Tobacco Smoke Exposure in Pregnant Dogs: Maternal and Newborn Cotinine Levels: A Pilot Study

Active and passive smoking in pregnant women is associated with perinatal morbidity and mortality risk, including abortion, preterm birth, low birthweight, and malformations. No data are available on intrauterine exposure to smoking during pregnancy in dogs. This study aimed to fill this gap by exploring the detectability and quantity of cotinine, the major metabolite of nicotine, in maternal (serum and hair) and newborn (amniotic fluid and hair) biospecimens collected at birth in dogs. For this purpose, twelve pregnant bitches, six exposed to the owner's smoke and six unexposed, were enrolled. A further six non-pregnant bitches exposed to passive smoke were included to investigate the role of pregnancy status on cotinine uptake. Exposed dogs, dams, and puppies had greater cotinine concentrations than unexposed ones. Although without statistical significance, serum and hair cotinine concentrations were higher in pregnant compared to non-pregnant bitches, suggesting a different sensitivity to tobacco smoke exposure during gestation. The present results provide evidence for cotinine transplacental passage in the dog. It is conceivable that fragile patients such as pregnant, lactating, and neonate dogs may be more susceptible to the harmful effects of second-hand smoke exposure. Owners should be sensitized to the risk of smoke exposure for their pets.

Association of maternal snuff use and smoking with Sudden Infant Death Syndrome: a national register study

BACKGROUND

The aim was to study whether non-combustible nicotine (Swedish snuff) use in pregnancy is associated with elevated risk of post neonatal mortality, Sudden Infant Death Syndrome (SIDS), and Sudden Unexpected Infant Death (SUID) and to study how cessation before the antenatal booking influenced these risks.

METHODS

This was a population-based register study of all infants with information on tobacco exposure in early pregnancy born in Sweden 1999-2019, n = 2,061,514. Self-reported tobacco use in early pregnancy was categorized as nonuse, snuff use, and moderate and heavy smoking. Multiple logistic regression models were used to estimate crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. The risks of snuff use and moderate smoking were of similar magnitude. Heavy smoking was associated with the highest risks. Cessation of smoking and snuff use before the antenatal booking was associated with lower risks of SIDS and SUID compared to that of continuous usage.

CONCLUSIONS

Maternal snuff use was associated with increased risks of post neonatal mortality, SIDS, and SUID. Nicotine is the common substance in cigarette smoke and snuff. These findings support the hypothesis that nicotine contributes to an elevated risk of SIDS.

IMPACT

Maternal snuff use and smoking in early pregnancy were associated with increased risks of post neonatal mortality, SIDS, and SUID. Cessation of smoking and snuff use before the first antenatal visit was associated with reduced risks of SIDS and SUID. The common substance in cigarette smoke and snuff is nicotine. Our findings suggest that nicotine contributes to an elevated risk of SIDS and SUID. The implication of our findings is that all forms of nicotine should be avoided in pregnancy.

Oral Candidiasis of Tobacco Smokers: A Literature Review

The mouth is a vital point of entry into the human body, the health of the mouth entails mental, physical as well as social well-being. Studying diseases, microbiota and environmental conditions of the mouth is important to maintain oral health and all body. The smoke of tobacco cigarettes is one of the worst habits that affect the health of the mouth and the body. Therefore, this review has been conducted to study the effect of smoking on the balance of the oral microbiota and the opportunistic organisms, one of the most important of them <i>Candida</i>. Although a few studies have found that cigarette smoking does not influence carriage by <i>Candida</i> significantly. However, most of the studies had results completely contrary to that, smoking cigarettes affect <i>Candida</i> pathogenic characteristics such as a transition from yeast to hyphal form, biofilm formation and, virulence-related gene expressions. Tobacco is not only an inducer of the transition process but it considers an excellent medium for this process. Furthermore, smoking was significantly associated with <i>Candida</i> pathogenicity in patients with clinically suspected oral leukoplakia and smoking worsens oral candidiasis and dampens epithelial cell defense response. Nicotine significantly altered the composition and proportion of yeast cells, as well as the extracellular polysaccharide amounts which increase biofilm matrix and thickness which could promote oral candidiasis. Smoking has the potential to alter the oral condition and cause severe oxidative stress, thereby damaging the epithelial barrier of the mouth. These oxidative molecules during smoking activate epithelial cells proteins called oxidative stress-sensing proteins. If some of these proteins induced, widely thought to have anti-inflammatory properties, inhibit the secretion of pro-inflammatory cytokines and are linked to inflammation and oxidative stress is thought to be a possible therapeutic objective and a crucial regulator for smoking-related oral diseases and mouth candidiasis for instance leukoplakia. Also, it is transported into the cell nucleus in the existence of additional electrophilic chemicals to activate antioxidant enzyme gene expression. Therefore, smoking cigarettes destroys oral health and consequently destroys the health of the whole body.

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

BACKGROUND AND AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Toxic effects of smokeless tobacco on female reproductive health: A review

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Smokeless tobacco use can lead to impairments of ovarian function, morphology, oocyte quality and hormonal regulation.

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Use of smokeless tobacco during pregnancy has adverse health effects on both the mother and fetus.

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Exposure to smokeless tobacco in utero has long term health consequences on offspring.

