Tobacco and nicotine delivery product use in a U.S. national sample of women of reproductive age

Behavior change, health, and health disparities 2024: Smoking and other tobacco use among women and girls

This Special Issue (SI) of Preventive Medicine is the 11th in an annual series on behavior change, health, and health disparities. The theme of this 2024 issue is Smoking and Other Tobacco Use among Women and Girls. Cigarette smoking remains the single most preventable cause of death in the U.S., causing the premature death of more than 200,000 U.S. women annually, a mortality rate that far exceeds levels from conditions more commonly associated with premature death in women (e.g., breast cancer). Of course, cigarette smoking among women and girls is also a well-known cause of intergenerational adverse health effects. Women and girls are also using e-cigarettes and many other tobacco products that are flooding the U.S. tobacco marketplace. This SI includes eleven peer-reviewed articles that advance knowledge across a wide range of topics on disproportionate adverse effects, prevalence, and risk factors for cigarette smoking and other tobacco use in women and girls.

Reduced Nicotine Cigarettes and E-Cigarettes in High-Risk Populations: 3 Randomized Clinical Trials

Importance

Prohibiting the sale of commonly preferred e-cigarette flavors (eg, fruity and sweet) to discourage use among youths poses a risk of diminishing efforts to decrease smoking in adults.

Objective

To compare reductions in smoking achieved in adults with psychiatric conditions or lower educational level using very low nicotine content (VLNC) cigarettes alone, combined with e-cigarettes limited to tobacco flavor (TF), or combined with e-cigarettes in participant-preferred flavors.

Design, Setting, and Participants

Three randomized clinical trials were conducted for 16 weeks from October 2020 through November 2023 at the University of Vermont, Brown University, and Johns Hopkins University. Participants were adults who smoked daily and were not planning to quit in the next 30 days. These participants were from 3 at-risk populations: those with affective disorders, exemplifying mental illness; those with opioid use disorder, exemplifying substance use disorders; and females of reproductive age with a high-school education or less, exemplifying lower educational level. Participants were randomly assigned to 1 of 4 experimental conditions: (1) normal nicotine content (NNC) cigarettes only; (2) VLNC cigarettes only; (3) VLNC cigarettes plus e-cigarettes with classic TF (hereafter, VLNC + TF); and (4) VLNC cigarettes plus e-cigarettes with preferred flavors (hereafter, VLNC + PF).

Interventions

The NNC cigarettes contained 15.8 mg nicotine/g tobacco, the VLNC cigarettes contained 0.4 mg nicotine/g tobacco, the VLNC + TF had pods containing 5% nicotine by weight and only classic TF, and the VLNC + PF had pods containing 5% nicotine in 8 flavors (including fruity and sweet) from which participants selected 3 flavors.

Main Outcomes and Measures

The primary outcome was mean total cigarettes smoked per day (CPD) during week 16. Tobacco-related biomarkers were assessed, including total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific carcinogen.

Results

A total of 326 participants (mean [SD] age, 40.09 [10.79] years; 243 females [74.5%]) from 3 randomized clinical trials were included. The VLNC cigarettes decreased total CPD, with least square (LS) means (SEMs) of 22.54 (1.59) in the NNC, 14.32 (1.32) in the VLNC, 11.76 (1.18) in the VLNC + TF, and 7.63 (0.90) in the VLNC + PF conditions. Each VLNC condition differed significantly from NNC, with an adjusted mean difference (AMD) of -8.21 (95% CI, -12.27 to -4.16; P < .001) in the VLNC, -10.78 (95% CI, -14.67 to -6.90; P < .001) in the VLNC + TF, and -14.91 (95% CI, -18.49 to -11.33; P < .001) in the VLNC + PF conditions. Participants in the VLNC + PF condition also decreased smoking below the VLNC and the VLNC + TF conditions (AMDs, -6.70 [95% CI, -9.84 to -3.55; P < .001] and -4.13 [95% CI, -7.05 to -1.21; P = .02]); the VLNC and VLNC + TF conditions did not differ significantly. Consistent with decreases in CPD, NNAL levels in the VLNC + PF condition were lower than in all other conditions, with AMDs (in pmol/mg creatinine) of -0.94 (95% CI, -1.41 to -0.47; P < .001) compared with the NNC condition, -0.47 (95% CI, -0.87 to -0.08; P = .03) compared with the VLNC condition, and -0.46 (95% CI, -0.83 to -0.10; P = .04) compared with the VLNC + TF condition.

Conclusions and Relevance

These results provide further evidence that a reduced-nicotine standard for cigarettes has the potential to decrease smoking and tobacco-toxicant exposure in high-risk populations and that these effects may be enhanced when adults can access e-cigarettes in commonly preferred flavors.

Trial Registration

ClinicalTrials.gov Identifiers: NCT04092387, NCT04090879, NCT04092101.

α7-nAChR/P300/NLRP3-regulated pyroptosis mediated poor articular cartilage quality induced by prenatal nicotine exposure in female offspring rats

Nicotine is developmentally toxic. Prenatal nicotine exposure (PNE) affects the development of multiple fetal organs and causes susceptibility to a variety of diseases in offspring. In this study, we aimed to investigate the effect of PNE on cartilage development and osteoarthritis susceptibility in female offspring rats. Wistar rats were orally gavaged with nicotine on days 9-20 of pregnancy. The articular cartilage was obtained at gestational day (GD) 20 and postnatal week (PW) 24, respectively. Further, the effect of nicotine on chondrogenic differentiation was explored by the chondrogenic differentiation model in human Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs). The PNE group showed significantly shallower Safranin O staining and lower Collagen 2a1 content of articular cartilage in female offspring rats. Further, we found that PNE activated pyroptosis in the articular cartilage at GD20 and PW24. In vitro experiments revealed that nicotine inhibited chondrogenic differentiation and activated pyroptosis. After interfering with nod-like receptors3 (NLRP3) expression by SiRNA, it was found that pyroptosis mediated the chondrogenic differentiation inhibition of WJ-MSCs induced by nicotine. In addition, we found that α7-nAChR antagonist α-BTX reversed nicotine-induced NLRP3 and P300 high expression. And, P300 SiRNA reversed the increase of NLRP3 mRNA expression and histone acetylation level in its promoter region induced by nicotine. In conclusion, PNE caused chondrodysplasia and poor articular cartilage quality in female offspring rats. PNE increased the histone acetylation level of NLRP3 promoter region by α7-nAChR/P300, which resulting in the high expression of NLRP3. Further, NLRP3 mediated the inhibition of chondrogenic differentiation by activating pyroptosis.

Characterizing the use, preferences, and perceptions of flavors in cigars in pregnant women

BACKGROUND

Flavors contribute to the appeal of tobacco products, but less is known about flavors in cigar products. The current study is the first to focus on characterizing the use and perceptions of flavors in cigar products among pregnant women.

METHODS

Pregnant women (N = 124) reported their use, preferences (liking, attractiveness, smoothness, interest), perceptions of harm (general, pregnancy-specific, fetal), and postpartum intention to use eight flavor categories (menthol/mint, spices, fruit, chocolate, alcohol, other beverages, candy/sweet, tobacco). We utilized correspondence analysis of contingency tables to investigate clustering of preferences and perceptions of flavors across the sample, and examined how preferences and perceptions of flavors may differ based on history of cigar use (none vs. lifetime vs. prenatal).

RESULTS

Overall, 37% reported never trying cigars, 51% reported lifetime use, and 12% reported prenatal use. Fruit (37%), tobacco (36%), and alcohol (14%) were the most common cigar flavors participants reported ever trying. Correspondence analysis revealed clustering in preferences for alcohol, fruit, and candy flavors compared to other flavors, and revealed lower intentions to use menthol/mint and tobacco flavors compared to other flavors. Participants who reported prenatal cigar use also reported more positive perceptions and greater intentions to use (1) spice and alcohol flavors compared to those who reported lifetime use (ps < .05); and (2) spice, alcohol, fruit, and tobacco cigar flavors compared to participants reporting never using cigars (ps < .04).

CONCLUSIONS

Regulations to restrict the availability of flavors, especially fruit, spice, and alcohol, may reduce the appeal and use of cigar products in pregnant women.

