Perceived threats, benefits and barriers of e-cigarette use during pregnancy. A qualitative analysis of risk perception within existing threads in online discussion forums

Cigarette and E-Cigarette Harm Perceptions During Pregnancy

BACKGROUND

Research suggests that pregnancy status (prior, current, and future intention) is associated with differences in perceived harm of electronic cigarette (e-cigarette) use during pregnancy. However, perceptions of health outcomes attributed to cigarette and e-cigarette use during pregnancy have not been explored among a sample of pregnant women who smoke.

OBJECTIVES

The purpose of this study was to explore differences in perceived harms of cigarette and e-cigarette use and perceived birth and health outcomes associated with cigarette and e-cigarette use during pregnancy among a sample of pregnant women who currently smoked.

METHODS

Using a cross-sectional online survey, we examined perceptions about cigarette and e-cigarette use during pregnancy among a sample of U.S. pregnant women ( n = 267) who smoked in the past 30 days. Participants were grouped into categories based on e-cigarette use status (current, past, and never e-cigarette users). Differences between e-cigarette use status and perceived harm (absolute of cigarettes, e-cigarettes, and relative of e-cigarettes) and perceived health outcomes attributed to smoking/e-cigarette use were examined.

RESULTS

Among our sample, 45.7%, 39.7%, and 14.6% were current, ever, and never e-cigarette users, respectively. Associations existed between e-cigarette use status and absolute perceived harm of cigarettes, relative perceived harm of e-cigarettes, and perceived health outcomes. Current e-cigarette users believed pregnant women who smoked cigarettes were more likely to lose a child because of miscarriage or sudden infant death syndrome or give birth to a child with low birth weight, reduced lung function, cleft lip, reduced brain function, or attention-deficit/hyperactivity disorder than never e-cigarette users. No associations were found between perceived birth and health outcomes of e-cigarette use by e-cigarette user status.

DISCUSSION

Pregnant women who smoked and used e-cigarettes had lower risk perceptions about e-cigarette use during pregnancy than those who only smoked. Health messages and research about the harms of nicotine exposure during pregnancy should address the risks of dual-use versus only e-cigarette use. In addition, messages about the relative harm of e-cigarettes compared to cigarettes are needed for pregnant women who smoke and have trouble quitting.

College Students' E-health Literacy, Social Media Use, and Perceptions of E-cigarettes in Taiwan

This study aimed to examine the relationship between social media use, e-health literacy, and the risk and benefit perceptions of e-cigarettes among college students in Taiwan. A cross-sectional online survey was conducted with 1,571 Taiwanese college students, which included four questionnaires to assess participants' perceptions, social media use behavior, e-health literacy, and sociodemographic factors. The data were presented in terms of means, standard deviations, and percentages. Stepwise regression was used to identify factors associated with the participants' perceptions. The study found that 75.01% of the participants were exposed to e-cigarette information on social media, with 31.26% actively searching for it and 15.95% sharing it. Participants had a high e-cigarette risk perception, indicating low benefit perception, but acceptable e-health literacy. Factors such as current e-cigarette and tobacco use, e-health literacy, academic achievement, and sex significantly predicted e-cigarette risk perception, while sharing e-cigarette related information, sex, age, academic achievement, and current e-cigarette use significantly predicted its benefit perception. Thus, implementing effective e-health literacy programs to enhance college students' e-cigarette risk perception is recommended along with a proactive approach to tackle e-cigarette advertising messages on social media, minimizing their sharing behavior to decrease their perception of associated benefits.

The stigma of smoking among women: A systematic review

BACKGROUND

Smoking stigma has been well documented, but little is known regarding its specific features and effects on women. Notably, women face unique social, cultural, and economic challenges that may interact with smoking stigma and impact health outcomes. This review investigates the extent to which smoking women encounter and internalise stigma, while examining the various coping mechanisms they employ to manage these negative experiences.

METHODS

In November 2022, major databases were systematically searched with no time restrictions. After applying inclusion and exclusion criteria, 23 studies (three quantitative and 20 qualitative) met our criteria. We conducted a quality assessment and summarised the findings pertaining to public stigma, self-stigma, and coping strategies.