The habitual consumption of tobacco in its various form is widespread and a serious public health issue globally. In particular, the use of smokeless tobacco has increased substantially due to its easy availability and misconception that it is relatively harmless compared to smoking. Tobacco use has been well established from numerous studies as a causative agent of devastating illnesses such as cancer, insulin resistance, hypertension, acute respiratory disease, osteoporosis, etc. Limited but growing evidence have also suggested its role in adversely affecting reproductive capabilities and outcomes in women of reproductive age and during pregnancy. This paper provides an updated review on available literature regarding the negative effects of smokeless tobacco use on female reproductive health, during pregnancy and its adverse consequences on the offspring. Existing data suggests the association between chronic smokeless tobacco use and impairment of ovarian morphology and function, oocyte quality, hormonal perturbations, fetal development and long-term health effects on the fetus. Improved understanding of these issues can contribute to better awareness of the dangers of smokeless tobacco products.

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

OBJECTIVE

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

DESIGN

Cross-sectional questionnaire study.

SETTING

Three out of 16 Finnish Defence Forces units.

PARTICIPANTS

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

PRIMARY AND SECONDARY MEASURES

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

RESULTS

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

CONCLUSION

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

Maternal smoking and smokeless tobacco use during pregnancy and offspring development: sibling analysis in an intergenerational Swedish cohort

Background

The association between maternal smoking in pregnancy and offspring intellectual disability (ID) is less well understood than that of smoking and fetal growth restriction. As fetal growth and cognitive development may share similar confounding structures, comparison of the two associations may improve understanding of the causal nature of the association with ID. Furthermore, comparisons of smoking with smokeless tobacco use may aid identification of mechanisms of action.

Methods

This was a cohort study of all Swedish births between 1999 and 2012 (n = 1 070 013), with prospectively recorded data. We assessed the association between maternal smoking during pregnancy and offspring outcomes ID and born small for gestational age (SGA). Analyses were repeated for snus use in pregnancy. Using a sibling design, we estimated within-family effects that control for shared sibling characteristics.

Results

Those exposed to maternal smoking in pregnancy had increased odds of ID [odds ratio (OR) = 1.24, 95% confidence interval (CI): 1.16-1.33] and SGA (OR = 2.19, 95% CI: 2.11-2.27) after confounder adjustment. Within-family effects were found for SGA (OR = 1.44, 95% CI: 1.27-1.63) but not ID (OR = 0.92, 95% CI: 0.74-1.14). For snus use, the results for ID were similar to smoking. We found increased odds of offspring SGA among mothers who used snus in pregnancy in sensitivity analyses but not in primary analyses.

Conclusions

Our findings are consistent with a causal effect of maternal smoking in pregnancy on risk of offspring born SGA but not on risk of ID. We found no evidence for a causal effect of snus use in pregnancy on ID and inconclusive evidence for SGA.

The Effects of Nicotine on Development

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

The impact of anti-tobacco legislation on birth weight in Peru

Background

Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA.

Methods

This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis.

Results

A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42).

Conclusions

The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.

Maternal Characteristics and Obstetric and Neonatal Outcomes of Singleton Pregnancies Among Adolescents

Background

Adolescent pregnancy remains a global public health issue with serious implications on maternal and child health, particularly in developing countries The aim of this study was to investigate maternal characteristics and obstetric and neonatal outcomes of singleton pregnancies among adolescents.

Material/Methods

A total of 241 adolescent women who gave birth to singletons between January 2015 and December 2015 at our hospital were included in this descriptive cross-sectional study. Data on maternal sociodemographic and obstetric characteristics as well as neonatal outcome were recorded.

Results

Primary school education (66.0%), lack of regular antenatal care (69.7%), religious (36.7%) and consanguineous (37.0) marriage, Southeastern Anatolia hometown (34.9%) and Eastern Anatolia hometown (21.2%) were noted in most of the adolescent pregnancies, while 95% were desired pregnancies within marriage. Pregnancy complications were noted in 19.5% (preeclampsia in 5.8%) and cesarean delivery was performed in 44.8% of adolescent pregnancies. Preterm delivery rate was 27.0% (20.3% were in >34 weeks). Overall, 13.3% of neonates were admitted to neonatal intensive care unit (NICU) in the postpartum period (prematurity in 28.1%), while 25.3% were re-admitted to NICU admission in the post-discharge 1-month (hyperbilirubinemia in 55.7%). Adolescent pregnancies were associated considerably high rates of fetal distress at birth (28.7%), preterm delivery (26.9%), and re-admission to NICU after hospital discharge (25.3%).

Conclusions

In conclusion, our findings indicate that along with considerably high rates of poor antenatal care, maternal anemia and cesarean delivery, adolescent pregnancies were also associated with high rates for fetal distress at birth, preterm delivery, and NICU re-admission within post-discharge 1-month.

Trends in maternal use of snus and smoking tobacco in pregnancy. A register study in southern Norway

BACKGROUND

The use of tobacco products including Swedish snus (moist snuff) in pregnancy may cause adverse health outcomes. While smoking prevalence has decreased among fertile women in Norway, snus use has increased during the last years. We investigated whether these trends were reflected also during pregnancy in a population of women in Southern Norway.

METHODS

Data on smoking tobacco and snus use at three time points before and during pregnancy for 20,844 women were retrieved from the electronic birth record for the years 2012-2017. The results for the three-year period 2015-2017 were compared with a previously studied period 2012-2014. Prevalence and quit rates of tobacco use within groups of age, parity and education were reported. Within the same groups adjusted quit rates were analyzed using logistic regression. Mean birthweight and Apgar score of offspring were calculated for tobacco-users and non-users.