Association between history of hookah use and symptoms of postpartum depression: A population-based study

OBJECTIVE

Although several biologic, psychosocial, and behavioral factors have been linked to postpartum depressive symptoms, studies examining the association between non-cigarette tobacco products and symptoms of postpartum depression are currently lacking. This study examined the association between hookah use and postpartum depressive symptoms.

METHODS

A cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System 2016-2020. Self-reported data on hookah use in the last 2 years and maternal mental health were captured using a structured questionnaire. Descriptive and inferential statistics were performed.

RESULTS

The final study sample consisted of 106 894 participants. Approximately 8.2% of the participants reported postpartum depressive symptoms and 4.1% reported hookah use in the past 2 years. Compared with those without postpartum depressive symptoms, participants with postpartum depressive symptoms were more likely to be hookah users (5.5% vs 4.0%, P < 0.001). After adjustment for confounders, the odds of having postpartum depressive symptoms were significantly higher among participants who used a hookah in the past 2 years compared with non-users; adjusted odds ratio (95% confidence interval) 1.20 (1.03-1.40); P = 0.022.

CONCLUSION

In a large, population-based sample of US women, hookah use in the past 2 years significantly increased the odds of having postpartum depressive symptoms, independent of potential confounders. This finding underscores the need for healthcare providers to communicate effectively about the health risks of hookah use.

Association between maternal cigarette smoking cessation and risk of preterm birth in Western New York

BACKGROUND

Although many studies suggested the benefit of smoking cessation among pregnant women in reducing the risk of preterm birth (PTB), the timing of the effect of the cessation remains inconclusive.

OBJECTIVES

To examine the association of trimester-specific smoking cessation behaviours with PTB risk.

METHODS

We included 199,453 live births in Western New York between 2004 and 2018. Based on self-reported cigarette smoking during preconception and in each trimester, we created six mutually exclusive groups: non-smokers, quitters in each trimester, those who smoked throughout pregnancy, and inconsistent smokers. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using Poisson regression to examine the association between smoking cessation and PTB. Effect modification by illegal drug use, maternal age, race and ethnicity and pre-pregnancy body mass index (BMI) was investigated multiplicatively by ratio of relative risk and additively by relative excess risk due to interaction (RERI).

RESULTS

Overall, 6.7% of women had a PTB; 14.1% smoked throughout pregnancy and 3.4%, 1.8% and 0.8% reported quitting smoking during the first, second and third trimesters, respectively. Compared to non-smokers, third-trimester cessation (RR 1.20, 95% CI 1.01, 1.43) and smoking throughout pregnancy (RR 1.27, 95% CI 1.21, 1.33) were associated with a higher PTB risk, while quitting smoking during the first or second trimester, or inconsistent smoking was not associated with PTB. A positive additive interaction was identified for maternal age and late smoking cessation or smoking throughout pregnancy on PTB risk (RERI 0.17, 95% CI 0.00, 0.36), and a negative interaction was observed for pre-pregnancy BMI ≥30 kg/m2 (ratio of relative risk 0.70, 95% CI 0.63, 0.78; RERI -0.42, 95% CI -0.56, -0.30).

CONCLUSION

Compared to non-smokers, smoking throughout pregnancy and third-trimester smoking cessation are associated with an increased risk of PTB, while quitting before the third trimester may not increase PTB risk.

National and regional economic inequalities in first- and second-hand tobacco consumption among women of reproductive ages in Iran

INTRODUCTION

The epidemic of tobacco consumption is one of the major public health threats the world has been facing so far. This study was performed to investigate the economic inequalities in tobacco consumption among women of reproductive ages at national and regional levels in Iran.

METHODS

We used data from 10,339 women of reproductive ages (18-49 years) who participated in Iran's 7th Non-Communicable Disease Risk Factor Surveillance (STEPS). Wagstaff normalized concentration index and decomposition method were applied to measure economic inequalities in first- and second-hand tobacco consumption and determine their corresponding contributory factors, respectively.

RESULTS

The prevalence of women's first-hand tobacco consumption, and their exposure to second-hand smoke in the home, and workplace were 3.6%, 28.3%, and 8.4%, respectively. First- and second-hand tobacco consumption was significantly more concentrated among low-economic women. Exposure to home second-hand smoke, education, and economic status had the largest contributions to the measured inequality in first-hand tobacco consumption (48.9%, 38.9%, and 30.8%, respectively). The measured inequality in women's secondhand smoke exposure at home was explained by their level of education (43.8%), economic status (30.3%), and residency in rural areas (18%), and at work by residency in rural areas (42.2%), economic status (38.8%), and level of education (32%). Our results also revealed diversity in the geographical distribution of inequalities in rural and urban areas and five regions of the country.

CONCLUSION

The present study highlighted the need for more enforcement of tobacco control rules and increasing tobacco taxes as general measures. Furthermore, there is a need for gender-sensitive initiatives at national and regional levels to educate, support, and empower low-economic women and households for tobacco cessation, and complying with restrictive smoking rules.

Randomized clinical trial examining financial incentives for smoking cessation among mothers of young children and possible impacts on child secondhand smoke exposure

This randomized clinical trial examined whether financial-incentives increase smoking cessation among mothers of young children and potential impacts on child secondhand-smoke exposure (SHSe). 198 women-child dyads were enrolled and assigned to one of three treatment conditions: best practices (BP, N = 68), best practices plus financial incentives (BP + FI, N = 63), or best practices, financial incentives, and nicotine replacement therapy (BP + FI + NRT, N = 67). The trial was completed in Vermont, USA between June 2015 and October 2020. BP entailed staff referral to the state tobacco quitline; financial incentives entailed mothers earning vouchers exchangeable for retail items for 12 weeks contingent on biochemically-verified smoking abstinence; NRT involved mothers receiving 10 weeks of free transdermal nicotine and nicotine lozenges/gum. Baseline, 6-, 12-, 24-, and 48-week assessments were conducted. Primary outcomes were maternal 7-day point-prevalence abstinence and child SHSe through the 24-week assessment with the 48-week assessment exploratory. Results were analyzed using mixed model repeated measures for categorical data. Odds of maternal abstinence were greater among mothers in BP + FI and BP + FI + NRT compared to BP at the 6- and 12-week assessments (ORs ≥ 7.30; 95% CIs: 2.35-22.71); only abstinence in BP + FI remained greater than BP at the 24-week assessment (OR = 2.95; 95% CIs: 1.06-8.25). Abstinence did not differ significantly between treatment conditions at the 48-week assesssment. There was a significant effect of treatment condition (F[2109] = 3.64, P = .029) on SHSe with levels in BP and BP + FI significantly below BP + FI + NRT (ts[109] ≥ -2.30, Ps ≤ 0.023). Financial incentives for smoking abstinence are efficacious for increasing maternal cessation but that alone was insufficient for reducing child SHSe. ClinicalTrials.gov:NCT05740098.

E-cigarette, cigarette, dual e-cigarette with cigarette use, and disability status among reproductive-aged women

OBJECTIVE

E-cigarettes have increased steadily among reproductive-aged women, despite our limited understanding of their effect on reproductive health. This study examined the associations of e-cigarette, cigarette, and dual use with disability in reproductive-aged women.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Data for this study were obtained from reproductive-aged women (18-44 years; n = 24,904) from the 2020 Behavioral Risk Factor Surveillance System. Descriptive statistics and logistic regression analyses were conducted to assess the associations of tobacco use patterns (dependent variable, i.e. non-use, current e-cigarette use, current cigarette use, and current dual use of e-cigarettes and cigarettes) with overall disability and the type of disability (independent variables).

RESULTS

Among women who reported any disability, 70.6%, 8.7%, 11.4% and 9.3% reported non-use, e-cigarette, cigarette, and dual use, respectively. In adjusted analysis, relative to non-use, women who reported any disability had higher odds of e-cigarette (adjusted odds ratio [aOR]: 1.88; 95% confidence interval [CI]: 1.15-3.07), cigarette (aOR: 1.58; 95% CI: 1.12-2.25), and dual use (aOR: 2.37; 95% CI: 1.55-3.62) compared with women without disabilities.

CONCLUSIONS

This cross-sectional study found higher odds of current e-cigarette use, cigarette use, and dual use of e-cigarettes and cigarettes among women of reproductive age with ≥1 disability. Improved screening for the use of nicotine products among women of reproductive age with disabilities may be necessary to lessen the use of nicotine products in this vulnerable population.

