Snus users had high levels of nicotine, cotinine and 3-hydroxycotinine in their breastmilk, and the clearance was slower than in smoking mothers

Tobacco and alcohol use among lactating women and its association with child nutrition in India: findings from National Family Health Survey 2019-2021

OBJECTIVES

Tobacco use is one of the greatest public health problems in the world. Prevalence of alcohol and tobacco use among lactating women ranged between 35.9-83.0% and 1.4-6.1%, respectively, in various parts of the world. Both alcohol and nicotine pass quickly into breast milk. The objective of this study is to estimate the prevalence of alcohol and tobacco use in lactating women and its association with having underweight, stunted, and wasted nursing children in India. The study also draws comparisons to identify the common associated socio-economic factors for alcohol and tobacco use among lactating women and having underweight, stunted, and/or wasted children.

STUDY DESIGN

A cross-sectional analytical study involving secondary data from the National Family Health Survey-5.

METHODS

A cross-sectional analytical study involving secondary data from the National Family Health Survey-5 conducted nationally in community settings in two phases during 2019-2021. Alcohol and tobacco use among lactating women was self-reported, and the nutritional status of children was assess anthropometrically during the survey and categorised into under-weight, stunted, and wasted as per standardised growth charts.

RESULTS

prevalence of tobacco use among currently lactating mothers in India was 3.24%. Prevalence of alcohol use among currently lactating mothers was 0.57%. Nursing children of mothers consuming alcohol had significantly higher odds of being wasted [OR = 1.44; (95% CI = 1.07-1.92)]. Richer wealth index {compared to poor, poorer [OR = 0.74; (95% CI = 0.59-0.91)], rich [OR = 0.64; (95% CI = 0.50-0.84)], richer [OR = 0.46; (95% CI = 0.33-0.65)], richest [OR = 0.19; (95% CI = 0.11-0.33)]}, higher education status {compared to illiterate, secondary education [OR = 0.79; (95% CI = 0.63-0.97)], higher education [OR = 0.38; (95% CI = 0.24-0.62)]}, and non-tribal ethnicity [OR = 0.40; (95% CI = 0.33-0.50)] were found to be significantly associated with lower odds of alcohol and tobacco use among lactating mothers. Age, religion, residence, and occupation were also found to be significantly associated.

CONCLUSIONS

Lactating women with lower education status or belonging to lower income groups needs to be prioritised for further qualitative assessment of alcohol and tobacco use during lactation. Our study reflects the national and state-level prevalence of alcohol and tobacco use among lactating women, which often masks the local and community-level intricacies. There is a need to further explore local and community-level factors affecting alcohol use during lactation and its association with child nutrition.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Factors associated with postpartum smoking relapse at early postpartum period of Japanese women in the Japan Environmental and Children's Study

BACKGROUND

Postpartum smoking relapse is a serious public health concern. Previous studies have identified several risk factors for postpartum smoking relapse; however, very little is known about the predictors of early postpartum smoking relapse. This study aimed to determine postpartum smoking relapse status and its associated risk factors at 1 month postpartum among Japanese women.

METHODS

Data were obtained from 93,851 mothers with live births in an ongoing birth cohort study, the Japan Environment and Children's Study. Data on smoking status and confounding variables were collected using self-administered questionnaires and medical record transcripts. Self-administered questionnaires were administered during the first trimester, second/third trimester, and 1 month after delivery. A multiple logistic regression analysis was performed.

RESULTS

Among the 14,326 mothers who smoked during pregnancy, 10,917 (76.2%) quit smoking during pregnancy. Subsequently, 617 (5.7%) of the mothers who had quit relapsed smoking at 1 month postpartum. Maternal age (≤24, ≥35), maternal education (≤12 years), parity (≥Second), feeding method (Formula milk), partner smoking status during pregnancy (Smoker), number of cigarettes per day before the cessation of smoking (≥11), maternal alcohol consumption at 1-month postpartum (Drinker), postpartum depression (EPDS score ≥9), and spending time at the parents' home after delivery (≥14 days) were associated with smoking relapse.

CONCLUSIONS

A certain number of mothers relapsed even 1 month postpartum. Besides mother's alcohol and smoking habit before pregnancy, breastfeeding and partner smoking are important factors in early postpartum smoking relapse in Japan.