RESULTS

There was an increase of snus use before pregnancy from the period 2012-2014 to the period 2015-2017 from 5.1% (CI; 4.6 to 5.5) to 8.4% (CI; 7.8 to 8.9). Despite this, the use of snus during pregnancy did not increase from the first to the second period, but stabilized at 2.8% (CI; 2.5 to 3.2) in first trimester and 2.0% (CI; 1.7 to 2.2) in third trimester. Cigarette smoking decreased significantly both before and during pregnancy. Snus use and smoking during pregnancy were associated with a reduction in average birthweight, but no significant effects on Apgar scores. Odds ratios for quitting both snus and smoking tobacco during pregnancy were higher for women aged 25-34 years, for the primiparas and for those with a high level of education. Pregnant women were more likely to have quit tobacco use in the last time period compared to the first.

CONCLUSIONS

While smoking during pregnancy was decreasing, the use of snus remained constant, levelling off to around 3% in first trimester and 2% in third trimester. Approximately 25% of those that used snus, and 40% that smoked before pregnancy, continued use to the third trimester. This calls for a continuous watch on the use of snus and other nicotine products during pregnancy.

Snus in pregnancy and infant birth size: a mother-child birth cohort study

Rationale

While recent studies show that maternal use of snus during pregnancy is increasing, the potential effects on infant birth size is less investigated, with conflicting results.

Objectives

We aimed to determine if maternal use of snus during pregnancy influences the infant anthropometric and proportional size measures at birth.

Methods

In 2313 mother–child pairs from the population-based, mother–child birth cohort PreventADALL (Preventing Atopic Dermatitis and ALLergies) in Norway and Sweden, we assessed nicotine exposure by electronic questionnaire(s) at 18 and 34 weeks of pregnancy, and anthropometric measurements at birth. Associations between snus exposure and birth size outcomes were analysed by general linear regression.

Results

Birthweight was not significantly different in infants exposed to snus in general, and up to 18 weeks of pregnancy in particular, when adjusting for relevant confounders including maternal age, gestational age at birth, pre-pregnancy body mass index, parity, fetal sex and maternal gestational weight gain up to 18 weeks. We found no significant effect of snus use on the other anthropometric or proportional size measures in multivariable linear regression models. Most women stopped snus use in early pregnancy.

Conclusion

Exposure to snus use in early pregnancy, with most women stopping when knowing about their pregnancy, was not associated with birth size. We were unable to conclude on effects of continued snus use during pregnancy because of lack of exposure in our cohort.

Snus use in pregnancy, reported by 7.1% of 2313 women, was not associated with infant birth size. As most women stopped snus use by 6 weeks gestational age, it was not possible to assess potential birth size effects of persistent use during pregnancy.http://bit.ly/2IG8Vnk

Correlates of substance use in pregnant women under community supervision after conviction for a criminal offence: The role of psychological distress

BACKGROUND

Being pregnant while under community supervision after conviction for a criminal offence can be a highly stressful experience, and pregnant women under community supervision are at an elevated risk for substance use.

AIMS/HYPOTHESES

To test for relationships between psychological distress and use of tobacco, alcohol, or marijuana during the month prior to a research assessment among pregnant women under community supervision, controlling for demographic characteristics.

METHODS

Data from the National Survey on Drug Use and Health were aggregated for the years 2008-2016, inclusive. Logistic regression analyses were conducted to examine correlates of past-month use of each substance.

RESULTS

Of all 505,796 people in the survey, 6,974 were pregnant women of whom 280 reported being under community supervision for a criminal offence; relevant data were available for 271 of these cases. The pregnant women under community supervision reported higher rates of past-month substance use of each kind and of psychological distress than pregnant women not under community supervision. Past-month serious psychological distress, but not remitted psychological distress, corresponded strongly with past-month alcohol use even when controlling for demographic characteristics and other substance use.

CONCLUSIONS

Our findings add to the very sparse literature about a group of women likely to be exceptionally vulnerable during pregnancy and underscore the importance of screening for symptoms of substance use and of psychological distress amongst them. Among women under community supervision, alcohol use was less likely in the second or third trimester than the first, but as those using alcohol were more likely to report past month psychological distress, it may be important to provide additional resources and treatment services for these women.

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

Background

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

Methods and Results

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

Conclusions

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

See Editorial Watanabe and Parikh

Impact of snus use in teenage boys on tobacco use in young adulthood; a cohort from the HUNT Study Norway

Background

As smoking rates decreased, the use of Swedish snus (smokeless tobacco) concordantly increased in Norway. The role of snus as possible contributor to the reduction of smoking has been widely discussed. Our aim was to quantitate transitions in snus use, smoking and dual use of snus and cigarettes in a young male population.

Methods

This prospective cohort study includes 1346 boys participating in the Nord-Trøndelag Health Study in Young-HUNT1 1995–97, age 13–19 and in HUNT3 2006–08, age 23–30. Participants reported on tobacco use at both points of time. Models with binominal regression were applied to examine relative risks (RRs), of adolescent ever snus users, dual users or smokers (reference: never tobacco use), to be current snus only users, smokers (including dual users), or tobacco free in adulthood.

Results

Current tobacco use in this male cohort increased from 27% in adolescence to 49% in adulthood, increasing more for snus only use and dual use than for smoking only.

The adjusted RR (95% CI) of becoming a smoker as young adult, was 2.2 (CI 1.7–2.7) for adolescent snus users, 3.6 (CI 3.0–4.3) for adolescent dual users, and 2.7 (CI 2.2–3.3) for adolescent smokers. RR to become snus only users as adults was 3.1 (2.5–3.9) for adolescent dual users, 2.8 (2.2–3.4) for adolescent snus users and 1.5 (1.0–2.2) for adolescent smokers. The adjusted RR for the transition from adolescent tobacco use to no tobacco use in adulthood was similar for snus users and smokers with RR 0.5 (CI 0.4–0.7), but considerably lower for dual users with RR 0.2 (CI 0.2–0.3).

