What is the medical opinion on electronic cigarettes?

REF: #3 • JUNE 2020 | VERSION.PDF

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Quitting smoking is a major health issue for pregnant women. The difficulty is heightened due to the accelerated metabolism of nicotine, social pressure, and the urgency to help these women quit. Given this situation, vaping could be a possible risk mitigation tool.

Our analysis is based on existing data and research. We sought expert advice to enrich this knowledge base.

A WORRYING SITUATION

The prevalence of smoking before pregnancy in France, according to Santé Publique France, is about 30%. This smoking rate increases from 20 to 24% during pregnancy from the first trimester to the third trimester. The smoking rate during pregnancy will decrease between 14 and 20%. Less than half (45.8%) of smokers before becoming pregnant manage to quit during pregnancy.

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Smoking during pregnancy is strongly associated with low birth weight, a doubled risk of miscarriage, an increased risk of premature birth by about 25%, and more than doubled risk of sudden infant death syndrome.

The issue of smoking cessation support is therefore a central concern for 54.2% of pregnant smokers in France who do not quit smoking, despite the risks to themselves and their future child.

MORE TROUBLE TO QUIT

Generally, awareness of the proven risks of smoking and under strong social pressure, among other things, the self-esteem of pregnant women who smoke is altered. This guilt phenomenon can be counterproductive and lead some to smoke “in secret.”

Pregnant women are particularly vulnerable when it comes to quitting tobacco. They do not have the “choice” of the date, the best time. This time limitation combined with social pressure creates additional stress. It has been justified for many years that doctors advise their patients to continue smoking a few cigarettes to reduce their stress and that of the child.

However, early cessation of smoking during pregnancy can almost completely prevent the risks associated with smoking.

WHAT HELP?

Although the announcement of pregnancy is a powerful driver for smoking cessation, it requires energy for others that is difficult to mobilize.

In France, the method by which smokers most often quit remains without any other help. In this way, there is a very high failure rate of over 95% relapses after six months. Successful quitting is generally associated with low physical, mental, and behavioral dependence. Subject to a doctor’s prescription, pharmacological methods such as bupropion (Zyban) or varenicline (Champix) are contraindicated during pregnancy due to the risk of undesirable side effects.

Psychological and behavioral support. Support for caregivers plays an important role in smoking cessation among pregnant women. Cognitive behaviors and general psychosocial approaches can be combined with nicotine replacement.

Although no study has been able to significantly demonstrate their own effectiveness in the specific case of pregnant women, particularly due to difficulties encountered in conducting compliance studies. In this situation, nicotine substitutes (NS) are used as a recommended aid for smoking cessation for pregnant women who smoke as a precaution, given the risk of smoking.

In France, they are reimbursed by health insurance. “It is recommended to inform women that the use of nicotine replacement medications (NRT) during pregnancy is less harmful than continuing to smoke (HA, 2014): NRT helps avoid the compensation phenomenon and increases the chances of quitting.”

The urgent need for pregnant women to quit smoking due to immediate risks to themselves and their children faces higher challenges related to the feeling of urgency, social pressure, and the reduction of available support tools.

NICOTINE

Nicotine is one of the alkaloids present in tobacco. It is considered the most important psychoactive substance sought by the smoker. Other components (pyridine, MAO…), among the more than 4000 substances released in cigarette smoke, as well as behavioral and psychological aspects, contribute to the addiction to smoking.

In pregnant women, the metabolism of nicotine is significantly increased, which can worsen the feeling of deprivation in case of withdrawal. This phenomenon promotes the prevention of under-doses in the case of nicotine substitution. Due to the increased blood volume, adjusting nicotine doses during pregnancy can be considered by trained and sensitized nurses.

Outside of smoked tobacco, nicotine alone has a toxicological profile similar to that of caffeine, according to the Royal Society of Public Health (UK). Nicotine replacement has been used since the early 1980s to quit smoking. In France, the prescription of nicotine substitutes has been allowed for pregnant smokers since 1997.