RESULTS

The stigma about smoking emerges from a variety of sources, such as family, healthcare providers, or internet forums. Women smokers are universally aware of the negative image they have in society. Yet, their experiences and management of the stigma of smoking are shaped by other variables such as cultural background, social class, or motherhood status. Smoking stigma produces ambivalent effects, such as concealment, reduced usage of support services, and to a lesser extent, smoking cessation motivation.

CONCLUSIONS

These results indicate that smoking stigma is an important social justice and public health issue and that further research is needed to better prevent its effects on women's well-being and health behaviours.

Addictive Potential of e-Cigarettes as Reported in e-Cigarette Online Forums: Netnographic Analysis of Subjective Experiences

BACKGROUND

While e-cigarettes usually contain nicotine, their addictive potential is not yet fully understood. We hypothesized that if e-cigarettes are addictive, users will experience typical symptoms of addiction.

OBJECTIVE

The aim of our study was to investigate whether and how e-cigarette users report signs of addiction.

METHODS

We identified 3 large German-language e-cigarette online forums via a systematic Google search. Based on a netnographic approach, we used deductive content analysis to investigate relevant posts in these forums. Netnography has the advantage of limiting the social desirability bias that prevails in face-to-face research, such as focus groups. The data were coded according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for tobacco use disorder, adapted for e-cigarettes. The DSM-5 criteria were used to portray a broad spectrum of possible experiences of addiction.

RESULTS

Overall, 5337 threads in 3 forums were screened, and 451 threads containing relevant information were included in the analysis. Users reported experiences consistent with the DSM-5 criteria, such as craving e-cigarettes, excessive time spent vaping, and health issues related to e-cigarette use. However, our analysis also showed that users reported the absence of typical tobacco use disorder criteria, such as successful attempts to reduce the nicotine dosage. For most themes, reports of their absence were more frequent than of their presence. The absence of perceived addiction was mostly reported in contrast to prior tobacco smoking.

CONCLUSIONS

This is the first study to use a netnographic approach to explore unfiltered self-reports of experiences of e-cigarette addiction by users in online forums. As hypothesized, some but not all users reported subjective experiences that corresponded to the criteria of tobacco use disorder as defined by the DSM-5. Nevertheless, subjective reports also indicated that many e-cigarette users felt in control of their behavior, especially in contrast to their prior use of tobacco cigarettes. The finding that some e-cigarette users subjectively experience addiction highlights the need for effective cessation programs to support users who experience their e-cigarette use as burdensome. This research can guide the refinement of instruments to assess e-cigarette addiction and guide cessation programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40359-021-00682-8.

E-cigarette use during pregnancy and its association with adverse birth outcomes in the US

The popularity of e-cigarette use among young adults is a growing concern. However, little is known about factors associated with e-cigarette use in pregnant women and birth outcomes. In this retrospective cohort study, we evaluated the influence of several factors on behavioral changes in e-cigarette use before and during pregnancy, and assessed the association between e-cigarette use and subsequent birth outcomes among pregnant women. The Population Assessment of Tobacco and Health (PATH) study, a government-sponsored national longitudinal study based in the US, Waves 1 through 4 (2013-2018) were used. Multivariate logistic regressions were conducted to estimate behavioral changes in e-cigarette use during pregnancy and subsequent influence on high-risk birth (e.g., preterm birth, low birth weight, birth defects, etc.) and fetal death. Although pregnant women who quit vaping before pregnancy (OR = 1.14, 95% CI 0.54-2.40) or had any use during pregnancy (OR = 1.19, 95% CI 0.38-3.73) showed non-differential risk of having a high-risk birth in comparison to women who did not initiate vaping, we observed that the usage of mint/menthol flavor was correlated with higher risk of fetus death (OR = 3.27, 95% CI 1.17-9.19). Healthcare providers should encourage e-cigarette users to quit prior to and during early pregnancy.

