Shayla Keane
Pick your Poison:
Is Vaping Safer than Cigarettes During a Pregnancy?
Shayla M. Keane
Human Development 270
Final Paper
May 1st, 2020
The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically (American College of Obstetricians and Gynecologists, 2017). Therefore, the main goal of Obstetricians and Gynecologists has been to analyze the possible health risks young women are facing and more specifically, pregnant women. There is the perception that these products represent a safer alternative compared with cigarette smoking, because the products of tobacco combustion are not present. However, nicotine in any form poses considerable health risks and has known adverse effects on fetal brain and lung tissue (American College of Obstetricians and Gynecologists, 2017).
Electronic cigarettes (also called electronic nicotine delivery systems or e-cigarettes) come in different sizes and shapes, including pens, mods, (i.e., these types are modified by the user) and tanks. Most e-cigarettes contain a battery, a heating device, and a cartridge to hold liquid. The liquid typically contains nicotine, flavorings, and other chemicals. The battery-powered device heats the liquid in the cartridge into an aerosol that the user inhales (Centers for Disease Control and Prevention, 2019). Nicotine is a stimulant drug that speeds up the messages traveling between the brain and body (Alcohol and Drug Foundation, 2020). Tobacco is a plant grown for its leaves, which are dried and fermented before being put in tobacco products. Tobacco contains nicotine, an ingredient that can lead to addiction, which is why so many people who use tobacco find it difficult to quit. There are also many other potentially harmful chemicals found in tobacco or created by burning it (National Institute on Drug Abuse, 2020).
Theoretical Framework
In past studies and examinations, researchers have found the use of tobacco to negatively affect a developing fetus. Smoking during pregnancy is a public health problem because of the many adverse effects associated with it. These include intrauterine growth restriction, placenta previa, abruptio placentae, decreased maternal thyroid function, preterm premature rupture of membranes, low birth weight, perinatal mortality, and ectopic pregnancy. An estimated 5–8% of preterm deliveries, 13–19% of term deliveries of infants with low birth weight, 23–34% cases of sudden infant death syndrome (SIDS), and 5–7% of preterm-related infant deaths can be attributed to prenatal maternal smoking. The risks of smoking during pregnancy extend beyond pregnancy-related complications. Children born to mothers who smoke during pregnancy are at an increased risk of asthma, infantile colic, and childhood obesity. Researchers report that infants born to women who use smokeless tobacco during pregnancy have levels of nicotine exposure, low birth weight, and shortened gestational as high as infants whose mothers smoked during pregnancy. Secondhand prenatal exposure to tobacco smoke also increases the risk of having an infant with low birth weight by as much as 20% (American College of Obstetricians and Gynecologists, 2017). This then raises the question, if smoking cigarettes or chewing tobacco are bad for a developing child; are e-cigarettes a safe alternative?
Methodology and Type of Research
Some of the research being done is experimental, such as a study done by The University of Technology in Sydney, Australia. They studied how maternal E-cigarette vaping enhances the development of allergic asthma in offspring through experimenting on mice. Others are observational such as one conducted by the University of Connecticut School of Medicine where they observed associations between electronic cigarette use and participant characteristics. The only problem with these studies is that vapes have only been around for about a decade. They were first created in China in 2003 and didn’t become popular in the US until 2013. Therefore, we have little to no knowledge about the long term or life long effects of vaping. As a youtube video published by the account AsapSCIENCE explains, for now, juuling is healthier than smoking but they both contain a similar amount of a mind-altering drug (nicotine), which as we understand from its use in tobacco products has an addictive quality that hooks users physiologically.