Waterpipe Smoking in Pregnant Women of Zahedan City in 2020: Prevalence and Associated Factors

BACKGROUND

Waterpipe smoking is associated with maternal and fetal complications, and valid data contribute to evidence-based planning. This study was conducted to determine the prevalence and factors related with waterpipe smoking among pregnant women of Zahedan city in 2020.

METHODS

This cross-sectional study was conducted in 2020, and 400 pregnant women in the third trimester of pregnancy who lived in Zahedan participated in it by single stage randomized cluster sampling. A questionnaire was used to measure awareness of waterpipe complications, and another one investigated the status of waterpipe smoking to collect data. For data analysis, descriptive statistics and multiple logistic regression were used through SPSS 21.

RESULTS

The findings indicated that the prevalence of waterpipe smoking was 18.8%. In the waterpipe smoking group, 46.6% smoked every day, 89.3% had tried to reduce the smoking, and 64.8% reported fetal death as their main motivation to reduce smoking. Only 5.6% of subjects stated receiving training as the reason for reduction of their waterpipe smoking. The women's level of education, economic status, ethnicity, and awareness of the risks of waterpipe smoking were the predictors for waterpipe smoking (P < 0.05, P = 0.03, P = 0.006, and P < 0.001, respectively).

CONCLUSIONS

The results of this study show the high prevalence of waterpipe smoking in pregnant women of Zahedan. Further investigation and training in this regard are essential for pregnancy as well as pre-pregnancy care. Special attention should be paid to groups with better economic status and level of education, Baluch women, and those with low level of awareness.

Association Between a History of Hookah Use and Breastfeeding Duration

Background: There is limited evidence on the relationship between hookah use and breastfeeding. This study examines the association between a history of hookah use and breastfeeding duration among women in the United States. Materials and Methods: This cross-sectional study examined 96,392 women from the Pregnancy Risk Assessment and Monitoring System (PRAMS) 2016-2019 data. The main outcome of interest was any breastfeeding for at least 3 months. Descriptive statistics, chi-square test, and multivariable regression analyses were performed. Results: Overall, 68.3% of women breastfed for at least 3 months and 4.6% reported using hookah in the last 2 years. Women who reported using hookah in the last 2 years were significantly less likely to breastfeed for at least 3 months compared with women who did not report using hookah in the last 2 years (56.0% versus 68.9%; p < 0.001). In the multivariable model, the odds of breastfeeding for at least 3 months were significantly lower in women who used hookah in the last 2 years compared with those who did not use hookah; odds ratio (95% confidence interval) 0.82 (0.74-0.92; p < 0.001). Additionally, the odds of breastfeeding for at least 3 months were significantly lower for dual users of hookah and cigarettes 0.48 (0.33-0.68; p < 0.001). Conclusion: A history of hookah use is associated with early weaning, independent of potential confounders. This finding suggests the need for educating women about the negative consequences of hookah use on breastfeeding during preconception, prenatal, and postpartum care encounters.

Informing women about the risks of exposing babies to tobacco smoke: outreach and education efforts using Facebook "boost posts"

Maternal smoking is associated with a host of negative health outcomes, including an increased risk of children developing attention-deficit/hyperactivity disorder (ADHD). This study evaluated the efficacy of health messages disseminated through Facebook Ads focused on reducing tobacco smoke exposure during pregnancy. Two message versions were promoted via post advertisements on Facebook-a static infographic and a video containing an animated version of the infographic. The reach of and engagement with each message version was evaluated. Comments made to the posts were assessed using content analysis. The infographic reached approximately 60,000 people and the video reached about 16,000 people. The average costs were $10.00 and $40.00 per 1,000 people reached for the infographic- and video-based posts, respectively. While there was no engagement with the video, the infographic was liked (n = 157), given alternative likes (n = 59), shared (n = 171 to 341), and commented on (n = 221). About one-quarter of comments contained a personal narrative and mentions of health history related to ADHD and/or smoking. Comments were more often negative (than positive) (16.6% vs 3.9%) and expressed skepticism more often than message acceptance (21.5% vs 12.2%). Facebook users were more responsive to the infographic (compared to the video) and static posts were a preferred channel (i.e., higher engagement at a lower cost) to disseminate messages when using the boost post feature on Facebook for health education. Our review of the comments provided insights into message acceptance and guidance for future social media-based health message campaigns. However, it is not known whether and if so, how, these findings on message exposure would correlate with behavioral intentions or changes in behavior, such as intentions to quit smoking or smoking cessation.

Changes in the National Prevalence of Current E-Cigarette, Cannabis, and Dual Use among Reproductive Age Women (18-44 Years Old) in the United States, 2013-2016

Background: Electronic cigarette (e-cigarette) and cannabis (marijuana) use is rapidly increasing. Objectives: To report percentage prevalence and changes over time in current (past 30 days) e-cigarette, cannabis, and dual (concurrent) use in the population of reproductive age women (18-44 years old) in the United States. Methods: Our cross-sectional analysis involved data of 11, 004 women from Waves 1 to 3 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2016). We estimated weighted percentage prevalence and 95% confidence intervals (CIs) and changes between 2013 and 2016 in current e-cigarette, cannabis, and dual use at each wave overall and across race/ethnicity, age, education, cigarette smoking status, alcohol use, and perceived mental health. Changes were reported as p for trend. Results: Between 2013 and 2016, e-cigarette use increased 13.6% (p for trend <.001) [15.2% (95% CI:14.2, 16.2) in 2013-2014; 22.2% (95% CI: 20.2, 24.3) in 2014-2015; and 28.8% (95% CI: 26.3, 31.3) in 2015-2016]; cannabis use increased 6.2% (p for trend <.001) [23.6% (95% CI: 22.1, 25.1) in 2013-2014; 28.5% (95% CI: 26.0, 31.0) in 2014-2015; and 29.8% (95% CI: 27.9, 31.1) in 2015-2016]; and dual use declined 0.3% (p for trend <.001) [5.8% (95% CI: 5.2, 6.3) in 2013-2014; 4.8% (95% CI: 3.7, 5.8) in 2014-2015; and 5.5% (95% CI: 4.2, 6.7) in 2015-2016]. Increases and declines in prevalence varied across sociodemographic characteristics, cigarette smoking status, alcohol use, and perceived mental health. Conclusions: Continued monitoring can capture further changes in prevalence and patterns to inform targeted public health intervention programs.

Prevalence and trends in tobacco use, secondhand smoke exposure at home and household solid fuel use among women in 57 low- and middle-income countries, 2000-2018

BACKGROUND

Tobacco use, secondhand smoke (SHS) exposure and household solid fuel use in women of reproductive age can cause morbidity and mortality for both women and offspring.

OBJECTIVES

We aimed to determine the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women in low- and middle-income countries (LMICs) and their secular trends between 2000 and 2018.

METHODS

We used the most recent data from the Demographic and Health Surveys in 57 LMICs (n = 1,598,111) that were completed between 2010 and 2018 to assess the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women of reproductive age (15-49 years). We also used data from 41 selected LMICs that had data from two or more surveys completed between 2000 and 2018 to assess secular trends in the prevalence of tobacco use and household solid fuel use among women.

RESULTS

In 2010-2018, the overall prevalence of tobacco use, daily SHS exposure at home and household solid fuel use among women in 57 LMICs was 3.2% (95 %CI = 3.1-3.3), 23.0% (22.8-23.2), and 65.6% (65.3-65.9), respectively. The prevalence of tobacco use was lower among pregnant women than non-pregnant women (2.1% vs. 3.3%), but the prevalence of daily SHS exposure at home (24.4% vs. 22.8%) and household solid fuel use (69.1% vs. 65.3%) was higher among pregnant women than non-pregnant women. About 16% of the women presented two or three simultaneous risk factors. Between 2000 and 2018, the prevalence of tobacco use decreased in 24 (64.9%) of 37 countries, and the prevalence of household solid fuel use decreased in 20 (50.0%) of 40 countries.

CONCLUSIONS

Tobacco use among women was much low in LMICs, but SHS exposure at home was more common. Although the prevalence of household solid fuel use decreased over time in most LMICs, these recent estimates remained unacceptably high.