Conclusions

The use of snus, with or without concurrent smoking, carried a high risk of adult smoking as well as adult snus only use. Dual use seemed to promote the opportunity to become snus only users in adulthood, but made it also more difficult to quit. The benefit of snus use for harm reduction is not evident in our cohort, as the combination of smoking and dual use resulted in high smoking rates among the young adults.

Developmental toxicity of e-cigarette aerosols

Maternal smoking during pregnancy represents a major public health concern increasing the risk for low birth weight, congenital anomalies, preterm birth, fetal mortality, and morbidity. In an effort to diminish adverse developmental effects of exposure to cigarette smoking, pregnant women, and women of reproductive age, are increasingly turning to electronic nicotine delivery systems (ENDS), such as e-cigarettes, as an alternative. Given that health risks associated with ENDS use during pregnancy are largely unknown, there is an acute need to determine risks vs. benefits of e-cigarette use by pregnant women. While the most recent Surgeon General's Report on the "Health Consequences of Smoking" states that "the evidence is sufficient to infer that nicotine adversely affects maternal and fetal health during pregnancy, contributing to multiple adverse outcomes," it remains unclear whether use of ENDS represents a "safer alternative" to tobacco smoking during pregnancy. This is due, in part, to the lack of sufficient and conclusive evidence concerning whether or not maternal e-cigarette use adversely affects embryonic/fetal development. While several recent developmental studies have challenged the safety of nicotine inhalation via ENDS, the true risks of smoking e-cigarettes during the first trimester of pregnancy-the period of organogenesis-are largely unknown. Moreover, evidence is emerging that even nicotine-free e-cigarette aerosols may harm the developing conceptus, suggesting that components of e-cigarette liquid, including flavorings, may be developmentally toxicity. Focused human epidemiological analyses, and carefully designed animal studies are critically needed to address the question of the safety of ENDS use during pregnancy.

An intervention in contraceptive counseling increased the knowledge about fertility and awareness of preconception health-a randomized controlled trial

Background: Reproductive life plan counseling (RLPC) is a tool to encourage women and men to reflect upon their reproduction, to avoid unintended pregnancies and negative health behavior that can threaten reproduction. The aim was to evaluate the effect of RLPC among women attending contraceptive counseling. Outcomes were knowledge about fertility and awareness of preconception health, use of contraception, and women's experience of RLPC. Material and methods: Swedish-speaking women, aged 20-40 years, were randomized to intervention group (IG) or control group (CG). Participants (n = 1,946) answered a questionnaire before and two months after (n = 1,198, 62%) the consultation. All women received standard contraceptive counseling, and the IG also received the RLPC, i.e. questions on reproductive intentions, information about fertility, and preconception health. Results: Women in the IG increased their knowledge about fertility: age and fertility, chances of getting pregnant, fecundity of an ovum, and chances of having a child with help of IVF. They also increased their awareness of factors affecting preconception health, such as to stop using tobacco, to refrain from alcohol, to be of normal weight, and to start with folic acid before a pregnancy. The most commonly used contraceptive method was combined oral contraceptives, followed by long-acting reversible contraception. Three out of four women (76%) in the IG stated that the RLPC should be part of the routine in contraceptive counseling. Conclusions: Knowledge about fertility and awareness of preconception health increased after the intervention. The RLPC can be recommended as a tool in contraceptive counseling.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

Using snus, an oral moist tobacco, has increased among pregnant women in Sweden, the only European Union country where sales are legal. This study evaluated whether snus generated similar concentrations of nicotine and its metabolites in breastmilk to cigarette smoking.

METHODS

We analysed 49 breastmilk samples from 33 nursing mother - 13 snus users, six cigarette smokers and 14 controls - for concentrations of nicotine, cotinine and 3-hydroxycotinine. The mothers were recruited at antenatal clinics in Sweden from 2007 to 2012.

RESULTS

The median nicotine concentration in breastmilk of the snus users was 38.7 ng/mL (0-137) versus 24.0 ng/mL (0-56) in smokers, with median cotinine levels of 327.6 ng/mL (37-958) versus 164.4 ng/mL and median 3-hydroxycotinine levels of 202.7 ng/mL (28-452) versus 112.4 (0-231), respectively. Nicotine was still detected in the breastmilk of eight of the 13 snus users after abstaining from tobacco for a median duration of 11 hours (0.6-12.5), while the breastmilk of the smokers was nicotine-free after four hours' abstinence.

CONCLUSION

Snus users had high levels of nicotine and metabolites in their breastmilk and nicotine was found even after 12.5 hours of abstinence.

Prevention of snus use: Attitudes and activities in the Public Dental Service in the south-eastern part of Norway

Dental health care professionals have the opportunity to play a key role in tobacco prevention and cessation among adolescents. Snus use has increased in Norway, especially in the age group 16-24, whereas there has been a decline in smoking. This study investigated attitudes and activities related to snus prevention among dental health care professionals working in the Public Dental Service (PDS) in south-eastern Norway. A web-based survey with a total of 557 dentists and dental hygienists in seven counties in Norway, with a response rate of 53.5%, was carried out in 2017. Dentists' and dental hygienists' activities regarding preventive snus use intervention were analysed using the chi-square test. Intervention was measured with a score (1-5) based on four questions. Bivariate and multivariate linear regression analyses were used to investigate the associations between the explanatory variables of attitudes/activities and the outcome intervention variable. Approximately 87% of the dentists and 58% of the dental hygienists were not familiar with the "minimum intervention method" for tobacco prevention and cessation. Dental hygienists were most active in informing and supporting their patients in prevention and cessation of snus use. The PDS is an underutilized arena for tobacco prevention and cessation among adolescents, and the intervention potential is particularly high among the dentists.