Review of Related Literature
The American College of Obstetricians and Gynecologists posted an article in 2017 about helping soon-to-be mothers quit smoking. The article stated that the U.S. Preventive Services Task Force has concluded that current evidence is insufficient to assess the balance of benefits and harms of nicotine replacement products or other pharmaceuticals for smoking cessation aids during pregnancy. There is conflicting evidence as to whether or not nicotine replacement therapy increases abstinence rates in pregnant smokers, and it does not appear to increase the likelihood of permanent smoking cessation during postpartum follow-up of these patients (American College of Obstetricians and Gynecologists, 2017). This means that although nicotine is considered to be the ‘safer’ method of obtaining nicotine, it is not proven to be a better way to quit smoking. Due to this information, mothers are still putting their children at risk because they are still taking nicotine into their bodies. Even after birth, nicotine can still contaminate breast milk, therefore, continuing the child’s reliance on the drug. This then also puts the mother at risk of relapse in her addiction and continues to vape and or turn back to their original form of nicotine intake (i.e., cigarettes, chew).
The Mayo Clinic also provides blog posts based on questions they get from readers and then Doctors respond. In one titled, Is vaping during pregnancy OK? J. Taylor Hays, M.D. replies by stating, “Using electronic cigarettes (vaping) during pregnancy isn't safe”. It's well known that smoking cigarettes during pregnancy can harm women and their babies. But research suggests that pregnant women who vape believe that using e-cigarettes is less harmful than smoking cigarettes. Pregnant women often don't know if their e-cigarettes contain nicotine. Some also might use e-cigarettes during pregnancy because of the perception that the devices can help them quit or reduce cigarette smoking (Mayo Clinic, 2019). This answer directly correlates to that of the one given by the American College of Obstetricians and Gynecologists. Due to the way vapes are being advertised, mothers are continuing the use of nicotine rather than trying to quit but, this is still putting both them and their child at risk.
The UT Southwestern Medical Center follows a similar format with a blog post from Obstetrician & Gynecologist, Robyn Horsager-Boehrer, M.D. She aims to shed some light on common myths about vaping and e-cigarettes. Myth 1: Vaping is a safe alternative to cigarettes. In September 2019, the U.S. Food and Drug Administration (FDA) sent a warning letter to a prominent vaping products company, saying it had violated federal regulations because it did not receive agency approval to market its products as a healthier alternative to cigarettes. Vaping during pregnancy has deeper implications. In utero exposure to nicotine, which is found in many vaping products, is known to directly harm fetuses by causing abnormal lung, heart, brain, and immune system development, which carries lifelong consequences. Though the aerosol in ENDS (electronic nicotine delivery systems) contains fewer chemicals than cigarette smoke, it also contains harmful substances, such as Lead (& other heavy metals), Benzene, which is found in car exhaust and Diacetyl, which is linked to lung disease. Myth 2: Vaping can help me quit smoking. There is no data to suggest vaping can help people quit smoking. In fact, there are several reasons that vaping may keep patients addicted to smoking; vaping is more socially acceptable than smoking (ENDS typically don’t leave a noticeable scent in the user’s hair or clothing), sweet and fruity flavored products taste better than traditional tobacco to many patients, and the amount of nicotine is unregulated and not always appropriately labeled on the packaging. The truth is many people who vape also smoke cigarettes. A 2018 study in Women’s Health Issues found that 30% of nearly 400 patients reported using tobacco and ENDS during pregnancy, while nearly 12% used ENDS only. Myth 3: Vaping is safer than going cold turkey during pregnancy. Many pregnant women worry that going cold turkey will cause the baby to suffer nicotine withdrawals. This is not true – we do not see fetal distress or withdrawal issues from abrupt nicotine cessation as we do with illicit drugs such as heroin. Robyn Horsager-Boehrer, M.D. says, “The Ob/Gyns in our office support going cold turkey.” Finally, Myth 4: My doctor didn’t ask me about vaping, so it must not be a big deal. Just as you would speak to your doctor regarding your diet, supplements, and medication, you should also be speaking to them regarding any drug use. The more information doctors have about your unique pregnancy, the better they can recommend ways to optimize your health and pregnancy (UT Southwestern Medical Center, 2019).