Use of Swedish smokeless tobacco during pregnancy: A systematic review of pregnancy and early life health risk

BACKGROUND AND AIMS

Smokeless tobacco is a heterogeneous product group with diverse composition and prevalence globally. Tobacco use during pregnancy is concerning due to the risk of adverse pregnancy outcomes and effects on child health. Nicotine may mediate several of these effects. This systematic review measured health outcomes from Swedish smokeless tobacco (snus) use during pregnancy.

METHOD

Literature search was conducted by an information specialist in May 2022. We included human studies of snus use during pregnancy compared with no tobacco use, assessed risk of bias, conducted a meta-analysis and assessed confidence in effect-estimates using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

RESULTS

We included 18 cohort studies (42 to 1 006 398 participants). Snus use during pregnancy probably (moderate confidence in risk estimates) increase the risk of neonatal apnea, adjusted odds ratio 95% confidence interval [aOR (95% CI)] 1.96 (1.30 to 2.96). Snus use during pregnancy possibly (low confidence in risk estimates) increase the risk of stillbirths aOR 1.43 (1.02 to 1.99), extremely premature births aOR 1.69 (1.17 to 2.45), moderately premature birth aOR 1.26 (1.15 to 1.38), SGA aOR 1.26 (1.09 to 1.46), reduced birth weight mean difference of 72.47 g (110.58 g to 34.35 g reduction) and oral cleft malformations aOR 1.48 (1.00 to 2.21). It is uncertain (low confidence in risk estimates, CI crossing 1) whether snus use during pregnancy affects risk of preeclampsia aOR 1.11 (0.97 to 1.28), antenatal bleeding aOR 1.15 (0.92 to 1.44) and very premature birth aOR 1.26 (0.95 to 1.66). Risk of early neonatal mortality and altered heart rate variability is uncertain, very low confidence. Snus using mothers had increased prevalence of caesarean sections, low confidence.

CONCLUSIONS

This systematic review reveals that use of smokeless tobacco (snus) during pregnancy may adversely impact the developing child.

Higher blood nicotine concentrations following smokeless tobacco (pituri) and cigarette use linked to adverse pregnancy outcomes for Central Australian Aboriginal pregnancies

BACKGROUND

In central Australia, Aboriginal women use wild tobacco plants, Nicotiana spp. (locally known as pituri) as a chewed smokeless tobacco, with this use continuing throughout pregnancy and lactation. Our aim was to describe the biological concentrations of nicotine and metabolites in samples from mothers and neonates and examine the relationships between maternal self-reported tobacco use and maternal and neonatal outcomes.

METHODS

Central Australian Aboriginal mothers (and their neonates) who planned to birth at the Alice Springs Hospital (Northern Territory, Australia) provided biological samples: maternal blood, arterial and venous cord blood, amniotic fluid, maternal and neonatal urine, and breast milk. These were analysed for concentrations of nicotine and five metabolites.

RESULTS

A sample of 73 women were enrolled who self-reported: no-tobacco use (n = 31), tobacco chewing (n = 19), or smoking (n = 23). Not all biological samples were obtained from all mothers and neonates. In those where samples were available, higher total concentrations of nicotine and metabolites were found in the maternal plasma, urine, breast milk, cord bloods and Day 1 neonatal urine of chewers compared with smokers and no-tobacco users. Tobacco-exposed mothers (chewers and smokers) with elevated blood glucose had higher nicotine and metabolite concentrations than tobacco-exposed mothers without elevated glucose, and this was associated with increased neonatal birthweight. Neonates exposed to higher maternal nicotine levels were more likely to be admitted to Special Care Nursery. By Day 3, urinary concentrations in tobacco-exposed neonates had reduced from Day 1, although these remained higher than concentrations from neonates in the no-tobacco group.

CONCLUSIONS

This research provides the first evidence that maternal pituri chewing results in high nicotine concentrations in a wide range of maternal and neonatal biological samples and that exposure may be associated with adverse maternal and neonatal outcomes. Screening for the use of all tobacco and nicotine products during pregnancy rather than focusing solely on smoking would provide a more comprehensive assessment and contribute to a more accurate determination of tobacco and nicotine exposure. This knowledge will better inform maternal and foetal care, direct attention to targeted cessation strategies and ultimately improve long-term clinical outcomes, not only in this vulnerable population, but also for the wider population.