Perceptions of Safety Around Use of Cannabis and Nicotine/Tobacco in Pregnancy

The perceived safety of cannabis and nicotine/tobacco use contribute to use of these substances in pregnancy. We assessed time trends in self-reported perception of safety of use of cannabis and nicotine/tobacco among US women of reproductive age. We also reviewed qualitative literature to elucidate factors contributing to the perceived safety of use of cannabis and nicotine/tobacco. US women increasingly perceive cannabis use as posing no health risks; whereas cigarette smoking is perceived as posing substantial health risks. Qualitative studies suggest that personal experiences, sociocultural norms, and environmental factors contribute to the perceived safety of cannabis and nicotine/tobacco use in pregnancy.

'I don't need you to criticise me, I need you to support me'. A qualitative study of women's experiences of and attitudes to smoking cessation during pregnancy

BACKGROUND

Smoking is associated with health inequalities and is the most important modifiable risk factor for poor outcome in pregnancy.

AIM

To explore women's experiences of smoking during pregnancy, examine their attitudes and barriers to smoking cessation, and to discover what support they feel might enable them to have a smoke-free pregnancy in future.

METHODS

A qualitative study was conducted with nineteen women in the United Kingdom who had smoked at some stage in pregnancy during the last five years. Data were collected through in-depth telephone interviews between June and August 2021. The interviews were audio-recorded, transcribed verbatim, and thematically analysed.

FINDINGS

Four key themes were identified: the complex relationship with smoking, being ready to quit, the need for support and understanding, and ideas to support a smoke free pregnancy. The findings revealed that there were two distinct avenues for enabling the support process: encouraging a readiness to quit through identifying individual context, personalised support, and educational risk perception, and, supporting the process of quitting, and offering a range of options, underpinned by a personalised, non-judgemental approach.

CONCLUSION

Smoking in pregnancy is a complex issue resulting from a combination of social, emotional, and physical factors. The findings from this study suggest that a combination of approaches should be made available to enable pregnant women who smoke to select the best options for their individual needs. Irrespective of the practical support offered, there is a need for informed, sensitive, individualised support system that women can identify with.

Smoking and vaping patterns during pregnancy and the postpartum: A longitudinal UK cohort survey

INTRODUCTION

There is limited information about longitudinal patterns of vaping during pregnancy and the postpartum. We describe the prevalence, frequency, and reasons for vaping throughout pregnancy and postpartum. We also describe temporal patterns in pregnant women's vaping.

METHODS

A longitudinal cohort study across England and Scotland, with questionnaires in early pregnancy (8-24 weeks gestation), late pregnancy (34-38 weeks) and 3 months postpartum. A total of 750 women, aged 16 years or over, who were either current smokers, vapers or had smoked in the 3 months before pregnancy, were recruited between June and November 2017.

RESULTS

Vaping prevalence was 15.9% (n = 119/750) in early pregnancy: 12.4% (n = 93/750) were dual users and 3.5% (n = 26/750) exclusive vapers. Late pregnancy vaping prevalence was 17.8% (n = 68/383): 12.5% (n = 48/383) were dual users and 5.2% (n = 20/383) exclusive vapers. Postpartum vaping prevalence was 23.1% (n = 95/411): 14.6% (n = 60/411) were dual users and 8.5% (n = 35/411) exclusive vapers. The most frequently reported reason to vape among all vapers was to quit smoking. A total of 316 women completed all three surveys: 2.6% (n = 8/316) were exclusive vapers in early pregnancy with most remaining exclusive vapers postpartum (n = 6/8, 75%). Of the 11.5% (n = 35/316) dual users in early pregnancy, 31.4% (n = 11/35) were exclusive smokers by the postpartum.

CONCLUSION

Vaping prevalence was between 15.9% and 23.1% during pregnancy and the postpartum period, and the majority were dual users. Vaping habits of exclusive vapers remains stable throughout pregnancy and the postpartum. However, the vaping habits of dual users varies, with a third exclusively smoking in the postpartum.

Pregnant Smokers' Intention to Switch From Cigarettes to E-Cigarettes: A Reasoned Action Approach

INTRODUCTION

This study used the reasoned action approach (RAA) to examine 1) factors associated with pregnant smokers' intention to switch from cigarettes to e-cigarettes and 2) the influence that intention to switch had on future expectations to resume cigarette use postpartum.