Stopping when knowing: use of snus and nicotine during pregnancy in Scandinavia

The risk of adverse health effects in offspring due to maternal tobacco smoking during pregnancy is well documented [1], including epigenetic changes persisting in the offspring after prenatal exposure [2]. The effects of fetal exposure to nicotine from non-combustible tobacco products, such as snus or nicotine-replacement therapies (NRTs), are less clear. Use of snus leads to systemic absorption of nicotine into the maternal circulatory system, with subsequent exposure of the foetus through the placenta [3].

In young women, the use of snus increases in parallel with decreasing smoking rates but the  use in pregnancy is unclear. Our aims were to determine the prevalence of snus use, smoking and other nicotine-containing product use during pregnancy, and to identify predictors for snus use in pregnancy.

Prevalence was determined for 2528 women in Norway and Sweden based on the Preventing Atopic Dermatitis and ALLergies (PreventADALL) study, a population-based, mother–child birth cohort. Electronic questionnaires were completed in pregnancy week 18 and/or week 34, and potential predictors of snus use were analysed using logistic regression models.

Ever use of any snus, tobacco or nicotine-containing products was reported by 35.7% of women, with similar rates of snus use (22.5%) and smoking (22.6%). Overall, 11.3% of women reported any use of nicotine-containing products in pregnancy up to 34 weeks, most often snus alone (6.5%). Most women (87.2%) stopped using snus by week 6 of pregnancy.

Snus use in pregnancy was inversely associated with age and positively associated with urban living and personal or maternal history of smoking. While 11.3% of women used snus or other nicotine-containing products at some time, most stopped when recognising their pregnancy. Younger, urban living, previously smoking women were more likely to use snus in pregnancy.

Of the 11.3% of women using any nicotine products in pregnancy (most often snus (6.5%)), the majority stop within pregnancy week 6. Snus use is associated with urban living, previous smoking, in utero smoking exposure of the index woman and lower age.http://ow.ly/Gyg230nmxIo

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement

RATIONALE

The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency.

METHODS

Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public.

RESULTS

Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction.

DISCUSSION

This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

The toxicity of E-cigarettes and children's respiratory health

Electronic cigarettes (E-cig), also referred to as Electronic Nicotine Delivery System (ENDS), were initially developed in 2003 to reduce the harmful effects of tobacco smoking. Since then, E-cig have become widely available in many countries and are used by many young people who would be unlikely to take up cigarette smoking. However, the adverse effects on child health remain largely unknown. E-cigs are available through regulated sale in many countries, but easily accessible by the internet in others. Adverse effects may be ascribed to the nicotine itself, to the accompanying substances in the aerosol (often referred to as vapour) or to temperature modifications of the content. There is a lack of human studies to assess respiratory effects of nicotine exposure to the unborn or young child. Also assessing the effects of the vaping content apart from nicotine is challenging, with the huge variety of exposure by frequency, duration and content, but experimental studies are on the way that may indicate the level of harm by such products. This article will summarize what is currently known about the use of E-cigs in children and in pregnancy, and discuss adverse effects of direct or in utero exposure to E-cig on the respiratory health of children. We thereby hope to provide a background for discussing potential harms to the respiratory system of children by E-cig exposure in pregnancy and early post-natal life, in a setting where an increasing proportion of adolescent and young adults use E-cigs, marketed to be 95% less harmful than conventional cigarettes.

Implementation of Article 20 of the World Health Organization Framework Convention on Tobacco Control

BACKGROUND & OBJECTIVES

Article 20 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) deals with surveillance and research on all tobacco products including smokeless tobacco (SLT). Here we describe the availability of indicators related to SLT among 180 Parties to the convention (countries ratifying the WHO FCTC are referred as Parties to the Convention).

METHODS

Data on SLT use among adults and adolescents and SLT-related economic and health indicators among Parties were obtained through rigorous literature search. Data analysis for high-burden parties was done using SPSS.

RESULTS

Nearly 92 per cent (166) of the Parties reported SLT use prevalence among adults or adolescents at national or subnational level, of these nearly one-fifth of the Parties (20.5%) were high-burden Parties. Comparable SLT tax incidence rate was available for 19.4 per cent (n=35) Parties, and SLT attributable morbidity and mortality risks of major diseases were available for only five per cent (n=10) of Parties.

INTERPRETATION & CONCLUSIONS

SLT use is a global epidemic widespread among Parties to the Convention. There are a data gap and dearth of research on SLT-related issues. Parties need to monitor SLT use and related health and economic indicators regularly at periodic intervals.

Association between maternal sleep practices and late stillbirth - findings from a stillbirth case-control study

Objective

To report maternal sleep practices in women who experienced a stillbirth compared with controls with ongoing live pregnancies at similar gestation.

Design

Prospective case‐control study.

Setting

Forty‐one maternity units in the United Kingdom.

Population

Women who had a stillbirth after ≥ 28 weeks’ gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733).

Methods

Data were collected using an interviewer‐administered questionnaire that included questions on maternal sleep practices before pregnancy, in the four weeks prior to, and on the night before the interview/stillbirth.

Main outcome measures

Maternal sleep practices during pregnancy.