Association between maternal smoking and survival among infants with trisomy 21

BACKGROUND

Trisomy 21 (T21) is common, with affected infants having an increased risk of infant mortality (5.9-7.1%). Maternal smoking is associated with infant mortality in the general population, and we evaluated if similar associations were present among infants with T21.

METHODS

We identified infants with T21 from the Texas Birth Defects Registry, and maternal smoking and infant vital status were obtained from linked birth and death certificate data, respectively. Cox proportional hazards regression models were used to calculate hazard ratios between maternal smoking and death between 0 to ≤ 364 days, 28-364 days, and 0-27 days.

RESULTS

We found a significant association between maternal smoking and death between 0 to ≤ 364 (unadjusted HR 1.72, 95% CI 1.07, 2.77), which was no longer statistically significant after adjustment for covariates (adjusted HR 1.55, 95% CI 0.94, 2.56). A similar pattern was observed for death between 28-364 days (adjusted HR: 1.68, 95% CI 0.93, 3.03), whereas the association for 0-27 days (adjusted HR: 1.30, 95% CI 0.51, 3.29) was not statistically significant before and after adjustment.

CONCLUSIONS

The observed magnitudes of associations were similar to previous estimates among the general population. Further work considering the role of other maternal and infant risk factors and social determinants of health is necessary to better understand the observed results.

Substance Use During Pregnancy: A Comparative Review of Major Guidelines

Importance

Substance use during pregnancy is a major health issue for both the mother and the fetus, but it also represents an important public health concern.

Objective

The aim of this review was to summarize and compare recommendations from recently published guidelines on substance use during pregnancy and especially regarding alcohol, smoking, and drug use.

Evidence Acquisition

A descriptive review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the World Health Organization (WHO), the Society of Obstetricians and Gynaecologists of Canada, and the American College of Obstetricians and Gynecologists on substance use was conducted. Regarding the term "substance use," the most recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition substances were used.

Results

All the reviewed guidelines recommend appropriate counseling and screening women regarding alcohol, smoking, and drug use during the antenatal period, while the management options vary. More specifically, the prompt management of alcohol dependence is emphasized by all the guidelines except from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, which makes no recommendation upon. The use of alcohol during breastfeeding should be avoided. Regarding smoking cessation, all guidelines recommend the use of certain psychosocial, behavioral interventions, and pharmacotherapy. All the guidelines, except the one from the WHO, suggest screening drug users for coexistent sexually transmitted infections. Brief interventions are considered beneficial, while a gradual decrease in benzodiazepines is suggested, as well as the discontinuation of marijuana and methamphetamine use. However, there is controversy regarding breastfeeding in those women as the WHO recommends in favor, whereas the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists recommend against this practice. Finally, all the guidelines state that, following delivery, close monitoring of the neonate is needed.

Conclusions

The diversity of guidelines' recommendations concerning substance use reflects the different ways of the management of pregnant women during routine antenatal care due to absence of strong evidence. More research in the areas of dispute may allow the adoption of an international consensus, in order to early detect and appropriately manage pregnant women with harmful addictions.

Use of electronic nicotine delivery systems (ENDS) among U.S. women of reproductive age: Prevalence, reported reasons for use, and toxin exposure

Given the rapidly expanding marketplace for Electronic Nicotine Delivery Systems (ENDS), it is important to monitor patterns of use, particularly among vulnerable populations. This study examined ENDS prevalence, reasons for use (i.e., to help quit smoking and for appealing flavors), and toxin exposure among U.S. women of reproductive age using data from the Population Assessment of Tobacco and Health (PATH) Study (2013-17). Exclusive ENDS users, dual users of ENDS and cigarettes, and exclusive cigarette smokers were compared within and between pregnant and not-pregnant women. Among pregnant women, prevalence of exclusive ENDS and dual use was similar (0.8%; 95%CI = 0.4-1.2% vs. 1.4%; 95%CI = 0.9-2.0%, respectively), but exclusive ENDS use was less prevalent than dual use among not-pregnant women (1.1%; 95%CI = 0.9-1.4% vs. 3.7%; 95%CI = 3.3-4.0%, respectively). Most women reported ENDs were used to help quit smoking (66.5-90.0%) and for appealing flavors (57.6-87.4%), and endorsement rates did not differ by use pattern or pregnancy status. Except for metals, toxin exposure was substantially lower for exclusive ENDS users relative to dual users and exclusive cigarette smokers regardless of pregnancy status. Pregnant and not-pregnant U.S. women regularly report using ENDS for help with quitting smoking and for appealing flavors. Although no type or pattern of tobacco/nicotine use is safe, especially during pregnancy, using ENDS exclusively is consistent with lower overall toxin exposure for pregnant and not-pregnant women. This study advances understanding of ENDS use and toxin exposure in women of reproductive age, a population highly vulnerable to the effects of nicotine/tobacco consumption.

Lifestyle Habits and Exposure to BPA and Phthalates in Women of Childbearing Age from Northern Italy: A Pilot Study

Background: Endocrine-disrupting chemicals (EDCs) are compounds that interfere with aspects of hormonal signaling. Considerable attention has been paid to their biological effects especially in women of childbearing age or during pregnancy as EDCs have been reported to cross the placenta becoming concentrated in the fetus' circulation. Lifestyle habits, daily consumption of packaged foods and use of healthcare/cosmetic products are associated with increased EDCs levels. This cross-sectional research examined the EDCs levels and the lifestyle determinants of EDC exposure in a cohort of reproductive-age women from Northern Italy. Methods: Forty-five women (median age: 36, IQR: 30-38) were evaluated for urinary bisphenol A (BPA) and phthalates levels and also studied for EDCs' major determinants of daily exposure; food frequency/dietary, physical activity, smoking habits and weight status. Results: Although 100% of women seemed to have been exposed to common sources of EDCs, they reported a healthy lifestyle. The multivariable model described a positive and significant association between consumption of sauces/dressings in plastic containers and monoethyl phthalate exposure (p = 0.037). Conclusions: Since reproductive age encompasses a critical window for future health and functioning of the "mothers-to-be" and their children, future studies on prenatal dietary BPA and phthalate exposure and the role of consumer product choices in reducing such exposure are recommended.

Associations between electronic nicotine delivery systems and birth outcomes

OBJECTIVES

Nicotine crosses the placenta and is a known teratogen. The use of electronic nicotine delivery systems (ENDS) has increased among pregnant women in the US, but there is limited knowledge about their effects on birth outcomes. We examined the associations between ENDS and cigarette use during pregnancy with birth outcomes.

METHODS

We conducted a cross-sectional analysis of 57,046 respondents from 32 US states in the 2016-2017 Pregnancy Risk Assessment Monitoring System. Respondents self-reported use of ENDS and cigarettes during the last 3 months of pregnancy; this was linked with birth outcomes documented on the birth certificate, including birth weight, gestational age, small-for-gestational age, and preterm birth.

RESULTS

During the last 3 months of pregnancy, 0.5% of women used ENDS only, 0.8% were dual users of ENDS and cigarettes, and 8.0% used cigarettes only. In adjusted models, infants of women who used ENDS only weighed 57.8 grams less (95% CI -134.2, 18.6; p = .14) and were born 0.21 weeks earlier (95% CI -0.45, 0.03; p = .09) than infants of non-users. Infants born to dual users were 193.9 grams less (95% CI -274.9, -112.8; p < .01) and had a 1.93 higher odds of being born small-for-gestational age (95% CI 1.31, 2.83; p < .01) than infants of non-users.

CONCLUSIONS

Our results provide some indication that prenatal ENDS use may adversely affect birth outcomes by reducing birth weight and gestational age. Estimates were imprecise, suggesting that larger samples of ENDS users with more detailed information about patterns of use are needed.

