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Ndeke JM, Klaunig JE, Commodore S. Nicotine or marijuana vaping exposure during pregnancy and altered immune responses in offspring. JOURNAL OF ENVIRONMENTAL EXPOSURE ASSESSMENT 2024; 3:10.20517/jeea.2024.03. [PMID: 38840831 PMCID: PMC11152453 DOI: 10.20517/jeea.2024.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Electronic nicotine delivery systems (ENDS) - which include electronic cigarettes or e-cigarettes, or simply e-cigs, and marijuana vaping have become increasingly popular. ENDS devices have been established as one of the tobacco quit methods and promoted to be safer compared to traditional tobacco cigarettes. Emerging evidence demonstrates that e-cigarette and marijuana vape use can be harmful, with potential associations with cancer. Herein, we summarize the level of evidence to date for altered immune response, with a focus on cancer risks in the offspring after maternal use of, or aerosol exposures from, ENDS or marijuana vape during pregnancy. From 27 published articles retrieved from PubMed, we sought to find out identified carcinogens in ENDS aerosols and marijuana vapor, which cross the placental barrier and can increase cancer risk in the offspring. Carcinogens in vaping aerosols include aldehydes, metals, tobacco-specific nitrosamines, tobacco alkaloids, polycyclic aromatic hydrocarbons, and volatile organic compounds. Additionally, there was only one passive vaping exposure case study on a human fetus, which noted that glycerol, aluminum, chromium, nickel, copper, zinc, selenium, and lead crossed from the mother to the offspring's cord blood. The carcinogens (metals) in that study were at lower concentrations compared to the mother's biological matrices. Lastly, we observed that in utero exposures to ENDS-associated chemicals can occur in vital organs such as the lungs, kidneys, brain, bladder, and heart. Any resulting DNA damage increases the risk of tumorigenesis. Future epidemiological studies are needed to examine the effects of passive aerosol exposures from existing and emerging electronic nicotine and marijuana products on developing offspring to cancer.
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Affiliation(s)
- Jonas M. Ndeke
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN 47405, USA
| | - James E. Klaunig
- Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, IN 47408, USA
| | - Sarah Commodore
- Department of Environmental and Occupational Health, Indiana University School of Public Health, Bloomington, IN 47408, USA
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White D, Bush A, Smyth AR, Bhatt JM. Why and how should children be protected from the deluge of vaping related media and marketing overexposure? Breathe (Sheff) 2023; 19:230141. [PMID: 38125806 PMCID: PMC10729810 DOI: 10.1183/20734735.0141-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023] Open
Abstract
E-cigarettes are products delivering nicotine via inhalation and are devised to mimic tobacco smoking. While they were initially introduced as a device putatively to aid with smoking cessation, their use is now far broader than that. Use by children is significantly increasing. There is growing evidence of the potential harms of vaping. E-liquids used for e-cigarettes contain a wide range of harmful substances, and the clinical consequences of this are now being increasingly demonstrated, such as the rise in cases of e-cigarette- or vaping-associated lung injury. In addition, early use may result in long-term nicotine addiction. Vaping companies utilise marketing methods that distinctly target young people, and weak legislation in the UK allows them free rein to expose children to vaping. In this review we demonstrate why children must be protected from vaping. We must have stringent legislation to prevent easy access to e-cigarettes, including banning the convenience and affordability disposable vapes provide, and prevent marketing that does not warn about the potential health effects. The Australia approach of prescription or pharmacy only access for smoking cessation should be considered to limit exposure of children and minimise use by nonsmokers.