Results

In multivariable analysis, supine going‐to‐sleep position the night before stillbirth had a 2.3‐fold increased risk of late stillbirth [adjusted Odds Ratio (aOR) 2.31, 95% CI 1.04–5.11] compared with the left side. In addition, women who had a stillbirth were more likely to report sleep duration less than 5.5 hours on the night before stillbirth (aOR 1.83, 95% CI 1.24–2.68), getting up to the toilet once or less (aOR 2.81, 95% CI 1.85–4.26), and a daytime nap every day (aOR 2.22, 95% CI 1.26–3.94). No interaction was detected between supine going‐to‐sleep position and a small‐for‐gestational‐age infant, maternal body mass index, or gestational age. The population‐attributable risk for supine going‐to‐sleep position was 3.7% (95% CI 0.5–9.2).

Conclusions

This study confirms that supine going‐to‐sleep position is associated with late stillbirth. Further work is required to determine whether intervention(s) can decrease the frequency of supine going‐to‐sleep position and the incidence of late stillbirth.

Tweetable abstract

Supine going‐to‐sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks’ gestation.

Plain Language Summary

Stillbirth, the death of a baby before birth, is a tragedy for mothers and families. One approach to reduce stillbirths is to identify factors that are associated with stillbirth. There are few risk factors for stillbirth that can be easily changed, but this study is looking at identifying how mothers may be able to reduce their risk.

In this study, we interviewed 291 women who had a stillbirth and 733 women who had a live‐born baby from 41 maternity units throughout the UK. The mothers who had a stillbirth were interviewed as soon as practical after their baby died. Mothers who had a live birth were interviewed during their pregnancies at the same times in pregnancy as when the stillbirths occurred. We did not interview mothers who had twins or who had a baby with a major abnormality.

Mothers who went to sleep on their back had at least twice the risk of stillbirth compared with mothers who went to sleep on their left‐hand side. This study suggests that 3.7% of stillbirths after 28 weeks of pregnancy were linked with going to sleep lying on the back. This study also shows that the link between going‐to‐sleep position and late stillbirth was not affected by the duration of pregnancy after 28 weeks, the size of the baby, or the mother's weight. Women who got up to the toilet once or more at night had a reduced risk of stillbirth.

This is the largest of four similar studies that have all shown the same link between the position in which a mother goes to sleep and stillbirth after 28 weeks of pregnancy. Further studies are needed to see whether women can easily change their sleep position in late pregnancy and whether changing the position a mother goes to sleep in reduces stillbirth.

Tweetable abstract

Supine going‐to‐sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks’ gestation.

This paper includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14967

Exploring men's pregnancy-planning behaviour and fertility knowledge:a survey among fathers in Sweden

INTRODUCTION

Research about pregnancy-planning behaviour mostly focuses on women, even though pregnancy planning usually also concerns men. The purpose of this study was to investigate how men plan for family, and to measure their fertility knowledge after having become fathers.

MATERIAL AND METHODS

Data were collected in 2014 as part of a Swedish longitudinal pregnancy-planning study. Men were recruited through their female partner one year after childbirth. Participants were asked to fill out a questionnaire about pregnancy planning, lifestyles, and fertility.

RESULTS

Of the 796 participants, 646 (81%) stated that the pregnancy had been very or fairly planned, and 17% (n = 128) had made a lifestyle adjustment before pregnancy to improve health and fertility. The most common adjustments were to reduce/quit the consumption of alcohol, cigarettes, or snuff, and to exercise more. First-time fathers and those who had used assisted reproductive technology to become pregnant were more likely to have made an adjustment. Fertility knowledge varied greatly. Men with university education had better fertility knowledge than men without university education.

CONCLUSION

Our findings indicate that there is variation in how men plan and prepare for pregnancy. Most men did not adjust their lifestyle to improve health and fertility, while some made several changes. Both pregnancy-planning behaviour and fertility knowledge seem to be related to level of education and mode of conception. To gain deeper understanding of behaviour and underlying factors, more research is needed.

Maternal smoking during pregnancy and risk of stillbirth: results from a nationwide Danish register-based cohort study

INTRODUCTION

Maternal smoking during pregnancy has been associated with an increased risk of stillbirth. Only a few studies have been conducted to determine whether smoking affects the risk of antepartum and intrapartum stillbirth differently or whether smoking cessation in early pregnancy reduces the risk. Previous results are inconclusive. We addressed these questions in a large Danish population-based cohort study.

MATERIAL AND METHODS

From the Danish Medical Birth Register, we identified 841 228 singleton births in Denmark between 1997 and 2010 and gathered detailed information on maternal smoking during pregnancy and the vital status of the infant. Associations (odds ratios with 95% confidence intervals) between maternal smoking and risk of stillbirth overall and separately for antepartum and intrapartum stillbirth were analyzed using logistic regression models (generalized estimating equations), adjusting for potential confounders.

RESULTS

Any smoking during pregnancy increased the risk of stillbirth, both overall (odds ratio 1.42, 95% confidence interval 1.30-1.55) and for antepartum (odds ratio 1.38, 95% confidence interval 1.25-1.53) and intrapartum (odds ratio 1.52, 95% confidence interval 1.18-1.96) stillbirths. Women who quit smoking at the beginning of the second trimester at the latest had no increased risk of stillbirth overall (odds ratio 1.03, 95% confidence interval 0.80-1.32).

CONCLUSIONS

Maternal smoking during pregnancy increases the risk of stillbirth, both overall and for antepartum and intrapartum stillbirth separately. Women who quit smoking in the beginning of their pregnancy reduce their risk compared with that of non-smokers.