Maternal Nicotine Exposure Alters Hippocampal Microglia Polarization and Promotes Anti-inflammatory Signaling in Juvenile Offspring in Mice

Accumulating evidence reveal that maternal smoking or perinatal nicotine replacement therapy impairs hippocampal neurogenesis, neural development, and cognitive behaviors in the offspring. Microglia is a source of non-neural regulation of neuronal development and postnatal neurogenesis. In this study, we explored the impact of nicotine on the microglia during the development of hippocampus. Developmental nicotine exposure in a mouse model was conducted by supplementing nicotine in the drinking water to mother mice during gestation and lactation period. We found that juvenile offspring with maternal nicotine exposure presented physical and neurobehavioral development delay and an increase in anxiety-like behavior in the open field test on postnatal day (PND) 20. To further detect possible developmental neurotoxic effects of nicotine in offspring and underlying mechanism, whole genome microarray analysis of the expression profile of the hippocampus was performed on postnatal day 20. Significant alterations in the expression of genes related to inflammatory, neurotransmitter, and synapsis were observed in the hippocampus after maternal nicotine exposure, as compared to the vehicle control. Concurrently, an increase in microglial markers and the presence of M2 polarity state in the hippocampus of the nicotine offspring were observed by histological analysis and confocal z-stacking scanning. The M2 microglial polarization state was further confirmed with in vitro primary microglia culture by cytokine array, and double-positive expression of BDNF/Iba1 in microglia by immunohistochemical staining in the juvenile offspring hippocampus was visualized. We also found that nicotine offspring showed an increase of neurite length in the molecular layer and CA1 by Tuj1 staining, as well as an increase in the expression of synapse associated protein, PSD95, but the expression of NeuroD1 in CA1 and CA3 reduced. In summary, maternal nicotine exposure dysregulates immune-related genes expression by skewing the polarity of M2 microglia in the hippocampus, which may cause abnormal cognitive and behavioral performance in the offspring.

Knowledge, Attitude and Smoking Patterns Among Pregnant Women: A Jordanian Perspective

Background:

Smoking during pregnancy is one of the main modifiable factors associated with perinatal morbidity and mortality and maternal complications. Literature is scant regarding smoking habits of pregnant women in Jordan.

Objectives:

To investigate smoking patterns and attitudes of Jordanian pregnant women towards smoking.

Methods:

A cross-sectional survey of patterns and attitudes towards smoking among 436 mothers attending healthcare facilities in the Governorate of Irbid, Jordan, between August and September 2019.

Results:

Out of 436 pregnant women in the Governorate of Irbid, Jordan, 13 (2.9%) quit smoking once pregnancy was conformed, and 77 (17.6%) continued to smoke.

Pregnant non-smokers believed that hookah and electronic cigarettes are as bad to health as cigarettes, while smokers believed that hookah and electronic cigarettes are less hazardous than cigarettes (5.19% versus 21.99%, p = 0.001, and 6.49% versus 19.37%, p = 0.009, respectively).

Non-smokers were significantly more aware regarding the hazards of smoking on perinatal outcomes, such as abortion (31.94% versus 10.39%, p = 0.001), placental abruption (31.94% versus 10.39%, p = 0.001), intrauterine growth restriction and fetal malformations (36.65% versus 14.29%, p = 0.007), fetal death (30.89% versus 6.49, p < 0.001), neonatal pulmonary diseases (44.50% versus 24.68%, p = 0.024), neonatal asthma (47.12% versus 28.57%, p = 0.038), and ear diseases (42.41% versus 20.8%, p = 0.012).

Conclusion:

There is a high prevalence of smokers among pregnant women in Jordan. The level of awareness regarding long-term consequences of tobacco use remains low. Educational programs should include information about the hazards of all forms of smoking. Pregnancy provides a good opportunity for promoting smoking cessation.

A longitudinal assessment of nicotine dependence, mental health, and attempts to quit Smoking: Evidence from waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study

BACKGROUND

Adult smokers with symptoms of any mental illness (AMI) are highly dependent on nicotine and may face additional difficulty quitting smoking. While there is evidence that adult smokers with AMI have high dependence, there is insufficient evidence regarding the unique role that AMI may play in moderating the relationship between dependence and cessation outcomes over time.

METHODS

7290 current established adult smokers at Wave 1 (2013-2014) of the PATH Study also participated in data collection in Waves 2-4 (2014-2018). Linear probability models with individual-level random effects were fit to the data, modeling associations between AMI, nicotine dependence, and the 1) likelihood of achieving cessation during the study period, 2) making a cessation attempt within the previous 12 months, and 3) log of past 30-day total consumption of cigarettes.

RESULTS

Adults who experienced both AMI symptoms and high dependence were 4.7 percentage points (PP) less likely to achieve cessation at any point during the study period (p < 0.01) and smoked more cigarettes per month (β = 0.214, p < 0.05) than adults with AMI who were not highly dependent, despite being as likely to attempt to quit. Adults with AMI who were not highly dependent were 4.6 PP more likely to report a quit attempt and 1.6 PP more likely to achieve cessation than those with neither AMI nor high dependence.

CONCLUSIONS

Adults with AMI are particularly affected by the burden of tobacco use, in part because of the likely interaction between nicotine dependence and AMI. Tobacco control efforts that focus on this interplay may provide an opportunity to better target interventions for this vulnerable population.

Biomarkers of Toxicant Exposure and Inflammation Among Women of Reproductive Age Who Use Electronic or Conventional Cigarettes

Background: Electronic cigarettes (e-cigarettes) generally have a more favorable toxicant profile than conventional cigarettes; however, limited information exists for women of reproductive age (WRA). Our aim was to compare biomarkers of toxicant exposure, inflammation, and oxidative stress among WRA who self-report exclusive e-cigarette use, exclusive cigarette smoking, or never tobacco use (controls). Methods: Multivariable linear regression models were used to compare the geometric means of urinary biomarkers of toxicant exposure and their metabolites, serum markers of inflammation [highly sensitive C-reactive protein, soluble intercellular adhesion molecule (sICAM), interleukin 6, fibrinogen], and a measurement of oxidative stress [prostaglandin F2a-8-isoprostane (F2PG2a)] among WRA from the Population Assessment of Tobacco and Health survey. Results: E-cigarette users had higher levels of lead, tobacco-specific nitrosamines, nicotine metabolites, and some volatile organic compounds (VOCs) than controls. Except for cadmium and lead, e-cigarette users had lower levels of the analyzed urinary toxicant biomarkers compared with cigarette smokers. Cigarette smokers had higher levels of all the biomarkers of toxicant exposure than controls. There were no significant differences in the levels of markers of inflammation and oxidative stress between e-cigarette users and controls. E-cigarette users and controls had lower levels of sICAM and F2PG2a than cigarette smokers. Conclusion: WRA who use e-cigarettes had lower levels of some of the evaluated urinary biomarkers of toxicant exposure and serum biomarkers of inflammation and oxidative stress than those who smoke cigarettes, but higher lead, nicotine metabolites, and some VOCs than controls, which can increase health risks.

Does the Trimester of Smoking Matter in the Association between Prenatal Smoking and the Risk of Early Childhood Caries?

INTRODUCTION

Development of the primary tooth bud commences at the end of the 5th week of gestation, with mineralization starting at about the 13th week and continuing throughout pregnancy to the end of the first year of life. During this critical period, exposure to maternal lifestyle factors, specifically, prenatal smoking can negatively affect the quality (i.e., tooth calcification and mineralization) and timing of tooth eruption.

METHODS

This study evaluated the association between the trimester of smoking and offspring caries experience at 3 time points (31, 43, and 61 months) by analyzing data from 1,429 mother-offspring participants in the 1991/92 Avon Longitudinal Study of Parents and Children, conducted in Bristol, England. Prenatal smoking in the first, second, and third trimesters were self-reported during pregnancy while offspring caries experience was determined by clinical oral examinations. Adjusted for confounders, log-binomial regression estimated the risk ratio (RR) and 95% confidence interval (CI) of the association between trimester of smoking and the risk of offspring caries.

RESULTS

Twenty percent smoked in the first trimester of their pregnancy, 15% in the second, and 17% in the third. Forty-six percent of children whose mothers smoked during pregnancy had caries experience (i.e., dmft ≥1) with a mean dmft count of 1.58, versus children whose mothers did not smoke during pregnancy (33% of whom had dmft ≥1 with a mean dmft count of 0.33). Smoking in the first, second, and third trimesters were independently associated with a higher adjusted RR (95% CI) of caries experience at 61 months, i.e., 1.16 (0.93-1.43), 1.11 (0.75-1.65), and 1.60 (1.09-2.32), respectively.

