CASE REPORT
Demystifying Electronic Cigarette Use in Pregnancy Brooke Farquhar, BS, Katrina Mark, MD, Mishka Terplan, MD, MPH, and Margaret S. Chisolm, MD
Electronic cigarettes (ECIGs) are a relatively recent phenomenon, serving a dual role as a potential smoking-cessation tool and an alternative nicotine-delivery system. Although research has addressed the use of ECIGs in general populations, its use during pregnancy has not been studied. The authors seek to inform readers about the current evidence base regarding ECIG use in general and to describe a patient who began using ECIGs regularly during pregnancy as a smoking cessation tool. Continued research is needed to inform patients about the potential risks and benefits of ECIG use, including during pregnancy. Key Words: electronic cigarettes, pregnancy, tobacco, nicotine (J Addict Med 2015;9: 157–158)
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ne reason for the increasing use of electronic cigarettes (ECIGs) is the perception that they are safer than regular cigarettes (Agaku et al., 2014). Pregnant women, too, may share this perception and see ECIGs as a tool to help them quit smoking and avoid the carcinogens of tobacco smoke (Agaku et al., 2014). However, even the use of smokeless tobacco products during pregnancy is associated with decreased gestational periods and/or low birth weight (Gupta and Subramoney, 2004). This case report describes a patient who began using ECIGs regularly during pregnancy as a smoking cessation tool. In the absence of a firm evidence base, understanding the thought processes behind ECIG use during pregnancy may aid physicians in counseling women about the potential risks and benefits.
CASE DESCRIPTION Ms. B is a 22-year-old, single white pregnant patient in a perinatal substance use treatment program. Her history includes depression and anxiety, and marijuana and opioid dependence, for which she is being treated with behavioral and methadone therapies. Ms. B did not begin smoking cigarettes until the age of 20 years. Before learning that she was pregnant, From the University of Maryland (BF, KM, MT), Baltimore; and Johns Hopkins University School of Medicine (MSC), Baltimore, MD. Received for publication September 10, 2014; accepted November 16, 2014. The authors declare no conflicts of interest. Send correspondence and reprint requests to Katrina Mark, MD, Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, 11 S Paca Street, Suite 400, Baltimore, MD 21201. E-mail: [email protected]. C 2015 American Society of Addiction Medicine Copyright ISSN: 1932-0620/15/0902-0157 DOI: 10.1097/ADM.0000000000000100
Ms. B smoked an average of 10 regular cigarettes per day and had used an ECIG on only 2 occasions. Upon learning of her pregnancy, Ms. B purchased a rechargeable ECIG device on the Internet. She uses the ECIG throughout the day and states that it has helped her cut down to fewer than 3 cigarettes daily. She decided to use ECIGs to help her quit smoking and thereby to “help the baby” and herself. She thinks that switching from regular to ECIGs will make her baby healthier, adding “it won’t get the nicotine in the baby’s body as much.” Ms. B has been to a vapor store but does not like the flavored vapors, so the experience of creating her own vapor does not contribute to her preference of electronic over regular cigarettes. She plans to continue to use ECIGs postpartum. She believes it is the habit of her “hand going in and out” that sustains her smoking. Ms. B adds that if friends or family wanted to quit smoking, she would recommend using ECIGs. When surveyed on her knowledge about ECIGs, Ms. B endorsed awareness that they contain nicotine and can be addictive. Some of the reasons she uses ECIGs are that (1) they “may not be as bad for [her] health” as regular cigarettes, (2) they “make it easier for [her] to cut down on the number of regular cigarettes” she smokes, and (3) they “might help her quit” smoking regular cigarettes altogether. Ms. B also believes that ECIGs are less harmful to both her and her baby than regular cigarettes. Two other reasons Ms. B endorsed for using ECIGs are that they “taste better” and are “fashionable.” She did not endorse using ECIGs to smoke in places where regular cigarettes are banned nor does she use ECIGs because they are cheaper than regular cigarettes.