METHODS

U.S. pregnant women (N = 267) who reported past 30-day use of cigarettes completed an online cross-sectional survey between November and December 2019. A 30-item scale measured RAA constructs (intention, instrumental attitudes, experiential attitudes, injunctive norms, descriptive norms, perceived autonomy, and perceived capacity). A confirmatory factor analysis confirmed and structural equation modeling tested the RAA constructs' association with intention to switch and the relationship between intention to switch and future expectations to resume smoking after pregnancy.

RESULTS

The confirmatory factor analysis confirmed the seven-factor measurement model. Structural equation modeling found instrumental attitudes (β = 0.43; p < .001) and descriptive norms (β = 0.53; p < .001) were associated with intention to switch from cigarettes to e-cigarettes. However, there were differences between the constructs' relationships with intention between those who did and did not use e-cigarettes in the past 30 days. Intention to switch was inversely related with future expectations to resume smoking postpartum (β = -0.13; p < .001).

CONCLUSIONS

This study examined multiple facets of behavioral decision-making that may influence pregnant smokers' intention to switch to e-cigarettes during pregnancy. In this sample, pregnant people who believed switching from cigarettes to e-cigarettes was important and that other smokers commonly switched during pregnancy reported greater intention to switch. Novel theories, such as the RAA, may provide an optimal lens to understand pregnant smokers' behavioral decision-making process as they consider switching from cigarettes to e-cigarettes.

Vaping in Pregnancy: A Systematic Review

INTRODUCTION

Smoking in pregnancy increases the risk of negative health outcomes. Vaping can be effective for smoking cessation in nonpregnant populations. We conducted a systematic review of vaping in pregnancy, covering prevalence, patterns of use, reasons for use, smoking cessation, and health effects.

METHODS

Five academic databases were searched on 17 February 2020. Studies reporting prevalence, patterns, reasons, cessation, or health effects of vaping in pregnancy were included; animal and in vitro studies were excluded. A narrative review was used, with risk of bias assessed using Hoy and colleague's tool, the Newcastle-Ottawa scale, and the Consolidated Criteria for reporting Qualitative Research.

RESULTS

Twenty-three studies were identified: 11 survey, 7 qualitative, 3 cohort, and 2 secondary analyses of randomized clinical trials. Prevalence of vaping in pregnancy (four studies) was between 1.2% and 7.0% overall, and <1% among nonsmokers. Twelve studies reported patterns of use, but findings were inconsistent. Twelve of 14 studies asking why pregnant women vaped reported that most vaped to reduce or quit smoking. Mixed findings were reported from six studies on smoking cessation. Of three studies with health-related outcomes, two were underpowered and one reported similar birthweights for babies born to nonsmokers and women who vaped, with both higher (p < .0001) than the birthweight of babies born to smokers.

CONCLUSIONS

There were insufficient data to draw conclusions about prevalence, patterns, and effects of vaping in pregnancy on smoking cessation. The limited literature suggests that vaping in pregnancy has little or no effect on birthweight.

IMPLICATIONS

Smoking causes many negative health outcomes for pregnant women and to babies born to people who smoke. There remains a paucity of research on the effects of vaping in pregnancy. There is, however, the potential for vaping products to reduce the negative health outcomes associated with smoking. More research is needed to develop an evidence base in this area.

Study on E-Cigarettes and Pregnancy (STEP) - Results of a Mixed Methods Study on Risk Perception of E-Cigarette Use During Pregnancy

Introduction E-cigarette use during pregnancy is a risk factor for maternal and fetal health. Early studies on animals showed that in utero exposure to e-cigarettes can have negative health outcomes for the fetus. There has been only limited research into the risk perceptions of e-cigarette use during pregnancy. This study was conducted to comprehensively characterize the constructs of risk perceptions with regard to e-cigarette use during pregnancy using an I ntegrated H ealth B elief M odel (IHBM).