CONCLUSIONS

Within the limitations of covariates adjusted for, with the caveat that residual confounding and bias from unmeasured covariates are likely present, our findings suggest that smoking during pregnancy may be harmful to the oral health of the offspring irrespective of the trimester during which the smoking occurred. Nevertheless, these results should be interpreted cautiously because the findings might not generalize broadly.

Effects of E-Cigarette Exposure on Prenatal Life and Childhood Respiratory Health: A Review of Current Evidence

In the last decade, widespread use of E-cigarettes (EC) has occurred all over the world. Whereas, a large amount of evidence on harm to children from conventional cigarette exposure is available, data on health effects in this population throughout different vulnerability windows are still a matter of concern. Exposure to EC during pregnancy may compromise placental function, resulting in fetal structural abnormalities. Specifically, this may cause physio-pathologic changes in the developing lung, which in turn may impair respiratory health later in life. Furthermore, there is evidence that using EC can cause both short- and long-term respiratory problems in the pediatric population and there is great concern for future young people with nicotine addiction. The low parental perception of the risks connected to EC exposure for children increases their susceptibility to harmful effects from passive vaping. This minireview aims to summarize the current evidence focusing on: (i) prenatal effects of EC passive exposure; (ii) post-natal respiratory effects of EC exposure in youth; (iii) parental attitudes toward EC use and perception of children's health risks connected to EC exposure; and (iv) addressing gaps in our current evidence.

Perceived harms of and exposure to tobacco use and current tobacco use among reproductive-aged women from the PATH study

Data for this study were obtained from reproductive-aged women (aged 18-44 years, at wave 1) from waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health Study (n = 13,241). Bivariate and multinomial regression analyses were performed associating past 30-day use of cigarettes only, e-cigarettes only, and dual use with perceptions of harm, exposure to tobacco product use, and sociodemographic variables. Cross-sectional and longitudinal analyses were conducted. Of all reproductive-aged women included in the analyses, 75.5 percent reported no tobacco use, 16.9 percent reported cigarette use only, 1.5 percent reported e-cigarette use only, and 6.1 percent reported dual use within the past 30 days. Perceived harm, tobacco exposure, pregnancy status, age, race/ethnicity, income, education, and sexual orientation were associated with the past 30-day use, cross-sectionally at wave 1. Similar associations were found for longitudinal analyses using wave 2 data, except for income and education, which were no longer associated. The results of this study contribute to knowledge regarding the prevalence and correlates of tobacco use across exclusive cigarette, exclusive e-cigarette, and dual use among reproductive-aged women.

Reducing tobacco use among women of childbearing age: Contributions of tobacco regulatory science and tobacco control

Tobacco use has unique, adverse health consequences for reproductive-aged women, particularly should these women become pregnant. Thus, successful efforts to reduce tobacco use among this population have strong potential to improve public health and reduce health disparities. The present review examines contributions to reducing tobacco use among women of childbearing age spanning the domains of tobacco regulatory science and tobacco control from the passage of the Family Smoking Prevention and Tobacco Control Act in 2009 through September 2019. In the domain of tobacco regulatory science, such efforts include research conducted by various National Institutes of Health/Food and Drug Administration (FDA)-supported Tobacco Centers of Regulatory Science, epidemiological surveillance studies, as well as studies examining the potential impact of tobacco regulatory policies currently under consideration by the FDA (e.g., reduced nicotine content cigarettes, health warning labels). Tobacco control efforts within this same 10-year timeframe include developments in pharmacological and psychosocial approaches to promoting tobacco cessation, mHealth interventions, and tobacco control policy. Emerging issues pertinent to ongoing efforts to reduce tobacco use within the domains of both tobacco regulatory science and tobacco control are also reviewed, including e-cigarettes, comorbid health conditions, course of tobacco and other drugs of abuse, and obstacles to the dissemination and implementation of evidence-based treatment and policy. Although the past decade has seen numerous important contributions to reducing tobacco use among reproductive-aged women within both domains, existing obstacles must be surmounted to continue reducing tobacco use and protecting health among this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Changes in Cigarette Consumption With Reduced Nicotine Content Cigarettes Among Smokers With Psychiatric Conditions or Socioeconomic Disadvantage: 3 Randomized Clinical Trials

IMPORTANCE

This study is part of a programmatic effort evaluating the effects of reducing nicotine content of cigarettes to minimally addictive levels.

OBJECTIVE

To examine whether very low-nicotine-content (VLNC) cigarettes decrease smoking rates and dependence severity among smokers with psychiatric disorders or socioeconomic disadvantage.

DESIGN, SETTING, AND PARTICIPANTS

These 3 randomized clinical trials were performed at the University of Vermont, Brown University, and Johns Hopkins University between October 2016 and September 2019. Participants received 12 weeks of exposure to study cigarettes with nicotine content ranging from levels representative of commercial cigarettes (15.8 mg nicotine/g tobacco) to less than a hypothesized addiction threshold (2.4 mg/g and 0.4 mg/g). Daily smokers from 3 at-risk populations participated: individuals with affective disorders, exemplifying smokers with mental illness; individuals with opioid use disorder, exemplifying smokers with substance use disorders; and women with high school educations or less, exemplifying smokers with socioeconomic disadvantage. Data were analyzed from September 2019 to July 2020.

INTERVENTIONS

Random assignment to 1 of 3 study cigarettes provided weekly at no cost for 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was between-group differences in mean total cigarettes smoked daily (CPD) during week 12; secondary outcomes included CPD for study and nonstudy cigarettes and dependence severity across weeks analyzed using analysis of covariance, random coefficients growth modeling, or repeated measures analysis of variance.

RESULTS

A total of 775 participants were included (mean [SD] age, 35.59 [11.05] years; 551 [71.10%] women [owing to 1 population being exclusively women]); participants smoked a mean (SD) of 17.79 (9.18) CPD at study intake. A total of 286 participants were randomized to 0.4 mg/g, 235 participants were randomized to 2.4 mg/g, and 254 participants were randomized to 15.8 mg/g. Participants randomized to VLNC cigarettes had decreased mean [SEM] total CPD during week 12 across populations (Cohen d = 0.61; P < .001). At week 12, mean (SEM) CPD decreased to 17.96 (0.98) CPD in the 0.4 mg/g group and to 19.53 (1.07) CPD in the 2.4 mg/g group, both of which were significantly different from the 15.8 mg/g group (25.08 [1.08] CPD at week 12) but not each other (0.4 mg/g adjusted mean difference: -7.54 [95%CI, -9.51 to -5.57]; 2.4 mg/g adjusted mean difference: -5.34 [95% CI, 7.41 to -3.26]). Several secondary outcomes differed across populations randomized to VLNCs, including mean total CPD across weeks, with linear trends lower in participants receiving 0.4 mg/g (-0.28 [95%CI, -0.39 to -0.18]; P < .001) and 2.4 mg/g (-0.13 [95%CI, -0.25 to -0.01]; P < .001) doses compared with those receiving the 15.8 mg/g dose (0.30 [95% CI, 0.19 to 0.41]). Fagerström Test of Nicotine Dependence mean total scores were significantly lower in participants who received VLNCs (Cohen d = 0.12; P < .001), with those who received the 0.4 mg/g dose (mean [SD] score, 3.99 [0.06]; P < .001 vs 15.8 mg/g) or 2.4 mg/g dose (mean [SD] score, 4.07 [0.06]; P = .01 vs 15.8 mg/g) differing from those who received the 15.8 mg/g dose (mean [SD] score, 4.31 [0.06]) but not from each other.

CONCLUSIONS AND RELEVANCE

These findings demonstrate that decreasing the nicotine content of cigarettes to very low levels reduced smoking rate and nicotine-dependence severity in these high-risk populations, effects that may facilitate successful cessation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT02232737, NCT02250664, NCT02250534.

E-Cigarette Use Patterns and High-Risk Behaviors in Pregnancy: Behavioral Risk Factor Surveillance System, 2016-2018

INTRODUCTION

The prevalence of e-cigarette use has increased dramatically in the last decade in the U.S. Understanding the prevalence, patterns of use, and risk factor associations of e-cigarette use in pregnant women is particularly important, as this could have potential health implications for the mother and the developing child.

METHODS

Using Behavioral Risk Factor Surveillance System Survey data from 2016 to 2018, adult women of reproductive age (18-49 years) who reported being pregnant (n=7,434) were studied. Self-reported current e-cigarette use was the main exposure. Other measures included combustible cigarette smoking status and high-risk behaviors (including other tobacco, marijuana, or heavy alcohol use; binge drinking; and others). All analyses were done in 2019.