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Affiliation(s)
- David White
- Nottingham University Hospitals NHS Trust, Nottingham Children's Hospital, Queen's Medical Centre, Nottingham, UK
| | - Andrew Bush
- Paediatrics and Paediatric Respirology, National Heart and Lung Institute, London, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Imperial Centre for Paediatrics and Child Health, London, UK
| | - Alan R. Smyth
- NIHR Biomedical Research Centre, Nottingham, UK
- School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, UK
| | - Jayesh Mahendra Bhatt
- Nottingham University Hospitals NHS Trust, Nottingham Children's Hospital, Queen's Medical Centre, Nottingham, UK
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3
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Ozekin YH, Saal ML, Pineda RH, Moehn K, Ordonez-Erives MA, Delgado Figueroa MF, Frazier C, Korth KM, Königshoff M, Bates EA, Vladar EK. Intrauterine exposure to nicotine through maternal vaping disrupts embryonic lung and skeletal development via the Kcnj2 potassium channel. Dev Biol 2023; 501:111-123. [PMID: 37353105 PMCID: PMC10445547 DOI: 10.1016/j.ydbio.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
Smoking cigarettes during pregnancy is associated with adverse effects on infants including low birth weight, defective lung development, and skeletal abnormalities. Pregnant women are increasingly turning to vaping [use of electronic (e)-cigarettes] as a perceived safer alternative to cigarettes. However, nicotine disrupts fetal development, suggesting that like cigarette smoking, nicotine vaping may be detrimental to the fetus. To test the impact of maternal vaping on fetal lung and skeletal development in mice, pregnant dams were exposed to e-cigarette vapor throughout gestation. At embryonic day (E)18.5, vape exposed litter sizes were reduced, and some embryos exhibited growth restriction compared to air exposed controls. Fetal lungs were collected for histology and whole transcriptome sequencing. Maternally nicotine vaped embryos exhibited histological and transcriptional changes consistent with impaired distal lung development. Embryonic lung gene expression changes mimicked transcriptional changes observed in adult mouse lungs exposed to cigarette smoke, suggesting that the developmental defects may be due to direct nicotine exposure. Fetal skeletons were analyzed for craniofacial and long bone lengths. Nicotine directly binds and inhibits the Kcnj2 potassium channel which is important for bone development. The length of the maxilla, palatal shelves, humerus, and femur were reduced in vaped embryos, which was further exacerbated by loss of one copy of the Kcnj2 gene. Nicotine vapor exposed Kcnj2KO/+ embryos also had significantly lower birth weights than unexposed animals of either genotype. Kcnj2 mutants had severely defective lungs with and without vape exposure, suggesting that potassium channels may be broadly involved in mediating the detrimental developmental effects of nicotine vaping. These data indicate that intrauterine nicotine exposure disrupts fetal lung and skeletal development likely through inhibition of Kcnj2.
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Affiliation(s)
- Yunus H Ozekin
- Section of Developmental Biology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maxwell L Saal
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Cell and Developmental Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ricardo H Pineda
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kayla Moehn
- Section of Developmental Biology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Madison A Ordonez-Erives
- Section of Developmental Biology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Maria F Delgado Figueroa
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Cell and Developmental Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Caleb Frazier
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Cell and Developmental Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kamryn M Korth
- Section of Developmental Biology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Melanie Königshoff
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Emily A Bates
- Section of Developmental Biology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Eszter K Vladar
- Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Cell and Developmental Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Goud TJ. Epigenetic and Long-Term Effects of Nicotine on Biology, Behavior, and Health. Pharmacol Res 2023; 192:106741. [PMID: 37149116 DOI: 10.1016/j.phrs.2023.106741] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 05/08/2023]
Abstract
Tobacco and nicotine use are associated with disease susceptibility and progression. Health challenges associated with nicotine and smoking include developmental delays, addiction, mental health and behavioral changes, lung disease, cardiovascular disease, endocrine disorders, diabetes, immune system changes, and cancer. Increasing evidence suggests that nicotine-associated epigenetic changes may mediate or moderate the development and progression of a myriad of negative health outcomes. In addition, nicotine exposure may confer increased lifelong susceptibility to disease and mental health challenges through alteration of epigenetic signaling. This review examines the relationship between nicotine exposure (and smoking), epigenetic changes, and maladaptive outcomes that include developmental disorders, addiction, mental health challenges, pulmonary disease, cardiovascular disease, endocrine disorders, diabetes, immune system changes, and cancer. Overall, findings support the contention that nicotine (or smoking) associated altered epigenetic signaling is a contributing factor to disease and health challenges.
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Affiliation(s)
- Thomas J Goud
- Department of Biobehavioral Health, The Pennsylvania State University, Penn State University, University Park, PA, USA.
