Electronic Cigarette Use among Pregnant Cigarette Smokers in the Quit4Baby Trial: Predictive Factors, of Use, the Efficacy of E-Cigarettes for Smoking Cessation, and the Associations between Combined Cigarette and E-Cigarette Use and the Risk of Adverse Neonatal Outcomes
Open AccessE-cigarettes were introduced into the market in 2007 and continue to gain popularity in the United States. Widely marketed as both a useful tool for cigarette smoking cessation and a safer alternative to cigarettes, the prevalence of e-cigarette use is steadily increasing in the pregnant population as well, and more commonly among pregnant smokers. Many pregnant smokers report using e-cigarettes in attempts to quit smoking, and also because they believe e-cigarettes to be less harmful for their health and their baby’s health in comparison to cigarettes. Very little is understood about the effects of e-cigarette use during pregnancy, and there is no evidence suggesting that e-cigarettes are effective for smoking cessation or reduction among pregnant individuals. More understanding regarding the predictors of e-cigarette use among pregnant smokers, as well as their efficacy for smoking cessation and health effects to the fetus, is crucial for future clinical practices. Data from a randomized trial examining the efficacy of a text messaging program for smoking cessation during pregnancy (Quit4Baby) were used to conduct three analyses involving the use of e-cigarettes among people who smoke during pregnancy. The first analysis used multivariable logistic regression to assess maternal demographic, lifestyle, and mental health factors as potential predictors of e-cigarette use. Maternal race and ethnicity, pre-pregnancy BMI, household income, education, and health concerns were found to be significant predictors of e-cigarette use among pregnant smokers. The second analysis examined the association between e-cigarette use and odds of smoking cessation or reduction among pregnant and recently postpartum smokers over the six-month study period (four time points), with marginal structural models using a weighted generalized estimating equations framework. Reported past 7-day e-cigarette use was associated with significantly lower odds of smoking cessation, and past 30-day e-cigarette use was associated with lower odds of both smoking cessation and smoking reduction. In analyses restricting to a three-month time period (three time points) and only including those still pregnant at the three-month follow-up, only past 30-day e-cigarette use was associated with lower odds of smoking cessation; other associations were not significant. The third analysis used modified Poisson regression to examine the risks of adverse neonatal outcomes in association with combined cigarette and e-cigarette use (dual use), compared with the use of cigarettes only during pregnancy. Past 30-day e-cigarette use in addition to cigarette use during pregnancy was associated with a lower risk of preterm birth compared with cigarette use only. The risks of other adverse neonatal outcomes observed (low birth weight, extended neonatal hospital stay, neonatal ICU admission, and death) were not significantly different among dual users compared with cigarette-only users. These analyses provide much needed information, as very little is known about the effects of e-cigarette use during pregnancy, and the findings could have a significant public health impact for pregnant smokers. The results from the first analysis provide clinicians with insight as to which pregnant smokers are most likely to use e-cigarettes. Such information is helpful for ongoing risk monitoring and consistent messaging about the potential harms of e-cigarette use during pregnancy. Results from the second analysis are important in that they contradict what is currently marketed regarding the efficacy of e-cigarettes as a tool for smoking cessation. Results from the third analysis are impactful in that they suggest that e-cigarette use could attenuate the risk of preterm birth among offspring born pregnant smokers. Additionally, it was found that the addition of e-cigarettes to cigarettes did not impact the risk of the remaining neonatal outcomes of interest. The results from this research collectively suggest that e-cigarettes should not be used by pregnant smokers, given their negative impact on smoking cessation and little health benefit from the addition to cigarettes. Public health agencies should continue to advise against e-cigarette use during pregnancy. All three analyses highlight a need for further research regarding the e-cigarette use in the pregnant population. Studies employing more stringent definitions of e-cigarette and cigarette use are also recommended. Overall, the knowledge gained from determining predictors of e-cigarette use, their efficacy for smoking cessation or reduction, and their effects on birth outcomes among pregnant smokers can lead to improvement of public health guidelines, more effective messaging, enhanced risk management, and better health outcomes for pregnant individuals and their offspring.
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