Smoking during pregnancy: A population-based study

AIMS

Tobacco is a major cause of disease and mortality in modern times. The risk of smoking in pregnancy is a serious threat to the development and future health of an unborn child. The aim of this study was to explore the epidemiological factors associated with smoking during pregnancy in a primary healthcare setting.

METHODS

All 856 maternity records at the Glaesibaer Health Care Centre in Reykjavik during 2006-2013 were reviewed and information on smoking habits investigated.

RESULTS

The records showed that in 108 (12.2%) pregnancies, women smoked at first visit and 63 stopped smoking in early pregnancy, leaving 45 (5.3%) mothers smoking throughout the whole gestational period. The mean age of the smoking women was 27.8 years and for the non-smokers 29.7 years. Low social status (odds ratio (OR) = 2.66; 95% confidence interval (CI): 1.19-5.96), previous mental health diagnosis (OR = 2.7; 95% CI: 1.3-5.6), and unstable relationship with a partner (OR = 3.78; 95% CI: 2.1-7.0) were associated with smoking. Smoking fewer cigarettes was associated with a 0.04-unit lower risk of smoking during pregnancy (OR = 0.04: 95% CI: 0.02-0.08).

CONCLUSIONS

Our results indicated that the women who smoked during pregnancy were often heavy smokers and living without a partner. They were younger, had worse mental health, and a lower social status than those pregnant women who did not smoke. Bearing in mind the consequence of smoking in pregnancy, this subgroup should get increased assistance to quit smoking before and during early pregnancy, as well as appropriate medical and social support.

Use of snus and smoking tobacco among pregnant women in the Agder counties

BACKGROUND

The use of snus during pregnancy increases the risk of stillbirths, premature delivery and reduced birthweight. People have been warned against smoking during pregnancy, but less so against the use of snus. We have investigated the use of snus and smoking tobacco among pregnant women in the Agder counties.

MATERIAL AND METHOD

Data on pregnant women and 10 583 births for the years 2012, 2013 and 2014 were retrieved from the electronic birth records of Sørlandet Hospital.

RESULTS

In the three-year period 2012 – 2014, altogether 5  % used snus and 19  % used smoking tobacco before pregnancy and 2  % and 8  % respectively at the end of pregnancy. The use of snus before pregnancy increased from 3.6  % in 2012 to 6.8  % in 2014. The equivalent figures for the first trimester were 1.7  % and 3.4  %, and for the last trimester 1.2  % and 2.1  %. The use of smoking tobacco declined by 2  % over the three-year period. In the age group 16 – 24 years, a total of 12  % used snus before pregnancy and 5  % at the end. Of 522 women who used snus before their pregnancy, altogether 57.5  % had quit during the first trimester and 71.4  % during the third trimester. The corresponding figures for those 2 015 women who used smoking tobacco before their pregnancy were 45.2  % and 58.0  % (p < 0.001).

INTERPRETATION

The use of snus before and during pregnancy doubled over the three-year period 2012 – 2014. The use was especially widespread in the youngest age groups. The proportion of women who quit using snus during their pregnancy was significantly higher than the proportion that quit smoking.

The Effects of Chewing Betel Nut with Tobacco and Pre-pregnancy Obesity on Adverse Birth Outcomes Among Palauan Women

The small Pacific Island nation of Palau has alarmingly high rates of betel nut with tobacco use and obesity among the entire population including pregnant women. This study aimed to determine the effects of betel nut with tobacco use and pre-pregnancy obesity on adverse birth outcomes. This study used retrospective cohort data on 1171 Palauan women who gave birth in Belau National Hospital in Meyuns, Republic of Palau between 2007 and 2013. The exposures of interest were pre-pregnancy obesity and reported betel nut with tobacco use during pregnancy. The primary outcomes measured were preterm birth and low birth weight among full-term infants. A significantly increased risk for low birth weight among full-term infants was demonstrated among those women who chewed betel nut with tobacco during pregnancy when other known risk factors were controlled for. Additionally, pre-pregnancy obesity was associated with a significantly increased risk for preterm birth when other known risk factors were controlled for. Both betel nut with tobacco use and pre-pregnancy obesity were associated with higher risks for adverse birth outcomes. These findings should be used to drive public health efforts in Palau, as well as in other Pacific Island nations where these studies are currently lacking.

Maternal tobacco use and extremely premature birth - a population-based cohort study

OBJECTIVE

To study the associations of maternal tobacco use (smoking or use of snuff) and risk of extremely preterm birth, and if tobacco cessation before antenatal booking influences this risk. To study the association between tobacco use and spontaneous or medically indicated onset of delivery.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

All live singleton births, registered in the Swedish Medical Birth Register, 1999-2012.

METHODS

Odds ratios (OR) with 95% confidence intervals (CI) were calculated using multiple logistic regression analysis.

MAIN OUTCOME MEASURES

Extremely preterm birth (<28 weeks of gestation), very preterm birth (28-31 weeks), moderately preterm birth (32-36 weeks).

RESULTS

Maternal snuff use (OR 1.58; 95% CI: 1.14-2.21) and smoking (OR 1.61; 95% CI: 1.39-1.87 and OR 1.91; 95% CI: 1.53-2.39 for moderate and heavy smoking, respectively) were associated with an increased risk of extremely preterm birth. When cessation of tobacco use was obtained there was no increased risk of preterm birth. Snuff use was associated with a twofold risk increase of medically indicated extremely preterm birth, whereas smoking was associated with increased risks of both medically indicated and spontaneous extremely preterm birth.