RESULTS

Approximately 2.2% of pregnant women reported current e-cigarette use, of whom 0.6% reported daily use. The highest prevalence of e-cigarette use was observed in the youngest age group of pregnant women (3.2%), with 41.7% of all pregnant current e-cigarette users being aged 18-24 years. There was a marked increase in the prevalence of current use of e-cigarettes among pregnant women from 1.9% in 2016 to 3.8% in 2018. Approximately 46% of pregnant current e-cigarette users reported concomitant cigarette smoking. Compared with pregnant never e-cigarette users, pregnant current e-cigarette users had a higher prevalence of other tobacco product use, marijuana use, heavy alcohol intake, binge drinking, and other high-risk behaviors.

CONCLUSIONS

These findings underscore the need to strengthen prevention and policy efforts, specifically in the vulnerable subgroup of pregnant women.

Perceptions, Characteristics, and Behaviors of Cigarette and Electronic Cigarette Use among Pregnant Smokers

INTRODUCTION

Smoking during pregnancy is a primary risk factor for adverse perinatal outcomes. Although electronic cigarette (e-cigarette) use has increased, reasons for and behaviors of use are not fully understood. The purpose of this study, composed exclusively of pregnant current smokers, was to describe perceptions of health risks associated with e-cigarette use among pregnant women, describe the use patterns of pregnant dual users (defined as those who simultaneously use conventional/combustible cigarettes and e-cigarettes), and examine smoking-related behaviors between conventional-only (defined as those smoking combustible cigarettes but not e-cigarettes) and dual users.

METHODS

Cross-sectional data from a larger study of pregnant conventional-only and dual users were analyzed. A brief survey measured perceptions of prenatal e-cigarette use and smoking behaviors. Analysis included descriptive statistics, bivariate analysis, and logistic and linear regression analysis.

RESULTS

Among 176 pregnant smokers (38% dual users), more than one-half of participants believed e-cigarettes were harmful to women (56%) and posed harm to the fetus (53%). Among dual users, 41% used their e-cigarette daily, on average eight times per day. Eleven percent of dual users smoked a pack of cigarettes per day, compared with 5% of conventional-only smokers, and dual users scored significantly higher (p = .026) on the Penn State Cigarette Dependence Index. The most common e-cigarette liquid flavor was fruit (64%), and the most frequently reported e-cigarette nicotine concentration was 1-6 mg.

CONCLUSIONS

Characterizing perceptions and behaviors of e-cigarette use during pregnancy is foundational for future research to explore the association between product use and maternal and infant outcomes.

Impact of electronic nicotine delivery systems and other respondent characteristics on tobacco use transitions among a U.S. national sample of women of reproductive age

BACKGROUND

Identifying predictors of tobacco use patterns that differ in harm among reproductive-aged women may inform efforts to protect women and children against adverse health impacts of tobacco use.

METHODS

Changes in tobacco use patterns were examined among women (18-49 years) who completed Wave 1 (W1) and Wave 2 (W2), or W2 and Wave 3 (W3) of the U.S. Population Assessment of Tobacco and Health (PATH, 2013-2016) study, and were using cigarettes, filtered cigars and/or cigarillos in the first wave over which data were included for that respondent (Time 1; T1). We examined the proportion of respondents whose tobacco use transitions from T1 to Time 2 (T2) were harm-maintaining (continued using combusted tobacco), harm-reducing (transitioned to electronic nicotine delivery systems (ENDS), or harm-eliminating (quit tobacco). Multinomial logistic regressions (with harm-maintaining as the baseline category) were conducted to examine associations between ENDS use, demographic, and psychosocial characteristics with each transition.

RESULTS

A majority of women (83 %) exhibited harm-maintaining transitions, followed by harm-eliminating (14.7 %) and harm-reducing (2.3 %) transitions. Use of ENDS at T1 was associated with increased odds of harm reduction and decreased odds of harm elimination. Younger women were more likely to make both harm-reducing and harm-eliminating transitions. Increased educational attainment, identifying as Black or Hispanic, increased psychiatric symptoms, and pregnancy were associated with harm elimination, whereas living at or above poverty was associated with harm reduction.

CONCLUSIONS

Study results contribute new information on the impact of ENDS, sociodemographic characteristics, psychiatric symptoms, and pregnancy on tobacco use transitions among reproductive-aged women.

A review of tobacco regulatory science research on vulnerable populations

In 2013 the U.S. Food and Drug Administration and National Institutes of Health established fourteen Tobacco Centers of Regulatory Science (TCORS) to advance scientific knowledge relevant to conducting evidence-based tobacco regulation. This report reviews TCORS-funded research with adult vulnerable populations. The literature search included a list of all TCORS-funded publications compiled by the TCORS coordinating center; all TCORS were requested to share publications not in the coordinating-center's list. Only TCORS-funded reports describing an empirical study with an adult vulnerable population published in a peer-reviewed journal between September 2013 and June 2018 were included. 71 reports met inclusion criteria; 39% (28/71) examined tobacco use among those with mental health and medical comorbidities, 34% (24/71) socioeconomic disadvantage, 31% (22/71) women of reproductive age, 30% (21/71) racial/ethnic minorities, 18% (13/71) rural residents, and 3% (2/71) each among active military/veterans and sexual/gender minorities. Regarding scientific domains, 63% (45/71) investigated behavior, 37% (26/71) addiction, 24% (17/71) health effects, 20% (14/71) impact analyses, 18% (13/71) toxicity, 8% (6/71) marketing influences, and 7% (5/71) communications. Totals exceed 100% because some reports addressed multiple populations/domains. TCORS funding has generated a substantial, multidisciplinary body of new scientific knowledge on tobacco use in adult vulnerable populations. However, considerable variability was noted in the amount of research conducted across the various vulnerable populations and scientific domains. Most notably, relatively few studies focused on active military/veterans or sexual/gender minorities, and the scientific domains of marketing influences and communications were conspicuously underrepresented. These are important knowledge gaps to address going forward.

Electronic nicotine delivery systems and pregnancy: Recent research on perceptions, cessation, and toxicant delivery

Electronic nicotine delivery systems (ENDS), which includes e-cigarettes (ECIGs), are a rapidly-expanding class of products that heat a liquid (which may or may not contain nicotine) to produce an aerosol. The variation of ECIG components is extensive as are their effects on users. Epidemiological data show that while both adults and youth use ECIGs, use among youth has increased dramatically in recent years. Other epidemiological data show that women of reproductive age and some pregnant women are also using ECIGs. The goal of this article is to provide readers with background information about ECIGs, with a focus on recent findings about ECIG use in pregnancy and potential implications. Among pregnant women, correlates of ECIG use include current cigarette smoking, among other factors. Regarding pregnant women's perceptions of ECIG use in pregnancy, two themes emerge from the literature: many pregnant women perceive ECIGs to be safer than conventional cigarettes, and that ECIGs can aid with smoking cessation. In contrast to these perceptions, there is little concrete evidence that ECIGs help smokers quit. In addition, there are concerns about ECIG nicotine and other toxicant delivery. Nicotine is a toxicant of particular concern for pregnant women, as nicotine is known to harm a developing fetus. There are many limitations to existing research, and the literature is scant in this area. Further, new "pod mod"-style ECIGs such as JUUL present new challenges. Overall, with limited evidence of their effectiveness, and concerns about developmental toxicology, the authors do not recommend that pregnant women use ECIGs.

Prevalence and patterns of cigarette smoking before and during early and late pregnancy according to maternal characteristics: the first national data based on the 2003 birth certificate revision, United States, 2016

BACKGROUND

The objective of this study was to examine the prevalence of smoking by intensity status before pregnancy and during early (first and second trimester) and late (third trimester) pregnancy according to race/ethnicity, age, and educational attainment of women who gave birth in the United States in 2016.

METHODS

This cross-sectional study was based on the 2016 National Center for Health Statistics (NCHS) Natality File of 3,956,112 live births, the first year that it became 100% nationally representative. Self-reported smoking data were used to create new seven smoking intensity status categories to capture natural variability in smoking patterns during pregnancy and to identify maternal smokers by race/ethnicity, age, and educational attainment. The risk of smoking at low and high intensity in early pregnancy was estimated in multivariable logistic regression analyses.