In 2019, the American Pregnancy Association posted an article titled, Electronic Cigarettes and Pregnancy to their blog. Here they stress that e-cigarettes are not regulated, and you cannot know what kinds or amounts of chemicals, such as nicotine, they contain. There are no known studies that have documented their safety, and the FDA has not approved e-cigarettes as a cessation aid. Yet again, we see a blog post state that nicotine is an addictive substance that is toxic to reproduction and interferes with fetal brain development. It may also adversely affect fetal lung development and increase the risk of SIDS (Sudden Infant Death Syndrome). (American Pregnancy Association, 2019).
The CDC offers two helpful journal entries on vaping while pregnant. The first titled, E-Cigarettes and Pregnancy, explains what vaping is. They then explain that although the aerosol of e-cigarettes generally has fewer harmful substances than cigarette smoke, e-cigarettes and other products containing nicotine are not safe to use during pregnancy. Nicotine is a health danger for pregnant women and developing babies and can damage a developing baby’s brain and lungs. Also, some of the flavorings used in e-cigarettes may be harmful to a developing baby. They also say that there is little information on vaping helping people to quit smoking. As seen in the past articles, it is highly unlikely that vaping will help quit smoking, in most cases it enables a way to relapse or begin to smoke cigarettes. The CDC at the very end of their article offers resources to quit smoking. (CDC, Feb 2019). The second article is titled, Tobacco and E-Cigarettes, explains that in addition to the risks of secondhand smoke for all exposed infants, the chemicals found in tobacco, including nicotine, can be passed from a breastfeeding mother who uses tobacco to her infant through breast milk. Smoking also decreases maternal milk supply, likely through the effect of nicotine, which lowers serum prolactin levels. Little is known about the effects of e-cigarette use by the mother on the infant’s health. E-cigarette aerosol can contain harmful and potentially harmful chemicals including nicotine and other toxicants, flavorings, and solvents. They then end this article with resources to quit and state, “The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recognize pregnancy and lactation as two ideal times to promote tobacco and smoking cessation” (CDC, Dec 2019). This article then raises a new concern - secondhand vaping. Vaping around your children can cause them to inhale vapor second hand, they are therefore still inhaling any particles from the mothers’ exhale which can contain unsafe levels of nicotine along with toxins from the e-liquid.
An article from the American Nonsmokers' Rights Foundation states a similar point on the topic of secondhand smoking. They quote Dr. Stanton Glantz, the Director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.
“If you are around somebody who is using e-cigarettes, you are breathing an aerosol of exhaled nicotine, ultra-fine particles, volatile organic compounds, and other toxins” (American Nonsmokers' Rights Foundation, 2019).
Lastly, Science Direct (journal) posted an observation of online forums and the ongoing debate for vaping while pregnant. They found the three main arguments were, 1) that Vaping is safer than quitting cold turkey. This, as we have seen in past articles, is false. Studies have found that when quitting cold turkey there are no nicotine withdrawals seen in the fetus, the only withdrawals undergone are with the mother. Although withdrawals can put a lot of stress onto a pregnant mother, with the right care and medical support, multiple organizations say it is the safest method for the fetus. 2) Vaping is healthier than cigarettes. This statement is also false, the FDA had to warn big tobacco about their ads which informed their audience that vaping is 99% safer than smoking. That’s the same company that sells cigarettes. As the youtube video by AsapSCIENCE said, a pack of cigarettes costs an average of $13 (Canada) and the average JUUL pod costs $16 (Canada) (AsapSCIENCE, 2018). This company would, therefore, profit by saying that vaping is safer than tobacco products by $3 a sale. Quite the incentive to sell if you ask me. Although it is true that vapes do not contain tobacco, there is still nicotine (a mind-altering drug) and a slew of other toxins hidden within e-liquids. A few vapes have said there is no nicotine in their products such as KININ, an essential oil company. Even then, the e-liquid is still unregulated, therefore, you could potentially be inhaling toxins and passing it into your baby. Lastly, 3) Vaping is not worth the risk. That was the most common rebuttal against nicotine, and as seen in past articles it is true based on the arguments against points 1 and 2. (ScienceDirect, 2017).