Despite massive use in many countries for over 20 years, no population study or follow-up of the population among women or their children has shown effects on the use of nicotine substitutes during pregnancy. Based on animal studies, doubts have been expressed about the possible effect of nicotine on the fetus.

According to the latest technology, replacing nicotine with cigarettes significantly reduces the risk for each consumer.

VAPING: A HELP?

“Smokers have various safer alternatives to cigarettes, including nicotine substitutes (NRT) and, more recently, vaping. The data available to date suggest that these products provide effective nicotine consumption without exposing the user to the many harmful chemicals present in tobacco, for example through nicotine pellets, patches, or chewing gum and, in the case of vaping, nicotine is administered orally by inhalation,” says the Royal Society for Public Health (UK).

Some organizations involved in the fight against smoking are in favor of nicotine abstinence and oppose the risk reduction approach, including for pregnant women.

However, vaping completely eliminates most of the thousands of toxic substances in cigarette smoke, including carbon monoxide and tar, and significantly reduces residual toxic substances. British health organizations, including the Royal College of Physicians and Public Health England, estimate based on their review of scientific studies that the risks of vaping compared to smoking.

To address the difficulties faced by pregnant smokers who quit smoking, the Leicester Stop Smoking Service (UK) launched a pilot test in 2016. “During the 2016/2017 period, 85 of the 228 pregnant users of the Leicester smoking cessation service vaped, with or without nicotine substitutes (NRT), followed by a cessation rate of 60%. In comparison, the success rate was 32% with only substitutes,” states the report from the Smoking in Pregnancy Challenge Group 2018.

“This is not scientific evidence that vaping is more effective for quitting smoking, but the case shows, based on local service data, that vaping can be an effective aid when combined with behavioral support,” explains the Smoking in Pregnancy Challenge Group (p. 19).

SPECIAL ACTIVE INGREDIENTS

As part of a risk reduction approach, the appeal of vaping is supposed to offer nicotine consumption without smoking. This allows the pregnant woman, like any other smoker, to avoid or reduce the feeling of deprivation.

Another advantage of vaping is that it is external or parallel to medicine; the support is accessible and can be combined with other nicotine substitutes.

In practice, users of specialized stores are encouraged to try to understand how the devices work. They also learn about vapor, which differs from smoking, and determine the nicotine dosage based on their feelings and needs. Inhalation preserves the phenomenon of self-titration of nicotine, already known to the smoker.

Vaping also offers a compensatory gesture that facilitates the cessation of cigarettes associated with certain daily rituals (coffee, meals, breaks, outings…). Vaping is another way to quit smoking. It is currently the most popular aid for French smokers who want to try to quit smoking. Therefore, given the urgency of their situation, it is natural for pregnant women to turn to vaping to quit smoking.

WHAT DO STUDIES SHOW?

Among smokers, smoking generally has serious adverse effects, which are usually observed long-term, including cardiovascular, respiratory, and cancer problems.

In the context of pregnancy, the consequences of smoking are short-term. Smoking significantly increases the risk of miscarriage, premature birth, and other fetal disorders. One of the main negative effects of smoking is the birth weight of newborns.

In accordance with the principles of risk reduction, British health organizations have launched research programs on this subject.

A team from Coombe Hospital in Dublin, Ireland, which records nearly 8,500 births per year, followed pregnant women in 2018 and 2019. Statistical analysis of the two studies shows a similar average weight (~ 3.47 kg) of infants born to non-smoking mothers and those of vaping mothers who completely quit smoking. On average, newborns of smokers weigh nearly 300 grams less (~ 3.16 kg).

Measurements of key maternal and infant health criteria and adequate delivery do not reveal significant differences between non-smokers and those who exclusively vape with or without nicotine. Birth weight, gestational period at birth, absence of severe maternal morbidity, modes of delivery, accidental trauma, postpartum hemorrhage, premature birth, and incubator use were similar between births of smoking and non-smoking mothers. No cases of neonatal respiratory distress syndrome were reported.