CONCLUSIONS This case report suggests that there may be knowledge gaps regarding the safety of ECIG use during pregnancy, gaps that may ultimately affect maternal and child health. As Ms. B’s case portrays, misconceptions exist regarding the relative safety of ECIGs compared to regular cigarettes during pregnancy, including the belief that they are “less harmful” to both her baby and herself. This misinformation is countered by recent studies revealing how smokeless tobacco products adversely affect pregnancy outcomes. For example, one study found that women who used smokeless tobacco (Swedish snuff) had increased rates of stillbirth comparable to heavy smokers (Wikstrom et al., 2010). Ms. B believes that ECIGs do not expose her infant to as high levels of nicotine as traditional cigarettes. Although not studied during pregnancy, blood nicotine levels rise significantly with ECIGs and can reach levels similar to those achieved with traditional cigarette smoking (Dawkins and Concoran, 2014). It is the nicotine
J Addict Med r Volume 9, Number 2, March/April 2015
Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
157
Farquhar et al.
concentration of the product, and not the design of the nicotine vehicle, that most affects the baby’s exposure. Furthermore, the use of traditional cigarettes in pregnancy and postpartum has been associated with an increased risk of sudden infant death syndrome (McDonnell et al., 2012). How the use of ECIGs in pregnancy might affect the risk of sudden infant death syndrome is unknown and it is an area worthy of future research as a major public health concern. Electronic cigarettes also pose a threat to the baby’s health postdelivery, as seen in the reported death of a 2-year-old who had ingested ECIG liquid (Breland et al., 2014). This risk is compounded by “e-liquid” flavorings such as “bubble gum” and “cookies and cream,” which are appealing to children. The second of Ms. B’s 2 main reasons for adopting regular use of ECIGs during pregnancy is her belief that these are better for her own health. Although ECIGs may not contain combustible products such as carbon monoxide, well known to cause pregnancy harm (Dempsey and Benowitz, 2001), ECIGs contain other hazardous products, including ethylene and propylene glycol (Hutzler et al., 2014). Classified as an irritant and a common ingredient in antifreeze, ethylene glycol has known toxic properties and is not allowed in traditional tobacco products (Hutzler et al., 2014). Although the effects of propylene glycol on pregnancy have not been studied in humans, inhalation of aerosolized propylene glycol is known to produce throat irritation and dry cough (Callahan-Lyon et al., 2014). Electronic cigarettes can also adversely affect lung function in a manner similar to that observed from the use of regular cigarettes (Breland et al., 2014). Not only have some brands of refill liquids for ECIGs been found to contain impurities of higher levels than permitted for pharmaceutical products (Etter et al., 2013), but also liquid chromatographytandem mass spectrometry has revealed tobacco-specific nitrosamines present at 10 times the level published by the ECIG manufacturer for liquid refills (Kim et al., 2013). Potential adverse effects of these impurities on pregnancy are yet to be determined. Although Ms. B asserted that using an ECIG will help her quit smoking, the efficacy of ECIGs to aid in smoking cessation has not been proven (Bullen et al., 2013) and ECIGs may be a deceptive smoking cessation tool. Studies have shown that of 10 products designated by the manufacturer as “free-ofnicotine,” 7 contained nicotine (Hutzler et al., 2014). Ms. B’s efforts to quit smoking may be compromised by the fact that many ECIG products labeled “free-of-nicotine” by