CONCLUSIONS

Snuff use and smoking in pregnancy were associated with increased risks of extremely preterm birth. Women who stopped using tobacco before the antenatal booking had no increased risk. These findings indicate that nicotine, the common substance in cigarettes and snuff, is involved in the mechanisms behind preterm birth. The use of nicotine should be minimized in pregnancy.

TWEETABLE ABSTRACT

Tobacco use increases risk of extremely preterm birth. Cessation is preventive. Avoid nicotine in pregnancy.

The effects of nicotine on human fetal development

Maternal smoking during pregnancy continues to represent a major public health concern. Nicotine is extremely harmful to the developing fetus through many different mechanisms, and the harms increase with later gestational age at exposure. Pregnancies complicated by maternal nicotine use are more likely to have significant adverse outcomes. Nicotine-exposed children tend to have several health problems throughout their lives, including impaired function of the endocrine, reproductive, respiratory, cardiovascular, and neurologic systems. Poor academic performance and significant behavioral disruptions are also common, including ADHD, aggressive behaviors, and future substance abuse. To diminish the adverse effects from cigarette smoking, some women are turning to electronic cigarettes, a new trend that is increasing in popularity worldwide. They are largely perceived as being safer to use in pregnancy than traditional cigarettes, although there is not adequate evidence to support this claim. At this time, electronic cigarette use during pregnancy cannot be recommended. Birth Defects Research (Part C) 108:181-192, 2016. © 2016 Wiley Periodicals, Inc.

Hormonal contraception among electronic cigarette users and cardiovascular risk: a systematic review

BACKGROUND

Women who use combined hormonal contraceptives and cigarettes have an increased risk for cardiovascular (CV) events. We reviewed the literature to determine whether women who use hormonal contraceptives (HC) and electronic cigarettes (e-cigarettes) also have an increased risk.

STUDY DESIGN

Systematic review.

METHODS

We searched for articles reporting myocardial infarction (MI), stroke, venous thromboembolism, peripheral arterial disease or changes to CV markers in women using e-cigarettes and HC. We also searched for indirect evidence, such as CV outcomes among e-cigarette users in the general population and among HC users exposed to nicotine, propylene glycol or glycerol.

RESULTS

No articles reported on outcomes among e-cigarette users using HC. Among the general population, 13 articles reported on heart rate or blood pressure after e-cigarette use. These markers generally remained normal, even when significant changes were observed. In three studies, changes were less pronounced after e-cigarette use than cigarette use. One MI was reported among 1012 people exposed to e-cigarettes in these studies. One article on nicotine and HC exposure found both exposures to be significantly associated with acute changes to heart rate, though mean heart rate remained normal. No articles on propylene glycol or glycerol and HC exposure were identified.

CONCLUSION

We identified no evidence on CV outcomes among e-cigarette users using HC. Limited data reporting mostly acute outcomes suggested that CV events are rare among e-cigarette users in the general population and that e-cigarettes may affect heart rate and blood pressure less than conventional cigarettes. There is a need for research assessing joint HC and e-cigarette exposure on clinical CV outcomes.

Protecting Children From Tobacco, Nicotine, and Tobacco Smoke

This technical report serves to provide the evidence base for the American Academy of Pediatrics' policy statements "Clinical Practice Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke" and "Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke." Tobacco use and involuntary exposure are major preventable causes of morbidity and premature mortality in adults and children. Tobacco dependence almost always starts in childhood or adolescence. Electronic nicotine delivery systems are rapidly gaining popularity among youth, and their significant harms are being documented. In utero tobacco smoke exposure, in addition to increasing the risk of preterm birth, low birth weight, stillbirth, placental abruption, and sudden infant death, has been found to increase the risk of obesity and neurodevelopmental disorders. Actions by pediatricians can help to reduce children's risk of developing tobacco dependence and reduce children's involuntary tobacco smoke exposure. Public policy actions to protect children from tobacco are essential to reduce the toll that the tobacco epidemic takes on our children.

Smoking, use of moist snuff and risk of celiac disease: a prospective study

Background

Smoking status has been linked to several chronic inflammatory conditions but earlier research on smoking and celiac disease (CD) is contradictive. There are little data on moist snuff use and CD. The purpose of this study was to investigate the association between smoking, moist snuff use and later CD.

Methods

We identified individuals with biopsy-verified CD (villous atrophy, histopathology stage Marsh III) through biopsy-reports from Sweden’s 28 pathology departments. Data on smoking and moist snuff were collected from the Swedish construction worker database “Bygghälsan” that includes preventive health care check-up data. Through poisson regression we calculated relative risks (RRs) for later CD according to smoking status (n = 305,722), and moist snuff status (n = 199,200) adjusting for age, sex and decade.

Results

During follow-up 488 individuals with smoking data, and 310 with moist snuff data had a diagnosis of CD. The risk of CD was independent of smoking status with all RRs being statistically insignificant and ranging between 0.9 and 1.0. Compared to non-smokers, neither current smokers (RR = 0.93; 95% CI = 0.76-1.14) nor ex-smokers (RR = 0.98; 95% CI = 0.75-1.28) were at increased or decreased risk of CD. Risk estimates were similar in moderate smokers (RR = 0.92; 0.72-1.16) and heavy smokers (RR = 0.95; 0.74-1.24), and did not change when we examined the risk more than ten years after health examination (RR-moderate: 0.90; and RR-heavy: 0.95; both p > 0.05). Moist snuff use was not associated with later CD (RR = 1.00; 0.78-1.28), or with CD after more than ten years of follow-up (RR = 1.05; 0.80-1.38).

Conclusions

We found no association between smoking, moist snuff use and future CD.