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Noël A, Yilmaz S, Farrow T, Schexnayder M, Eickelberg O, Jelesijevic T. Sex-Specific Alterations of the Lung Transcriptome at Birth in Mouse Offspring Prenatally Exposed to Vanilla-Flavored E-Cigarette Aerosols and Enhanced Susceptibility to Asthma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3710. [PMID: 36834405 PMCID: PMC9967225 DOI: 10.3390/ijerph20043710] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
Currently, approximately 8 million adult Americans use electronic cigarettes (e-cigs) daily, including women of childbearing age. It is known that more than 10% of women smoke during their pregnancy, and recent surveys show that rates of maternal vaping are similar to rates of maternal cigarette smoking. However, the effects of inhaling e-cig aerosol on the health of fetuses remain unknown. The objective of the present study was to increase our understanding of the molecular effects caused by in utero exposures to e-cig aerosols on developing mouse lungs and, later in life, on the offspring's susceptibility to developing asthma. METHODS Pregnant mice were exposed throughout gestation to either filtered air or vanilla-flavored e-cig aerosols containing 18 mg/mL of nicotine. Male and female exposed mouse offspring were sacrificed at birth, and then the lung transcriptome was evaluated. Additionally, once sub-groups of male offspring mice reached 4 weeks of age, they were challenged with house dust mites (HDMs) for 3 weeks to assess asthmatic responses. RESULTS The lung transcriptomic responses of the mouse offspring at birth showed that in utero vanilla-flavored e-cig aerosol exposure significantly regulated 88 genes in males (62 genes were up-regulated and 26 genes were down-regulated), and 65 genes were significantly regulated in females (17 genes were up-regulated and 48 genes were down-regulated). Gene network analyses revealed that in utero e-cig aerosol exposure affected canonical pathways associated with CD28 signaling in T helper cells, the role of NFAT in the regulation of immune responses, and phospholipase C signaling in males, whereas the dysregulated genes in the female offspring were associated with NRF2-mediated oxidative stress responses. Moreover, we found that in utero exposures to vanilla-flavored e-cig aerosol exacerbated HDM-induced asthma in 7-week-old male mouse offspring compared to respective in utero air + HDM controls. CONCLUSIONS Overall, these data demonstrate that in utero e-cig aerosol exposure alters the developing mouse lung transcriptome at birth in a sex-specific manner and provide evidence that the inhalation of e-cig aerosols is detrimental to the respiratory health of offspring by increasing the offspring' susceptibility to developing lung diseases later in life.
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Affiliation(s)
- Alexandra Noël
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Sultan Yilmaz
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Tori Farrow
- Department of Environmental Toxicology, Southern University and A & M College, Baton Rouge, LA 70813, USA
| | | | - Oliver Eickelberg
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Tomislav Jelesijevic
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
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Olszewski NA, Tetteh-Quarshie S, Henderson BJ. Understanding the Impact of Flavors on Vaping and Nicotine Addiction-Related Behaviors. Curr Behav Neurosci Rep 2022. [DOI: 10.1007/s40473-022-00253-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Orzabal MR, Naik VD, Lee J, Hillhouse AE, Brashear WA, Threadgill DW, Ramadoss J. Impact of E-cig aerosol vaping on fetal and neonatal respiratory development and function. Transl Res 2022; 246:102-114. [PMID: 35351623 PMCID: PMC9197928 DOI: 10.1016/j.trsl.2022.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/15/2022]
Abstract
Electronic cigarette (e-cig) use has increased over the past decade, and exposure to e-cig aerosols during pregnancy raises concern for maternal and fetal health. The developing fetal lung is known to be sensitive to prenatal tobacco product exposure. Utilizing a 3-pronged approach, we examined the effects of prenatal e-cig aerosols with, and without nicotine on respiratory development in a murine model. RNAseq analysis of fetal lungs revealed extensive dysregulation in gene expression. Morphologic assessment of distal airspaces in neonatal lungs display an emphysematic phenotype. Respiratory mechanics of neonates display signs of increased respiratory workload, with increased resistance and decreased compliance. These data are novel and provide evidence that prenatal e-cig exposure may result in altered lung function or development of disease.
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Affiliation(s)
- Marcus R Orzabal
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Vishal D Naik
- Department of Obstetrics & Gynecology, C.S. Mott Center for Human growth and Development, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Jehoon Lee
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Andrew E Hillhouse
- Institute for Genome Sciences and Society, Texas A&M University, College Station, Texas, USA
| | - Wesley A Brashear
- Institute for Genome Sciences and Society, Texas A&M University, College Station, Texas, USA
| | - David W Threadgill
- Institute for Genome Sciences and Society, Texas A&M University, College Station, Texas, USA
| | - Jayanth Ramadoss
- Department of Obstetrics & Gynecology, C.S. Mott Center for Human growth and Development, School of Medicine, Wayne State University, Detroit, Michigan, USA; Department of Physiology, School of Medicine, Wayne State University, Detroit, Michigan, USA.