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manufacturers are not truly nicotine-free. However, her efforts to quit may be assisted by the sensory satisfaction that comes with using an ECIG. It has been demonstrated that women benefit from the fulfillment of a sensory routine in smoking cessation attempts (Perkins, 1996) and Ms. B describes how the ECIG helps her fulfill the habit of her “hand going in and out.” This case report highlights some critical misconceptions about the safety of ECIGs versus regular cigarettes for physicians to consider when counseling patients about the use of nicotine and tobacco products during pregnancy. It is important for physicians and patients to understand that the contents of ECIGs are variable, unstudied in pregnancy, and not currently regulated by the Food and Drug Administration. This report highlights the need for research regarding ECIG in pregnancy particularly with regard to examination of pregnancy outcomes. REFERENCES Agaku I, King B, Husten C, et al. Tobacco Product Use Among Adults—United States 2012–2013. Morb Mortality Wkly Rep 2014;63(25):542–547. Breland A, Spindle T, Weaver M, et al. Science and electronic cigarettes: current data, future needs. J Addict Med 2014;8(4):223–233. Bullen C, Howell C, Laugesen M, et al. E-cigarettes for smoking cessation: a randomized controlled trial. Lancet 2013;382:1629–1637. Callahan-Lyon P. Electronic cigarettes: human health effects. Tob Control 2014;23(suppl 2):ii36–ii40. Dawkins L, Concoran O. Acute electronic cigarette use: nicotine delivery and subjective effects in regular users. Psychopharmacology 2014;231:401– 407. Dempsey D, Benowitz L. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Saf 2001;24(4):277–322. Etter JF, Zather E, Svensson S. Analysis of refill liquids for electronic cigarettes. Addiction 2013;10:1–9. Gupta P, Subramoney S. Smokeless tobacco use, birth weight, and gestational age: population based, prospective cohort study of 1217 women in Mumbai, India. BMJ 2004;328:1538. Hutzler C, Paschke M, Kruschinski S, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch Toxicol 2014;88:1295–1308. Kim HJ, Shin HS. Determination of tobacco-specific nitrosamines in replacement liquids of electronic cigarettes by liquid chromatography-tandem mass spectrometry. J Chromatogr 2013;1291:48–55. McDonnell-Naughton M, McGarvey C, O’Regan M, et al. Maternal smoking and alcohol consumption during pregnancy as risk factors for sudden infant death. Ir Med J 2012;105(4):105–108. Perkins A. Sex differences in nicotine versus nonnicotine reinforcement as determinants of tobacco smoking. Exp Clin Psychopharm 1996;4(2):166– 177. Wikstrom A, Cnattingius S, Stephansson O. Maternal use of Swedish snuff (snus) and risk of stillbirth. Epidemiology 2010;21(6):772–778.
C
2015 American Society of Addiction Medicine
Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
Demystifying Electronic Cigarette Use in Pregnancy Brooke Farquhar, BS, Katrina Mark, MD, Mishka Terplan, MD, MPH, and Margaret S. Chisolm, MD
Electronic cigarettes (ECIGs) are a relatively recent phenomenon, serving a dual role as a potential smoking-cessation tool and an alternative nicotine-delivery system. Although research has addressed the use of ECIGs in general populations, its use during pregnancy has not been studied. The authors seek to inform readers about the current evidence base regarding ECIG use in general and to describe a patient who began using ECIGs regularly during pregnancy as a smoking cessation tool. Continued research is needed to inform patients about the potential risks and benefits of ECIG use, including during pregnancy. Key Words: electronic cigarettes, pregnancy, tobacco, nicotine (J Addict Med 2015;9: 157–158)
O
ne reason for the increasing use of electronic cigarettes (ECIGs) is the perception that they are safer than regular cigarettes (Agaku et al., 2014). Pregnant women, too, may share this perception and see ECIGs as a tool to help them quit smoking and avoid the carcinogens of tobacco smoke (Agaku et al., 2014). However, even the use of smokeless tobacco products during pregnancy is associated with decreased gestational periods and/or low birth weight (Gupta and Subramoney, 2004). This case report describes a patient who began using ECIGs regularly during pregnancy as a smoking cessation tool. In the absence of a firm evidence base, understanding the thought processes behind ECIG use during pregnancy may aid physicians in counseling women about the potential risks and benefits.
