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    E-cigarettes and the ob/gyn: Key safety information for prenatal counseling

     

    How do these products compare with nicotine replacement medications (eg, patch, gum, inhaler, lozenge) for prenatal smoking cessation?

    Neither the American College of Obstetricians and Gynecologists (ACOG)9 nor the US Public Health Service Clinical Practice Guidelines (2008)7 promotes the use of nicotine replacement therapy (NRT) as a first-line treatment for smoking cessation during pregnancy. Most NRT products have an FDA pregnancy category D status (proven and known risk to the developing fetus). The few prenatal NRT clinical trials conducted have not demonstrated effectiveness for cessation. However, when counseling methods for smoking cessation have been unsuccessful, NRT is prescribed or recommended by many obstetric providers.7,9 NRT provides a measured amount of nicotine to the user and does not contain carbon monoxide and other toxic chemicals commonly found in the combustible tobacco products. Unlike NRT, e-cigarettes use a nicotine solution, flavoring, and propellants. Although the flavorings and propellants (typically propylene glycol and glycerin) have been approved as food additives for ingestion, they have not been cleared for repeated inhalation. In fact, aerosolized propylene glycol is a lung irritant.10

    It should be emphasized to patients that the use of any nicotine-containing products during pregnancy is potentially harmful for a developing fetus (Table 2). Abstinence from nicotine use is the safest action. If a patient does not choose abstinence, the next-safest choice is the use of a measured amount of nicotine without additional chemicals. That can be achieved with the NRT options.

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    The unknown and inconsistent content—and the difficulty in measuring the actual dosage of nicotine as women use these novel non-combusted nicotine delivery methods—is of concern to tobacco control experts. Moreover, it is unclear whether these products are safer than cigarette use during pregnancy. There is simply no evidence to support any level of safety. The avoidance of carbon monoxide may make e-cigarettes less dangerous but that does not mean that they are “safe.”

    If nicotine supplementation or replacement is determined to be indicated, the “safest” method at this time is the use of an FDA-controlled NRT that has been formally studied.9 As a bonus, many insurance plans cover the cost of NRT use during pregnancy.   

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    References

    1. Centers for Disease Control and Prevention. Trends in smoking before, during and after pregnancy – Pregnancy risk assessment monitoring system, United States, 40 Sites, 2000–2010. MMWR. 2013;62(6):1–19.

    2. Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2006. Natl Vital Stat Rep. 2009;57(7):1–104.

    3. Pearson JL, Richardson A, Niaura RS, Vallone DM, Abrams DB. E-Cigarette awareness, use and harm perceptions in US adults. American Journal of Public Health. 2012;102(9):1758–1766.

    4. Centers for Disease Control and Prevention. Calls to poison centers for exposures to electronic cigarettes — U.S. Sept. 2010–Feb 2014. MMWR. 2014:63(13);292–293.

    5. Cobb CO, Sahmarani K, Eissenberg T, Shihadeh A. Acute toxicant exposure and cardiac autonomic dysfunction from smoking a single narghile waterpipe with tobacco and with a “healthy” tobacco-free alternative. Toxicology Letters. 2012;215:70–75.

    6. Centers for Disease Control and Prevention. Notes from the field: Electronic cigarette use among middle and high school students — US 2011–2012. MMWR. 2013:62(35);729–730.

    7. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recomm...

    8. Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med. 2014;370:293–295.

    9. Smoking cessation during pregnancy. Committee Opinion No. 471. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2010;116:1241–1244.

    10. Reprotox Data Base. Propylene glycol Agent 1663 www.reprotox.org/Members/Printagentdetails.aspx?a=1663. Accessed Jan 2, 2014.

    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
    Jeanne Mahoney, RN, BSN
    Ms. Mahoney is Director, the Providers Partnership Project, American College of Obstetricians and Gynecologists, Washington, DC.

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