Scope and Limitations
Although the accounts above and the scientific experiments/observations below are incredibly important to the main question, there are still hindrances to finding a complete answer to the question of if vaping is a better alternative to smoking. For example, these pieces of evidence focus on the mother and no other partner(s) or close person in the child’s life. This could lead to adding variables that would affect the outcome of a study such as these. (i.e. a smoker and a vaper in a household, the mother an ex-smoker and is now a vaper, the mother always vaped never smoked, the mother doesn’t smoke or vape but another household member does,). Of course, another issue is that vaping is a recent phenomenon. Since it was invented in 2003, we are unsure of the long term or life long effects vaping will have on mothers and their children.
Significance of the Study
The following studies aim to determine what is happening to a child when exposed to vaping in prenatal and early childhood development. Some of these studies are experimental and others are observational.
The first study is titled Correlates of Electronic Cigarettes Use Before and During Pregnancy and was published by Oxford University Press in 2017 on behalf of the Society for Research on Nicotine and Tobacco. The goal of the study was to observe pregnant women who were attempting to quit smoking and track their methods of doing so. Fifty-three percent (55/103) of participants had previously tried electronic cigarettes. Ever users smoked more cigarettes per day before pregnancy (p = .049), had a greater number of previous quit attempts (p = .033), and were more likely to identify as being Hispanic or non-Hispanic white than never users (p = .027). Fifteen percent of participants (15/103) reported previous use of electronic cigarettes for smoking cessation, which was more common than the use of any specific FDA-approved smoking cessation medication. Fourteen percent of participants (14/103) reported electronic cigarette use during pregnancy, most commonly to quit smoking. A history of substance abuse (p = .043) and more previous quit attempts (p = .018) were associated with electronic cigarette use during pregnancy. The conclusion reached was that the use of e-cigarettes to quit smoking may be common in women of reproductive age, including those who are pregnant. More research is needed to determine the risks and benefits of electronic cigarette use in this population of smokers (Society for Research on Nicotine and Tobacco, 2017). ( graph of findings below.)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/5896457/bin/ntw22501.gif
The second study The Role of Nicotine in the Effects of Maternal Smoking during Pregnancy on Lung Development and Childhood Respiratory Disease. Implications for Dangers of E-Cigarettes (ATS Journals, 2015). Recent evidence strongly supports that much of the effect of smoking during pregnancy on offspring lung function is mediated by nicotine, making it highly likely that e-cigarette use during pregnancy will have the same harmful effects on offspring lung function and health as do conventional cigarettes. In fact, the evidence for nicotine being the mediator of harm of conventional cigarettes may be most compelling for its effects on lung development. This raises concerns about both the combined use of e-cigarettes plus conventional cigarettes by smokers during pregnancy as well as the use of e-cigarettes by e-cigarette–only users who think them safe or by those sufficiently addicted to nicotine to not be able to quit e-cigarette usage during pregnancy.
Table 1. (Below) Comparison of the Effects of Maternal Smoking during Pregnancy and the Effects of Nicotine Exposure from Animal Models during Pregnancy on Lung Development and Function
Category
Effect
Smoke Exposure
Nicotine Exposure
Smoke Exposure References
Nicotine Exposure References
Pulmonary function
Decreased forced expiratory flow
Yes
Yes
Decreased compliance*
Yes
Maybe
Altered flow ratio†
Yes
Unknown
Respiratory illness
Increased airway reactivity/asthma/wheeze‡
Yes
Yes
Decreased arousal/increased apnea§
Yes
Yes
Increased respiratory infections/hospitalizations/altered immune function||
Yes
Yes
Anatomic and cellular changes
Increased connective tissue/airway wall thickening
Yes
Yes
Increased narrow and smaller airways
Yes
Yes
Altered alveolar geometry
Yes
Yes
Increased type 2 cells/surfactant
Yes
Yes
Increased NEB/PNEC
Yes
Yes
Mechanistic underpinnings
Oxidative mechanisms underlying effects
Yes
Yes
Respiratory effects modified by nAChR SNPs/knockouts
Yes
Yes
Modified levels of nAChR expression
Yes
Yes
General
Decreased birth weight¶
Yes
No
Prematurity
Yes
Yes
Definition of abbreviations: nAChR = nicotinic acetylcholine receptor; NEB = neuroepithelial bodies; PNEC = pulmonary neuroendocrine cells; SNP = single-nucleotide polymorphism.