“Traditional smoking cessation procedures during pregnancy have limited effectiveness, and many women who struggle to quit smoking turn to vaping as a means of reducing harm. Our study suggests that exclusive vaping users give birth to infants with birth weights similar to those of non-smokers,” concluded Dr. Brendan McDonnell’s study at Coombe Hospital in February 2020.

A systematic review of 21 Cochrane studies on factors affecting the use of nicotine substitutes or vaping to quit smoking among pregnant women reveals that “the willingness of women to use vaping during pregnancy is influenced by the advice they receive from their healthcare professionals.”

HEALTH RECOMMENDATIONS

In the UK, the Smoking in Pregnancy Challenge Group, a group of 21 health organizations, has developed a number of resources on vaping during pregnancy. An information leaflet for the public and a guide for healthcare professionals were published in 2018 and updated in August 2019. A French translation of the 2018 edition was made by Stop-Tabac.ch.

In May 2019, the Royal College of British Midwives (RCM) published a position statement to support smoking cessation during pregnancy. “Vaping contains some toxins, but at levels well below those in tobacco smoke. If a pregnant woman who smokes chooses vaping and it helps her quit smoking and remain smoke-free, she should be supported in her approach. “Based on scientific studies, the RCM states that a “woman who has completely quit smoking, even if she continues to vape, should be considered a non-smoker.”

The 2020 issue of the Public Health England annual vaping report discusses how it can help pregnant women quit smoking. It notes based on available studies: “The most common reasons are to quit smoking or avoid relapse into smoking and to reduce harm to oneself, their newborn, and others. One study found that some participants who wanted to quit smoking during pregnancy and resumed smoking after childbirth had used vaping to prevent returning to smoking.”

The management of smoking cessation among pregnant women was recently the subject of an opinion from the French College of Gynecologists and Obstetricians (CNGOF) and the Francophone Society of Tobaccoology (SFT) in January 2020. Chapter 6 mixes vaping with tobacco products such as hookah and heated tobacco. Based on a “professional agreement” and without scientific reference, the opinion recommends that “the initiation or continuation of vaping products during pregnancy is not advised.”

Discouraging the use of vaping for pregnant women who want to quit smoking with this method and stopping those who quit smoking makes it a risk of smoking. However, in November 2019, the French Language Pneumology Society (SPLF) reminded that vaping is only prohibited for minors and is not recommended for non-smokers. It is difficult to know what the actual opinion of the SFT is between these two positions.

SOVAPE Trial Report

Given the known harms associated with smoking, the risk of relapse or failure to quit smoking in a pregnant woman by not recommending vaping as a means to quit smoking contradicts the precautionary principle. Given the serious identified risks, the absence of absolute scientific certainty should not serve as an excuse to compromise the maintenance of a dangerous situation.

Is vaping an effective way to quit smoking, even among pregnant women?

There has been no specific clinical study on smoking cessation among pregnant women using vaping. In particular, for ethical reasons, it is difficult for pregnant women to conduct double-blind studies with a control group. However, several clinical studies on smokers have shown that vaping can help quit smoking, which has been confirmed by observational population studies, including in France.

The follow-up of the Leicester Smoking Service shows that vaping with advice is an effective solution even for pregnant women.

Should pregnant women be advised to vape to quit smoking, and if so, under what conditions?

At the current level of knowledge, there is no reason to prevent a pregnant woman from vaping to avoid significant smoking risks for herself and her child. The urgent type of smoking cessation related to pregnancy requires the most effective assistance chosen by the concerned client — respect for the method used is essential.

Should pregnant women who vape be advised to quit smoking?

There is no reason to exert systematic pressure to quit vaping at the risk of relapse when smoking cessation has been achieved. Field surveys show that pregnant women and young mothers use vaping to maintain smoking cessation. A woman who has successfully quit cigarettes needs to be supported in this regard and is not guilty of devaluing them. Moreover, this approach, a ripple effect can encourage the partner to quit smoking, thus reducing passive, secondary, or tertiary smoking and the temptation to smoke among pregnant women.