CASE DESCRIPTION Ms. B is a 22-year-old, single white pregnant patient in a perinatal substance use treatment program. Her history includes depression and anxiety, and marijuana and opioid dependence, for which she is being treated with behavioral and methadone therapies. Ms. B did not begin smoking cigarettes until the age of 20 years. Before learning that she was pregnant, From the University of Maryland (BF, KM, MT), Baltimore; and Johns Hopkins University School of Medicine (MSC), Baltimore, MD. Received for publication September 10, 2014; accepted November 16, 2014. The authors declare no conflicts of interest. Send correspondence and reprint requests to Katrina Mark, MD, Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, 11 S Paca Street, Suite 400, Baltimore, MD 21201. E-mail: [email protected]. C 2015 American Society of Addiction Medicine Copyright ISSN: 1932-0620/15/0902-0157 DOI: 10.1097/ADM.0000000000000100
Ms. B smoked an average of 10 regular cigarettes per day and had used an ECIG on only 2 occasions. Upon learning of her pregnancy, Ms. B purchased a rechargeable ECIG device on the Internet. She uses the ECIG throughout the day and states that it has helped her cut down to fewer than 3 cigarettes daily. She decided to use ECIGs to help her quit smoking and thereby to “help the baby” and herself. She thinks that switching from regular to ECIGs will make her baby healthier, adding “it won’t get the nicotine in the baby’s body as much.” Ms. B has been to a vapor store but does not like the flavored vapors, so the experience of creating her own vapor does not contribute to her preference of electronic over regular cigarettes. She plans to continue to use ECIGs postpartum. She believes it is the habit of her “hand going in and out” that sustains her smoking. Ms. B adds that if friends or family wanted to quit smoking, she would recommend using ECIGs. When surveyed on her knowledge about ECIGs, Ms. B endorsed awareness that they contain nicotine and can be addictive. Some of the reasons she uses ECIGs are that (1) they “may not be as bad for [her] health” as regular cigarettes, (2) they “make it easier for [her] to cut down on the number of regular cigarettes” she smokes, and (3) they “might help her quit” smoking regular cigarettes altogether. Ms. B also believes that ECIGs are less harmful to both her and her baby than regular cigarettes. Two other reasons Ms. B endorsed for using ECIGs are that they “taste better” and are “fashionable.” She did not endorse using ECIGs to smoke in places where regular cigarettes are banned nor does she use ECIGs because they are cheaper than regular cigarettes.
CONCLUSIONS This case report suggests that there may be knowledge gaps regarding the safety of ECIG use during pregnancy, gaps that may ultimately affect maternal and child health. As Ms. B’s case portrays, misconceptions exist regarding the relative safety of ECIGs compared to regular cigarettes during pregnancy, including the belief that they are “less harmful” to both her baby and herself. This misinformation is countered by recent studies revealing how smokeless tobacco products adversely affect pregnancy outcomes. For example, one study found that women who used smokeless tobacco (Swedish snuff) had increased rates of stillbirth comparable to heavy smokers (Wikstrom et al., 2010). Ms. B believes that ECIGs do not expose her infant to as high levels of nicotine as traditional cigarettes. Although not studied during pregnancy, blood nicotine levels rise significantly with ECIGs and can reach levels similar to those achieved with traditional cigarette smoking (Dawkins and Concoran, 2014). It is the nicotine
J Addict Med r Volume 9, Number 2, March/April 2015
Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
157
Farquhar et al.