NOTE TO READERS

In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader group of Australian First Peoples. That choice has been maintained in the reporting of the research findings.

Prevalence of smoking and smokeless tobacco use during breastfeeding: A cross-sectional secondary data analysis based on 0.32 million sample women in 78 low-income and middle-income countries

BACKGROUND

Smoking and smokeless tobacco use during the postpartum period is well studied in high-income countries, whereas low-income and middle-income countries (LMICs) lack evidence.

METHODS

In this cross-sectional study we used data from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted in 78 LMICs between January 2010 and December 2019 to study tobacco use among 0.32 million sample lactating women. Age-standardized prevalence of smoking and smokeless tobacco use was estimated and presented with a 95% Confidence Interval (CI) for 78 LMICs. Pooled estimates overall and by WHO regions were obtained using random-effects meta-analyses. Country-level and community-level variance to understand contextual factors was also quantified using multilevel modelling.

FINDINGS

Pooled prevalence of any tobacco use among breastfeeding women in LMICs was 3.61% (95% CI 3.53-3.70); with the lowest prevalence in regions of the Americas (1.44%, 1.26-1.63) and the highest in the Southeast Asia region (6.13%, 6.0-6.27). The pooled prevalence of tobacco smoking was reported to be 1.16% (1.11-1.21), with the highest prevalence in the Eastern Mediterranean region (4.27%, 3.88-4.67) and the lowest in the African region (0.81%, 0.76-0.86). The pooled prevalence of smokeless tobacco use was reported to be 2.56% (2.49-2.63), with the highest prevalence in the Southeast Asia region (4.92%, 4.80-5.04). Illiterate and poor women in LMICs bore the enormous burden of tobacco use.

INTERPRETATION

The prevalence of smoking and smokeless tobacco use among lactating women in LMICs varied considerably across different WHO regions. Considering the cross-sectional design of the study, caution is required while interpreting the results. To improve mothers' and children's health and nutrition outcomes and reduce health inequalities in LMICs, reducing tobacco use through evidence-based interventions is critical.

FUNDING

None.

Prevalence, duration of exposure and predicting factors for snus use among young Finnish men: a cross-sectional study

OBJECTIVE

The health hazards of tobacco products depend on the level of exposure, but little is known about the characteristics of snus use. The aim of this study was to investigate the duration of daily exposure to snus among occasional and daily users and its associated predictive factors among young Finnish men.

DESIGN

Cross-sectional questionnaire study.

SETTING

Three out of 16 Finnish Defence Forces units.

PARTICIPANTS

1280 young Finnish male conscripts starting their military service in 2016 chosen by simple random sampling.

PRIMARY AND SECONDARY MEASURES

The prevalence, duration of use and the amount of daily usage of snus and cigarettes were investigated. The attitudes towards perceived harmfulness of snus and the predictive factors affecting the total time of snus consumption were examined.

RESULTS

Almost a fifth (19.5%) of the conscripts reported daily snus use, and a further 16% reported occasional use. Daily snus use was associated with an earlier starting age, longer duration of use and higher daily exposure time compared with occasional use. On average, daily snus users consumed 10 portions and occasional users three portions per day (p<0.001). The daily total exposure time for daily users was 372 min (95% CI 344 to 401) and for occasional users 139 min (95% CI 106 to 171). Respondents with an upper secondary education had significantly less daily total exposure than those with basic comprehensive education (p=0.036). Perceptions of snus as a harmful substance resulted in a significantly lower duration of exposure.

CONCLUSION

Snus use was very common among young Finnish men. High snus exposure duration was associated with an earlier starting age, a longer history of use and a careless attitude to its health hazards. A higher education level was a protective factor for total exposure time. Studies of the long-term health effects and dependency profile of snus use are needed.

Maternal use of nicotine products and breastfeeding 3 months postpartum

AIM

We aimed to determine the prevalence of and factors associated with maternal use of nicotine products in relation to breastfeeding.