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Cahill KM, Johnson TK, Perveen Z, Schexnayder M, Xiao R, Heffernan LM, Langohr IM, Paulsen DB, Penn AL, Noël A. In utero exposures to mint-flavored JUUL aerosol impair lung development and aggravate house dust mite-induced asthma in adult offspring mice. Toxicology 2022; 477:153272. [PMID: 35878681 DOI: 10.1016/j.tox.2022.153272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/04/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
There are few reports concerning electronic nicotine delivery system (ENDS) use during pregnancy and no studies on asthma in prenatally JUUL-exposed offspring. Here, we tested the hypothesis that in utero JUUL exposure causes unfavorable birth outcomes and lasting pulmonary health effects in adult offspring. BALB/c dams were exposed to either air or mint-flavored JUUL aerosol, 1-hr/d, 20 consecutive days during gestation. Offspring were sacrificed on post-natal day (PND) 0 or at 11-week of age, following house dust mite (HDM) challenge. Gene expression was assessed in the uterine/placental tissue of the dams and lung responses were assessed in offspring at PND0 and at 11 weeks of age. JUUL-exposed offspring exhibited decreased body weights and lengths at PND0. These birth outcomes were accompanied by dysregulation of 54 genes associated with hypoxia and oxidative stress in the uterine/placental tissues of JUUL-exposed dams, as well as 24 genes in the lungs of the offspring related to Wnt signaling, plus 9 genes related to epigenetics, and 7 genes related to inflammation. At 11 weeks of age, JUUL + HDM exposed mice exhibited pulmonary inflammation when compared to their respective air + HDM controls. Additionally, the JUUL + HDM exposure dysregulated several genes associated with allergies and asthma. Further, the JUUL + HDM females showed decreased methylation of the promoter region of the Il10ra gene. Taken together, our mouse model shows that inhalation of JUUL aerosols during pregnancy affects the intrauterine environment, impairs lung development, and heightens the effects of allergic airway responses later in life.
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Affiliation(s)
- Kerin M Cahill
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Trenton K Johnson
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Zakia Perveen
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Matthew Schexnayder
- Lincoln Memorial University, College of Veterinary Medicine, 6965 Cumberland Gap Parkway, Harrogate, TN, USA
| | - Rui Xiao
- Department of Anesthesiology, Columbia University Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Linda M Heffernan
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Ingeborg M Langohr
- Department of Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Daniel B Paulsen
- Department of Pathobiological Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Arthur L Penn
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Alexandra Noël
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA 70803, USA.
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Zhang Y, Angley M, Qi X, Lu L, D'Alton ME, Kahe K. Maternal electronic cigarette exposure in relation to offspring development: a comprehensive review. Am J Obstet Gynecol MFM 2022; 4:100659. [PMID: 35568317 DOI: 10.1016/j.ajogmf.2022.100659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/27/2022] [Indexed: 01/04/2023]
Abstract
Electronic cigarettes (e-cigarettes) have become increasingly popular in young generations in the United States. Because the adverse pregnancy outcomes associated with combustible cigarette smoking are well-recognized, many pregnant women switch to e-cigarettes believing that this alternative is low in toxic chemicals. However, most e-cigarettes contain nicotine, which can easily pass through the placenta and accumulate to a high concentration in fetal blood circulation. Studies have also detected toxic metals (eg, lead, cadmium, and nickel) in e-cigarettes, and carbonyl compounds and flavorings, which are suggested to be irritative and even carcinogenic. There are questions that need to be answered about the risks of e-cigarette exposure during pregnancy. Unfortunately, research evaluating the association between maternal e-cigarette exposure and offspring health is scarce, especially with regard to human studies. Some evidence from laboratory and animal studies, although inconsistent, showed that maternal exposure to e-cigarette vapor may lead to restricted growth of offspring. E-cigarette exposure may also have an impact on the metabolic health of offspring, manifested as distorted glucose homeostasis and energy metabolism. In addition, in utero exposure may lead to defects in respiratory, vascular, and neurologic system development. For humans, investigations mostly focused on immediate birth outcomes such as small-for-gestational-age neonates, low birthweight, and preterm birth; however, the results were inconclusive. Research also suggests that maternal e-cigarette exposure may result in compromised neurodevelopment in newborns. In summary, current evidence is insufficient to rigorously evaluate the health impacts of maternal e-cigarette use on offspring development. Future investigations are warranted.
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Affiliation(s)
- Yijia Zhang
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, XX D'Alton, and XX Kahe); Department of Epidemiology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, and XX Kahe)
| | - Meghan Angley
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, XX D'Alton, and XX Kahe); Department of Epidemiology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, and XX Kahe)
| | - Xinran Qi
- School of Nursing, Capital Medical University, Beijing, China (XX Qi)
| | - Liping Lu
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, XX D'Alton, and XX Kahe); Department of Epidemiology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, and XX Kahe)
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, XX D'Alton, and XX Kahe)
| | - Ka Kahe
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, XX D'Alton, and XX Kahe); Department of Epidemiology, Columbia University Irving Medical Center, New York, NY (XX Zhang, XX Angley, XX Lu, and XX Kahe).
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