concentration of the product, and not the design of the nicotine vehicle, that most affects the baby’s exposure. Furthermore, the use of traditional cigarettes in pregnancy and postpartum has been associated with an increased risk of sudden infant death syndrome (McDonnell et al., 2012). How the use of ECIGs in pregnancy might affect the risk of sudden infant death syndrome is unknown and it is an area worthy of future research as a major public health concern. Electronic cigarettes also pose a threat to the baby’s health postdelivery, as seen in the reported death of a 2-year-old who had ingested ECIG liquid (Breland et al., 2014). This risk is compounded by “e-liquid” flavorings such as “bubble gum” and “cookies and cream,” which are appealing to children. The second of Ms. B’s 2 main reasons for adopting regular use of ECIGs during pregnancy is her belief that these are better for her own health. Although ECIGs may not contain combustible products such as carbon monoxide, well known to cause pregnancy harm (Dempsey and Benowitz, 2001), ECIGs contain other hazardous products, including ethylene and propylene glycol (Hutzler et al., 2014). Classified as an irritant and a common ingredient in antifreeze, ethylene glycol has known toxic properties and is not allowed in traditional tobacco products (Hutzler et al., 2014). Although the effects of propylene glycol on pregnancy have not been studied in humans, inhalation of aerosolized propylene glycol is known to produce throat irritation and dry cough (Callahan-Lyon et al., 2014). Electronic cigarettes can also adversely affect lung function in a manner similar to that observed from the use of regular cigarettes (Breland et al., 2014). Not only have some brands of refill liquids for ECIGs been found to contain impurities of higher levels than permitted for pharmaceutical products (Etter et al., 2013), but also liquid chromatographytandem mass spectrometry has revealed tobacco-specific nitrosamines present at 10 times the level published by the ECIG manufacturer for liquid refills (Kim et al., 2013). Potential adverse effects of these impurities on pregnancy are yet to be determined. Although Ms. B asserted that using an ECIG will help her quit smoking, the efficacy of ECIGs to aid in smoking cessation has not been proven (Bullen et al., 2013) and ECIGs may be a deceptive smoking cessation tool. Studies have shown that of 10 products designated by the manufacturer as “free-ofnicotine,” 7 contained nicotine (Hutzler et al., 2014). Ms. B’s efforts to quit smoking may be compromised by the fact that many ECIG products labeled “free-of-nicotine” by
158
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manufacturers are not truly nicotine-free. However, her efforts to quit may be assisted by the sensory satisfaction that comes with using an ECIG. It has been demonstrated that women benefit from the fulfillment of a sensory routine in smoking cessation attempts (Perkins, 1996) and Ms. B describes how the ECIG helps her fulfill the habit of her “hand going in and out.” This case report highlights some critical misconceptions about the safety of ECIGs versus regular cigarettes for physicians to consider when counseling patients about the use of nicotine and tobacco products during pregnancy. It is important for physicians and patients to understand that the contents of ECIGs are variable, unstudied in pregnancy, and not currently regulated by the Food and Drug Administration. This report highlights the need for research regarding ECIG in pregnancy particularly with regard to examination of pregnancy outcomes. REFERENCES Agaku I, King B, Husten C, et al. Tobacco Product Use Among Adults—United States 2012–2013. Morb Mortality Wkly Rep 2014;63(25):542–547. Breland A, Spindle T, Weaver M, et al. Science and electronic cigarettes: current data, future needs. J Addict Med 2014;8(4):223–233. Bullen C, Howell C, Laugesen M, et al. E-cigarettes for smoking cessation: a randomized controlled trial. Lancet 2013;382:1629–1637. Callahan-Lyon P. Electronic cigarettes: human health effects. Tob Control 2014;23(suppl 2):ii36–ii40. Dawkins L, Concoran O. Acute electronic cigarette use: nicotine delivery and subjective effects in regular users. Psychopharmacology 2014;231:401– 407. Dempsey D, Benowitz L. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Saf 2001;24(4):277–322. Etter JF, Zather E, Svensson S. Analysis of refill liquids for electronic cigarettes. Addiction 2013;10:1–9. Gupta P, Subramoney S. Smokeless tobacco use, birth weight, and gestational age: population based, prospective cohort study of 1217 women in Mumbai, India. BMJ 2004;328:1538. Hutzler C, Paschke M, Kruschinski S, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch Toxicol 2014;88:1295–1308. Kim HJ, Shin HS. Determination of tobacco-specific nitrosamines in replacement liquids of electronic cigarettes by liquid chromatography-tandem mass spectrometry. J Chromatogr 2013;1291:48–55. McDonnell-Naughton M, McGarvey C, O’Regan M, et al. Maternal smoking and alcohol consumption during pregnancy as risk factors for sudden infant death. Ir Med J 2012;105(4):105–108. Perkins A. Sex differences in nicotine versus nonnicotine reinforcement as determinants of tobacco smoking. Exp Clin Psychopharm 1996;4(2):166– 177. Wikstrom A, Cnattingius S, Stephansson O. Maternal use of Swedish snuff (snus) and risk of stillbirth. Epidemiology 2010;21(6):772–778.
C
2015 American Society of Addiction Medicine
Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