RESULTS

Nearly 9.4% of women reported smoking before pregnancy and 7.1% during pregnancy, both at high and low intensity, and smoking rates were higher in the first trimester (7.1%) than in the second (6.1%) or the third (5.7%) trimester. Non-Hispanic White women, women 20-24 years old, and women with less than a high school education were the strongest predictors of smoking anytime during pregnancy. The odds of smoking in early pregnancy at high intensity were 88% lower (aOR 0.12, 95% CI: 0.11, 0.13) for Hispanic women, compared to non-Hispanic White women; 16% higher (aOR 1.16, 95% CI: 1.12, 1.21) for women 20-24 years old and 16% lower (aOR 0.84, 95% CI: 0.80, 0.89) for women ≥35 years old, compared to women 25-29 years old; as well as 13% higher (aOR 1.13, 95% CI: 1.09, 1.18) for women with less than a high school education and 92% lower (aOR 0.08, 95% CI: 0.08, 0.09) for women with a bachelor's degree or higher, compared to women with a high school diploma.

CONCLUSIONS

Despite the high prevalence of high intensity smoking before and during pregnancy, future intervention strategies need to focus on the proportion of low intensity quitters and reducers, who are ready to stop smoking. Continual monitoring of trends in smoking intensity patterns is necessary, including neonatal outcomes over time.

Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions

The United States lags far behind other industrialized countries on major markers of population health. Population health experts identify unhealthy behavior patterns (e.g., cigarette smoking, other substance use disorders, physical inactivity and poor food choices, nonadherence with recommended medical regimens) as the largest contributor to the status quo. Because these risk behaviors are overrepresented in socioeconomically disadvantaged and other vulnerable populations, they also increase health disparities. Hence, identifying evidence-based strategies to promote and sustain health-related behavior change is critical to improving U.S. population health. In this report, we review research demonstrating the efficacy of voucher-based contingency management delivered alone or in combination with other interventions for treating substance use disorders and other health-related behavior problems. The efficacy supporting these interventions is robust and discernible at the level of controlled randomized clinical trials and meta-analyses. Unfortunately, these evidence-based interventions are being underutilized in routine clinical care for substance use disorders, although they are used broadly in private-sector wellness programs and international programs to reduce chronic poverty. This report reviews the evidence supporting the efficacy of voucher-based contingency management using projects developed at the University of Vermont as exemplars and discusses dissemination of the model to public and private sector efforts to improve individual and population health.

E-cigarette minimum legal sale age laws and traditional cigarette use among rural pregnant teenagers

Teenagers under 18 could legally purchase e-cigarettes until states passed minimum legal sale age laws. These laws may have curtailed teenagers' use of e-cigarettes for smoking cessation. We investigate the effect of e-cigarette minimum legal sale age laws on prenatal cigarette smoking and birth outcomes for underage rural teenagers using data on all births from 2010 to 2016 from 32 states. We find that the laws increased prenatal smoking by 0.6 percentage points (pp) overall. These effects were concentrated in prepregnancy smokers, with no effect on prepregnancy non-smokers. These results suggest that the laws reduced cigarette smoking cessation during pregnancy rather than causing new cigarette smoking initiation. Our results may indicate an unmet need for assistance with smoking cessation among pregnant teenagers.

Responses to cigarette health warning labels, harm perceptions and knowledge in a national sample of pregnant and non-pregnant women of reproductive age

INTRODUCTION

Little is known about the effectiveness of cigarette health warning labels (HWLs) among U.S. pregnant and non-pregnant women of reproductive age. Our intent was to examine HWL responses by pregnancy status and their associations with knowledge and perceived harm.

METHODS

We conducted cross-sectional analyses of first (2013-2014) and second (2014-2015) Population Assessment of Tobacco and Health waves. The sample (N = 19,095) was representative of U.S. women of reproductive age (18-45 years). We examined three HWL responses (seeing HWLs, forgoing cigarettes because of HWLs, likely-to-quit because of HWLs), perceived harm from smoking, and knowledge of health effects to fetuses and others. Weighted logistic regression compared HWL responses by pregnancy status and their associations with perceived harm and knowledge, adjusting for demographics and tobacco use. Results were presented as marginal predicted probabilities.

RESULTS

Pregnant smokers were less likely than never-pregnant smokers to report likelihood of quitting (57% vs 67%, p = 0.020). Forgoing cigarettes and likely-to-quit due to HWLs-but not seeing HWLs-were positively associated with perceived harm and knowledge. Pregnant smokers were less likely to have knowledge of fetal harm (83%) than ever-pregnant (91%, p = 0.006) and never-pregnant (92%, p = 0.003) smokers. However, pregnant smokers who reported likelihood of quitting were much more likely to have knowledge of fetal harm than those who did not (93% vs. 67%, p = 0.028).

CONCLUSIONS

Implementation of HWLs that elicit stronger reactions-such as pictorial HWLs-and increase knowledge of fetal risks is one action to help reduce tobacco use in pregnant and non-pregnant U.S. women of reproductive age.

Editorial: 5th Special Issue on behavior change, health, and health disparities

This Special Issue of Preventive Medicine (PM) is the 5th in a series on behavior change, health, and health disparities. Unhealthy behavior patterns (i.e., lifestyle choices) including cigarette smoking and other substance abuse, physical inactivity, unhealthy food choices, and non-adherence with recommended medical regimens, undermine U.S. population health by increasing risk for chronic disease and premature death. This Special Issue brings together scholarly contributions from the emerging area of tobacco regulatory science to examine current topics of critical importance to reducing the burden of cigarette smoking on U.S. population health. More specifically, three related topics are examined including (a) the potential for reducing smoking by adopting a national policy that would cap the nicotine content of cigarettes at minimally-addictive levels; (b) increasing scientific understanding of cigarette smoking and other tobacco use among populations that are especially vulnerable to initiating smoking, tobacco addiction, and its adverse health consequences; and (c) the potential of a harm-reduction strategy for reducing the burden of smoking by advocating that those who are unwilling or unable to quit nicotine use substitute electronic cigarettes or other non-combusted sources of nicotine for cigarettes in order to avoid exposure to the other toxins in tobacco smoke that are most responsible for smoking morbidity and mortality. While tremendous progress has been made in reducing overall U.S. smoking prevalence and its adverse health impacts, more needs to be done. This Special Issue offers some ideas that have the potential to make a substantive contribution towards that goal.

Examining the relationship between pregnancy and quitting use of tobacco products in a U.S. national sample of women of reproductive age

This study examined quit rates longitudinally for cigarettes, e-cigarettes, hookah, cigars, and all tobacco products in a U.S. national sample of women aged 18-44 who completed both Wave 1 (W1) and Wave 2 (W2) of the Population Assessment of Tobacco and Health (PATH, 2013-2014, 2014-2015) study (N = 7814). Quit rates were examined among women who transitioned into pregnancy across survey waves, and among a comparable sample of non-pregnant women to provide contextual information about quitting among the broader population of reproductive-aged women. Multiple logistic regression modeling was used to estimate the associations of pregnancy and quitting adjusting for other demographic and psychosocial characteristics. Quit rates among women who were pregnant in W2 were highest for hookah (98.3%), followed by cigars (88.0%), e-cigarettes (81.3%), and lowest for tobacco cigarettes (53.4%). Slightly more than half (58.7%) of women reported quitting use all tobacco products while pregnant. Pregnancy was independently associated with increased odds of quitting hookah (AOR = 52.9, 95%CI = 3.4, 830.2), e-cigarettes (AOR = 21.0, 95%CI = 2.6, 170.3), all tobacco products (AOR = 9.6, 95%CI = 6.4, 14.5), and cigarettes (AOR = 6.5, 95%CI = 4.2, 10.1), although not cigars. Relative to other demographic and psychosocial characteristics, pregnancy was the strongest predictor of quitting use of each tobacco product. While these data indicate that pregnancy has strong, independent associations with quitting a variety of commercially available tobacco products, the comparatively lower quit rates for cigarettes versus other tobacco products underscores the long-standing need for more intensive, multipronged clinical and regulatory interventions to reduce cigarette use among reproductive-aged women.