*Most, though not all, studies show an effect. In animal studies there is a downward trend.
†Ratio of time to peak tidal expiratory flow to expiratory time.
‡In animal studies, increased airway reactivity is used as a surrogate for asthma and wheeze.
§Correlates of increased risk of sudden infant death syndrome in offspring of smokers.
||Alterations in immune function in animals used as a surrogate for hospital admissions.
¶There is a downward trend in birthweight, but it is not statistically significant in most studies.
The third study, Memory and Learning in Offspring Exposed to Maternal Vaping, (The FASEB Journal, 2019). Tested rat pup’s memory after exposing their mother to one of three environments, air, vape with no nicotine, or vape with nicotine. They found evidence that e-cig with nicotine resulted in reduced overnight learning retention but demonstrated enhanced short-term memory function (<30 mins) in both e-cig with no nicotine and e-cig with nicotine. No neurological or locomotor deficits were observed that would confound cognitive behavioral testing. Future studies will determine if and how this behavior changes in later stages of development through repeated measure testing. Present findings suggest electronic cigarettes, even nicotine-free products, affect the learning process (The FASEB Journal, 2019).
The fourth study, Maternal eCigarette vaping enhances Th2 driven asthma in the offspring, (European Respiratory Journal, 2017). Tested whether maternal eCig vaping enhances features of allergic asthma in the offspring. Female mice were vaped with either eCig vapor (with nicotine) or room air (control). eCig vaping was started prior to mating and continued during gestation and lactation. This led to the team finding an increase in features of airway remodeling and AHR in the eCig (+Nic) group when compared with eCig (-Nic). Mechanistically they found that eCig (±Nic) dose-dependently decreased cell viability, reduced mitochondrial transmembrane potential and respiration. They then concluded their study by saying, maternal eCig-vaping enhanced features of allergic asthma in the offspring and this could be attributed to aberrant mitochondrial function.
The fifth and final study, Effects of Maternal Nicotine Use on Brestfeeding Infants (NCBI, 2013). Studied both breastfeeding humans and animals and then compared their findings to one another.
Chart 1: Synthesis of the articles included in the integrative review - studies in human beings
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182966/bin/0103-0582-rpp-31-03-00392-gf01.jpg
Chart 2: Synthesis of the articles included in the integrative review - studies in animals
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182966/bin/0103-0582-rpp-31-03-00392-gf02.jpg
Concluding Statement
After reviewing multiple journals and scientific studies it is clear that there is no straight answer to whether or not vaping is safer than smoking. Due to insufficient evidence, both doctors and researchers suggest that with the information they do have, vaping poses many health risks for a mother and developing child. Due to these findings, it is suggested that the mother quits smoking altogether to avoid serious health defects with their child. Although vaping doesn’t pose the same threats as smoking conventional tobacco products, it is clear that vaping still poses serious threats to a developing child. Vaping can hinder the growth and development of lungs and other organs which can lead to birth defects and/or Th2 driven asthma and even early cases of respiratory disease. As we also saw in a study with rats, brain development can be cut short of what it should be which affects the child's behavior, long term memory, and learning.