Methods Our ST udy on E -cigarettes and P regnancy (STEP) used a mixed methods approach, with the study divided into an initial qualitative part and a quantitative part. A netnographic approach was used for the first part, which consisted of the analysis of 1552 posts from 25 German-language online discussion threads on e-cigarette use during pregnancy. Using these qualitative results, a quantitative questionnaire was developed to explore risk perception constructs about e-cigarette use during pregnancy. This questionnaire was subsequently administered to pregnant women (n = 575) in one hospital in Hamburg, Germany. Descriptive and bivariate analysis was used to examine differences in risk perception according to participantsʼ tobacco and e-cigarette user status before and during pregnancy. While the study design, methods and sample have been extensively described in our recently published study protocol in the January 2020 issue of Geburtshilfe und Frauenheilkunde , this paper is devoted to a presentation of the results of our mixed methods study.

Results Themes related to perceived threats identified in the qualitative study part were nicotine-related health risks and potential health risks of additional ingredients . Perceived benefits were possibility and facilitation of smoking cessation and a presumed potential to reduce harm . The subsequent quantitative part showed that nearly all participants (99.3%) perceived e-cigarettes which contained nicotine as constituting a threat to the health of the unborn child. The most commonly perceived barrier was health-related (96.6%), while the most commonly perceived benefit was a reduction in the amount of tobacco cigarettes consumed (31.8%). We found that particularly perceived benefits varied depending on the participantʼs tobacco and e-cigarette user status.

Conclusion When considering future prevention strategies, the potential health risks and disputed effectiveness of e-cigarettes as a tool for smoking cessation need to be taken into account and critically discussed.

A Qualitative Study of Factors Influencing Adherence among Pregnant Women Taking Part in a Trial of E-Cigarettes for Smoking Cessation

Use of e-cigarettes (vaping) has potential to help pregnant women stop smoking. This study explored factors influencing adherence among participants in the vaping arm of the first trial of vaping for smoking cessation in pregnancy. We conducted semi-structured telephone interviews (n = 28) with women at three-months postpartum. Interviews were analysed using thematic analysis, informed by the Theoretical-Domains Framework, Necessity-Concerns Framework and Perceptions and Practicalities Approach. Interviewees generally reported high levels of vaping. We found that: (1) intervention adherence was driven by four necessity beliefs-stopping smoking for the baby, and vaping for harm reduction, smoking cessation or as a last resort; (2) necessity beliefs outweighed vaping concerns, such as dependence and safety; (3) adherence was linked to four practicalities themes, acting as barriers and facilitators to vaping-device and e-liquid perceptions, resources and support, whether vaping became habitual, and social and environmental factors; and (4) intentional non-adherence was rare; unintentional non-adherence was due to device failures, forgetting to vape, and personal circumstances and stress. Pregnant smokers provided with e-cigarettes, and with generally high levels of vaping, had positive beliefs about the necessity of vaping for smoking cessation which outweighed concerns about vaping. Non-adherence was mainly due to unintentional factors.

A qualitative study of e-cigarette use among young people in Ireland: Incentives, disincentives, and putative cessation

BACKGROUND

Smoking prevalence in Ireland is falling in all age groups, but e-cigarette use is rising among young people. This qualitative study explores young people's accounts of e-cigarette use in Ireland.

METHODS

Semi-structured individual (22) and focus group (8) interviews were conducted with 62 young people aged 18-22 years, recruited from a higher-education institution and youth organisations working with early school-leavers across Dublin. All were smokers or ex-smokers; 41 had tried e-cigarettes, 11 continued as dual users. We identified themes using thematic data analysis.

RESULTS

Three broad themes were identified: incentivising features, disincentivising features, and ambivalent and unsuccessful cessation, named putative smoking cessation. Incentivising features included price, pleasing taste/ flavours, and the possibility of indoor use. Disincentivising features related to adverse health effects (pain, discomfort, sore throat, coughing, headache) and unpleasant physical effects (bad taste, problems resulting from device faults). Other disincentives were over-consumption arising from inability to control intake, "greater addictiveness", product taste, and device faults. Putative cessation refers to the conflict between participants' expected use of e-cigarettes as a smoking cessation/reduction aid and their observed reality of e-cigarettes' failure in this regard, with reported outcomes including: failure to quit or reduce; continued or resumed cigarette and/or roll-your-own smoking; dual use of e-cigarettes and other tobacco products; and inability to quit e-cigarettes.