Recommendations from NFTC and SFT for managing smoking during pregnancy – EXCERPT

In an “Expert Report and Recommendations” on managing smoking during pregnancy, the French National College of Gynecologists and Obstetricians (CNGOF) and the Francophone Society of Tobaccoology (SFT) Page 91 of Chapter VI. Other methods of use during pregnancy: e-cigarettes, heated tobacco, hookah, and snus:

“Exposure to nicotine continues to exist with e-cigarettes if it contains any. Although the fetus is not exposed to the toxicity of the fuel from “classic” cigarettes, further studies on the other components of e-cigarettes, such as flavors and propylene glycol and/or glycerol, are necessary to assess their balance between benefits and risks. Adhering to the precautionary principle in the current state of knowledge. It is recommended to treat the introduction or continuation of vaping products during pregnancy (professional agreement). For the use of vaping products, it is recommended to give the same instructions on adjustment as when smoking (professional agreement).

Expert Opinion

Dr. Marion ADLER

Physician and tobacco specialist at Antoine Béclère Hospital in Clamart (APF), responsible for a specific consultation on smoking cessation for pregnant women and their partners since 2001.

****-0How many pregnant women have come to my consultation recently after resuming tobacco, vaping has brilliantly helped them quit smoking? But their gynecologist advised them to stop during their pregnancy… The return to tobacco is then very rapid.

I do not think that gynecologists intentionally want these pregnant women to resume tobacco, but by giving advice to quit vaping, they are responsible for the reduction of tobacco with its toxicity for baby and mother being restored.

How can we take responsibility for telling patients that we must stop the “precautions” with vaping when we know that the risk is primarily the resumption of tobacco?

We know that tobacco, as a result of combustion, causes the inhalation of carbon monoxide (CO) by the mother, which is responsible for most obstetric pathologies, while vaping does not contain CO or any of the toxic substances in tobacco at all.

It should be remembered that we recommend vaping here to smokers to quit smoking and not for non-smokers.

For ten years, PHE (Public Health England) has been analyzing and critiquing studies on smoking cessation among all smokers worldwide. Their conclusion on vaping compared to tobacco is very clear: vaping is 95% less dangerous to health than tobacco.

How can patients be invited to use 95% less dangerous help than quitting tobacco, which, when restarting tobacco, clearly leads to increased toxicity for the mother and fetus? As a precautionary principle for health professionals at the expense of the health of the mother (and her baby)?

The same precautionary principle led to the inclusion of the pictogram “PREGNANCY = DANGER” on nicotine replacement boxes, while no study has shown the toxicity of nicotine during pregnancy. But this logo is still a little more than pregnant women quitting smoking… and dissolves the pregnancy experts.

What is vaping? It contains the same nicotine as nicotine substitutes, which helps smokers not suffer from deprivation when quitting smoking. It contains propylene glycol (PG), which is used in some medications that are not contraindicated during pregnancy and breastfeeding, and food flavors validated according to AFNOR standards, which are also included in the diet.

For this reason, pregnancy specialists in our English neighbors advise pregnant women to take nicotine substitutes to quit smoking before, during, and after pregnancy, and do not advise them to vape if it is the most effective way to help them quit smoking. Vaping is one of the most effective aids for pregnant women, and the percentage of smoking during pregnancy in England is less than 10%, where we are over 20%… So why not set an example for our friends throughout the chain?

In my practice, I advise patients who have quit smoking and continue to vape to avoid falling back into tobacco, to continue vaping, so as not to return to tobacco.

So, for all these pregnant women and their babies, be the one who gives the right advice and not vice versa: weigh the benefit-risk balance, ask these women, follow your patients transparently about their feelings; so that they know that tobacco is one of the worst risk factors for death, and that vaping is better than resuming smoking.

Expert Opinion

Dr. Rolf LÖWENSTEIN

Physician, addiction specialist, and president of SOS Addictions.

dear colleagues gynecologists and obstetricians,

You practice in our eyes as professionals and those of the French population one of the most beautiful medical and surgical specialties that exist. One of the most complex and delicate as well. Ensuring fertility, a good pregnancy, and the development of the fetus, a happy birth, the first days of life, and the future of the baby are both magnificent and dizzying missions. The woman and future mother you love, like her partner, count on you to have a happy pregnancy and give birth to the most beautiful and incredible little metaphysical mammals.