On a personal note, I would recommend the cessation of any and all tobacco/nicotine/smoking products. As proven, vaping has no clear results in helping smokers quit and acts as a gateway to tobacco products in most cases. Another concern was that quitting nicotine cold turkey could put the baby in distress but this was disproved by Robyn Horsager-Boehrer, M.D when she observed a fetus’s reaction to nicotine withdrawals. The fetus suffered no symptoms of withdrawal and was completely fine without the mother's intake of nicotine. Therefore, since the full risk of vaping while pregnant has yet to be determined, I would suggest women who are pregnant or planning to become pregnant to quit smoking/vaping/tobacco products. Vaping has not been proven to be safer than smoking and with the detrimental dangers we do know vaping to cause - why take the risk?
Works Cited
ACOG. (2010, October). Smoking Cessation During Pregnancy. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/10/smoking-cessation-during-pregnancy
ADF. (2020, March 20). Nicotine. Retrieved from https://adf.org.au/drug-facts/nicotine/
ANRF. (2020, January 27). Electronic Smoking Devices and Secondhand Aerosol - American Nonsmokers' Rights Foundation. Retrieved from https://no-smoke.org/electronic-smoking-devices-secondhand-aerosol/
APA. (2019, September 12). Electronic Cigarettes and Pregnancy: Is it Safe? Retrieved from https://americanpregnancy.org/is-it-safe/electronic-cigarettes-and-pregnancy/
AsapSCIENCE. (2018, November 22). Smoking vs Juuling. Retrieved from https://www.youtube.com/watch?v=vKXVtdkmZbs
CDC. (2019, December 28). Tobacco and E-Cigarettes. Retrieved from https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/tobacco-and-e-cigarettes.html
CDC. (2019, February 25). Substance Use During Pregnancy. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/substance-abuse/e-cigarettes-pregnancy.htm
Horsager-Boehrer, R. (2019, September 17). 4 myths about vaping and pregnancy – busted: Your Pregnancy Matters: UT Southwestern Medical Center. Retrieved from https://utswmed.org/medblog/4-myths-about-vaping-and-pregnancy-busted/
Mayo Clinic. (2019, October 12). Vaping during pregnancy: Is it safe? Retrieved from https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/expert-answers/vaping-during-pregnancy/faq-20462062
NIDA. (2020, January 8). Cigarettes and Other Tobacco Products. Retrieved from https://www.drugabuse.gov/publications/drugfacts/cigarettes-other-tobacco-products
Oncken, C., Ricci, K. A., Kuo, C.-L., Dornelas, E., Kranzler, H. R., & Sankey, H. Z. (2017, May 1). Correlates of Electronic Cigarettes Use Before and During Pregnancy. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28403454
O’Reilly, J. M., Aboaziza, E., Moore, J., Johnson, A., Chantler, P. D., Engler-Chiurazzi, E., & Olfert, I. M. (2019, April 1). Memory and Learning in Offspring Exposed to Maternal Vaping. Retrieved from https://www.fasebj.org/doi/abs/10.1096/fasebj.2019.33.1_supplement.737.7
Primo, C. C., Ruela, P. B. F., Brotto, L. D. de A., Garcia, T. R., & Lima, E. de F. (2013, September). Effects of maternal nicotine on breastfeeding infants. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182966/
Sharma, P., McAlinden, K., Chan, Y., Kota, A., Komalla, V., Chen, H., & Oliver, B. (2017, September 1). Maternal eCigarette vaping enhances Th2 driven asthma in the offspring. Retrieved from https://erj.ersjournals.com/content/50/suppl_61/PA4694.abstract
Spindel, E. R., & McEvoy, C. T. (2015, October 16). The Role of Nicotine in the Effects of Maternal Smoking during Pregnancy on Lung Development and Childhood Respiratory Disease. Implications for Dangers of E-Cigarettes. Retrieved from https://www.atsjournals.org/doi/full/10.1164/rccm.201510-2013PP
Wigginton, B., Gartner, C., & Rowlands, I. J. (2016, October 20). Is It Safe to Vape? Analyzing Online Forums Discussing E-Cigarette Use during Pregnancy. Retrieved from https://www.sciencedirect.com/science/article/pii/S1049386716301864