CONCLUSIONS

Participants were sceptical about e-cigarettes' "purported relative healthiness", concerned about addictiveness and potential long-term health consequences, and critically aware of advertising and industry strategies. E-cigarettes were viewed as being less denormalised, in part because they could be used in indoor spaces where smoking is banned in Ireland. Although price, taste, and perceived renormalisation were important motivators for young people's use of e-cigarettes, they wanted to quit smoking. The regulation of e-cigarettes through age restriction of access, licensing of outlets, pricing, point of sale and advertising restrictions as well as through the banning of indoor use should be considered by legislators and tobacco control policymakers.

Risk perception of cigarette and e-cigarette use during pregnancy: A qualitative postpartum perspective

AIM

The aim of this exploratory qualitative analysis is to assess the perceptions of risks of cigarette and e-cigarette use during pregnancy.

BACKGROUND

An important public health aim is a reduction of smoking at time of delivery (SATOD) from 10.6% to less than 6% by 2022 in the United Kingdom (UK). In order to successfully meet this target, we need to have a better understanding of the perceived risks associated with cigarette smoking. Additionally, the use of e-cigarettes is increasing in the general population, with pregnant women being supported to use such products if it helps them remain smoke free. However, in contrast to cigarette smoking, there is little definitive research assessing the safety of e-cigarette use during pregnancy, with most information disregarding the health of the growing fetus. E-cigarettes are of special interest, given they are an unlicensed product for use during pregnancy, yet women are being supported to use them as a method of harm reduction. A better understanding of perceived risks is essential.

METHOD

Fourteen interviews were conducted one month postpartum with women who smoked during pregnancy and continued to smoke after the birth. Thematic analysis was conducted.

FINDINGS

Two themes emerged for cigarette smoking; health and justifications. Six themes were identified for e-cigarette use; the unknown, experience, comparison to cigarettes, the product, advice and healthier option. A range of subthemes are discussed.

CONCLUSION

Women provided a range of justifications for continuing to smoke during pregnancy. Women felt e-cigarettes were a riskier option than continuing to smoke.

Gestational Women's Perceptions About the Harms of Cigarette and E-Cigarette Use During Pregnancy

OBJECTIVES

The purpose of this study was to examine differences between perceived harm of cigarette and electronic cigarette (e-cigarette) use while pregnant and differences between healthcare providers' communication about these products during pregnancy.

METHODS

A convenience sample of gestational women (n = 218; ages 18-45) living in the US completed an online survey between May and December 2017. Participants reported perceived likelihood of adverse health outcomes (e.g., low birth weight, sudden infant death syndrome) among infants/children born to mothers who used cigarettes/e-cigarettes. T-tests and two-way ANOVAs examined differences between risk perceptions of using cigarettes/e-cigarettes while pregnant based on pregnancy status (previously pregnant, currently pregnant, future pregnant). Chi-square analyses examined differences between healthcare provider communication about cigarette/e-cigarette use during pregnancy.

RESULTS

Overall, participants believed adverse health outcomes were significantly more likely to be caused by maternal use of cigarettes than e-cigarettes. Participants who planned to be pregnant reported higher endorsement that smoking combustible cigarettes would cause a miscarriage (p < .05) or increased blood pressure (p < .05) for a child than currently pregnant participants. Participants reported healthcare providers asked about (p < .05), advised them not to use (p < .001), and talked to them about health effects of smoking combustible cigarettes while pregnant (p < .001) significantly more than e-cigarettes.

CONCLUSIONS FOR PRACTICE

Healthcare providers working with pregnant women should perform the 5As behavioral intervention method to provide pregnant women with tobacco cessation care. They should also discuss the absolute harm nicotine exposure (via cigarettes or e-cigarettes) can have on fetal health and development.