Around Vaping in Pregnancy and Postpartum: A Qualitative Study. Nicotine & Tobacco Research. https://doi.org/10.1093/ntr/ntaa126
Kalamkarian, A., Hoon, E., Chittleborough, C. R., et al (2023). Smoking cessation care during pregnancy: A qualitative exploration of midwives’ challenging role. Women and Birth, 36(1), 89–98. https://doi.org/10.1016/j.wombi.2022.03.005
Mann, R., & Faflik, F. (2018). Survey of smoking cessation services and pregnant women’s views on use of electronic cigarettes in pregnancy. Journal of Health Visiting, 6(1), 32–39. https://doi.org/10.12968/johv.2018.6.1.32
McNeill, A., Brose, L., Robson, D., et al (2022). Nicotine vaping in England: An evidence update including health risks and perceptions, 2022. https://kclpure.kcl.ac.uk/portal/en/publications/nicotine-vaping-in-england(58869843-3d0c-40e7-a9e9-d92881a2ed22).html
National Health Service. (2019a). Stopping smoking in pregnancy: Your pregnancy and baby guide. National Health Service. Available from https://www.nhs.uk/conditions/pregnancy-and-baby/smoking-pregnant/ [accessed 28 August 2019]. Nhs.Uk.
National Health Service. (2019b). The NHS Long Term Plan. London: National Health Service. Available from https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf [accessed 2 Jan 2020). National Health Service.
National Institute for Health and Care Excellence. (2018). Smoking cessation interventions and services: Evidence reviews for advice on e-cigarettes on general sale. London: National Institute for Health and Care Excellence. Available from https://www.nice.org.uk/guidance/ng92/evidence/c-advice-on-ecigarettes-on-general-sale-pdf-4788920848 [accessed 8 January 2020].
NICE. (2021a). Recommendations on treating tobacco dependence in pregnant women | Tobacco: Preventing uptake, promoting quitting and treating dependence | Guidance | NICE. NICE. https://www.nice.org.uk/guidance/ng209/chapter/Recommendations-on-treating-tobacco-dependence-in-pregnant-women
NICE. (2021b, November 30). Scenario: Pregnant or breastfeeding | Management | Smoking cessation | CKS | NICE. https://cks.nice.org.uk/topics/smoking-cessation/management/pregnant-or-breastfeeding/
Nursing and Midwifery Council. (2020). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London. https://www.nmc.org.uk/standards/code/
Royal College of Midwives, 2019. Position statement: Support to quit smoking in pregnancy. London: Royal College of Midwives.
Amy
February 2023