METHODS

Nicotine use 3 months postpartum was determined in the Scandinavian PreventADALL mother-child birth cohort study recruiting 1837 women from 2014 to 2016. Electronic questionnaires at 18 weeks pregnancy and 3 months postpartum provided information on snus use, smoking or other nicotine use, infant feeding and socio-economic factors. The risk of nicotine use in relation to breastfeeding was analysed with logistic regression.

RESULTS

Overall, 5.6% of women used snus (2.9%), smoked (2.7%) or both (n = 2) 3 months postpartum, while one used other nicotine products. Among the 1717 breastfeeding women, 95.1% reported no nicotine use, while 2.4% used snus, 2.5% smoked and one dual user. Compared to 3.7% nicotine use in exclusively breastfeeding women (n = 1242), the risk of nicotine use increased by partly (OR 2.26, 95% CI 1.45-3.52) and no breastfeeding (OR 4.58, 95% CI 2.57-8.21). Nicotine use before (14.5% snus, 16.4% smoking) or in pregnancy (0.2% snus, 0.4% smoking) significantly increased the risk of using nicotine during breastfeeding.

CONCLUSION

Few breastfeeding women used snus or smoked 3 months postpartum, with increased risk by nicotine use before or during pregnancy.

The Effects of Nicotine on Development

Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

Blood Pressure and Heart Rate Variability in Preschool Children Exposed to Smokeless Tobacco in Fetal Life

Background

Maternal smoking during pregnancy has been associated with higher blood pressure and autonomic imbalance in the offspring. However, it has been difficult to determine the selective prenatal and postnatal contributions as children frequently have been exposed to smoking both before and after birth. The specific role of nicotine is also unclear. We aimed to determine whether exclusive prenatal exposure to nicotine from maternal use of smokeless tobacco (Swedish snus) in pregnancy was associated with blood pressure and autonomic heart rate control in their children.

Methods and Results

We measured oscillometric blood pressures in forty 5‐ to 6‐year‐old children with snus exposure in fetal life (n=21) and in tobacco‐free controls (n=19). Taking the child′s age and height into account, snus‐exposed children had 4.2 (95% CI, 0.2–8.1) mm Hg higher systolic blood pressure than controls (P=0.038). The corresponding sex‐, age‐, and height‐standardized systolic blood pressure centiles were 61 and 46 (95% CI of the difference, 2–28) (P=0.029). Heart rate variability was tested in 30 of the children. The spectral heart rate variability variable low‐frequency/high‐frequency ratio was higher (median, 0.69; interquartile range, 0.45–1.21) in snus‐exposed children than in controls (median, 0.21; interquartile range, 0.32–0.57; P=0.034).

Conclusions

Prenatal snus exposure was associated with higher systolic blood pressure and altered heart rate variability at 6 years of age. These findings may indicate adverse prenatal programming of nicotine, but implications for cardiovascular health in later life remain to be studied. Meanwhile, women should be recommended to abstain from all types of tobacco and nicotine products during pregnancy.

See Editorial Watanabe and Parikh

An update on prevalence and risk of snus and nicotine replacement therapy during pregnancy and breastfeeding

AIM

In parallel with falling smoking rates, use of the oral moist tobacco product snus increases among women in reproductive age. We report an update on prevalence and effects of maternal use of snus and nicotine replacement therapy (NRT) during pregnancy and breastfeeding.

METHODS

A literature search of human studies in Medline, PubMed and EMBASE was conducted from September 2016 to May 2018, with stepwise screening of abstracts and subsequent relevant full-text papers for inclusion in Scandinavian and English languages.

RESULTS

Based on three studies, the prevalence of snus use in pregnancy was up to 3.4% in the first trimester and 2.1% in the third trimester. In 12 studies, we found increased risk of several adverse effects, especially preterm delivery, stillbirth and small for gestational age associated with maternal snus use during pregnancy. Knowledge on effects of NRT during pregnancy was conflicting and inconclusive in 10 studies. We did not identify any studies on prevalence or potential health effects of snus or NRT during breastfeeding.

CONCLUSION

Few studies with updated data on the prevalence and adverse health effects of maternal use of snus and NRT during pregnancy were found. No studies during breastfeeding were identified.