The task is not always easy if the pregnant woman faces her addictions (alcohol, tobacco, psychotropics, much less often cocaine or opioids). Pregnancy is a “royal” moment to help a woman rid herself of addictions. Their priority is the protection and proper development of their fetus. However, this may not be enough to resolve the addiction, a genuine functional brain disease. Gynecologists, obstetricians, and addiction specialists, unfortunately, do not work together enough. Not enough clinical exchange, not enough joint presence in consultation with the pregnant woman, not enough joint congresses or training: obstetricians are not familiar with addiction, and most addiction specialists do not know better about dependencies. Gynecological obstetrics!

The most painful example of this is certainly the spectrum of fetal alcohol disorders: too often, preventive advice is forgotten or rejected by doctors and most addiction specialists who do not engage sufficiently with gynecologists. We are in France, and it would be stupid to drink alcohol (!) for at least 9 months of the pregnancy project: “As soon as we stop the pill,” as Professor Bérénice Doray, vice-dean of the University of Reunion Island, repeats.

Another serious addiction with consequences you know for the mother and child: nicotine addiction; more precisely, addiction to smoked cigarettes and nicotine. Despite real progress made in information over the past two years and the advice offered, the majority of pregnant women continue to smoke. The work of Sovape, a remarkable association for its seriousness, your fieldwork, and its effective commitment to tobacco consumption summarize the risks incurred, but also the difficulties of research to reduce these risks. Today, we know that people smoke nicotine as needed and die from combustion (carcinogens and carbon monoxide). In an ideal world, smoking cessation and nicotine dependence prevail. But our brain adapts less easily than we do with our noble and academic goals, our ideal morality: between a small emergency aid and a major future risk we choose the immediate present.

Pregnant women, despite neurohormonal changes, do not miss this “desire.” Over the past ten years, a revolution has taken place regarding smoking and vaping. Its effectiveness in eliminating danger is undeniable: disappearance of toxic substances with the disappearance of combustion. But this revolution can happen without major change: the need to move from a strategy of nothing at all, from good to bad, from good mother to bad mother, the need to finally move to a new paradigm, that of risk reduction. This is sometimes difficult for us, great ideals that we are, sometimes far from the most elementary pragmatism. “Big Tobacco,” “Big Pharma,” the WHO under the “Bloombergian” impetus, but also the main historical associations fighting against smoking lead this tyranny of ideals to better protect their budgets and their pensions: beware of vaping, it is dangerous!

Until the CNGOF influences its members to accuse or even endanger pregnant women by asking them to quit smoking when they finally stop smoking? Nevertheless, there are international studies that help us not to commit this in case of professional misconduct.

Ignoring these studies in 2020 is just as implausible as saying there is no difference between smoked tobacco (combustion), heated tobacco, hookah, and… vaping.

The enemy of the pregnant woman burns for her fetus. Condemning women to interrupt the means of smoking, which allowed them to stop this intoxication, exposes them once again to the harm of smoked tobacco. In the name of the precautionary principle, it is important to stop smoking. You, dear colleagues of the CNGOF, do not like morality, which has become immoral to “the absolutists,” in our eyes, who are suspected of defending their interests or their ideals much more than the lives of the people they want to protect.

Let women vape without fear if they have managed to save themselves from the worst criminal of peace, the worst serial killer invented: smoked tobacco. The child will be eternally grateful to you for preventing his mother from dying from a heart attack, a stroke, one of the many burning cancers, or COPD 10 or 20 years after birth. And you will continue to do one of the most beautiful “jobs” in the world.

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Factors influencing the consumption and use of nicotine replacement therapy and e-cigarettes among smoking women: a qualitative synthesis of evidence; Cochrane Database of Systematic Reviews May 202

What is the medical opinion on electronic cigarettes?