1. Introduction
Early exposures of the foetus to a range of toxic substances can adversely influence the life trajectory. Tobacco smoking has well-known major adverse effects on the developing foetus and also the mother [
1]. For the foetus, these influences from tobacco may include growth restriction, pre-term birth, stillbirth, abnormal lung and neurological development, and birth defects. If a mother smokes during pregnancy, her child is more likely to experience respiratory illnesses, childhood cancer, learning and behavioural problems, and chronic diseases such as obesity, respiratory, cardiac, and diabetes [
1].
The prevalence of tobacco smoking among Australian pregnant women has been reducing in the general population, from 15% in 2009, to 12% in 2013 [
2]. Slower rates of decline are reported globally in women in high priority groups and those experiencing health disparities [
3]. In Australia, smoking prevalence remains higher among pregnant women from low socio-economic postcodes (20%), geographically remote locations (37%), youth (34%), and Aboriginal and Torres Strait Islander women (47%) [
2].
Over 75% of health professionals in Australia are reliably asking pregnant women about their tobacco or cigarette smoking, and recording their smoking status [
4,
5]. However, pregnant women may be exposed to other types of smoking (such as cannabis), tobacco in other forms (smokeless tobacco), and some newer exposures to nicotine have appeared (e-cigarettes). The practices of health professionals may need to accommodate the advent of emerging and under-recognised exposures during pregnancy, along with other traditional exposures. These exposures may be country-specific such as snus (mucosal absorption of tobacco) in Sweden, waterpipe smoking (hookah) in the Middle East, and chewing tobacco in India. Aboriginal and Torres Strait Islanders in some rural or remote communities may chew block tobacco or native tobacco (pituri). However, some of these practices have become popular with youth outside of these countries. These other exposures have also been associated with low birth weight [
6,
7,
8], and other adverse effects such as pre-term birth and stillbirth [
8].
E-cigarette use, so far, is reported infrequently during pregnancy [
9,
10]. There are no surveillance figures to indicate the prevalence of e-cigarette smoking in pregnant women. Of 316 pregnant women surveyed through a US university clinic, 43% perceived e-cigarettes to be less harmful to the foetus than smoking [
11]. This perception may induce pregnant women to use e-cigarettes more freely or to switch to vaping once becoming pregnant [
12]. However, the nicotine delivered through e-cigarettes may not be innocuous for foetal lung development in humans [
13,
14]. There is also the potential for toxic exposure through e-cigarette aerosols according to mouse models [
15]. This needs to be balanced with the likelihood that smoking e-cigarettes in pregnancy may be less dangerous for the mother [
16].
Smoking cannabis (commonly mixed with tobacco) is reported in 2–3% of Australian women in general when pregnant [
17,
18], and in 15–20.5% of Aboriginal and Torres Strait Islander counterparts [
19,
20]. Persistent use of cannabis in pregnancy can cause growth restriction [
17]. Babies born to mothers who are using cannabis, are more likely to need neonatal intensive care [
21].
Exposure to second-hand smoke (SHS), can have adverse effects on the growing foetus, and is associated with pregnancy complications [
22,
23]. The number of smokers in the household impacts a pregnant woman’s level of exposure to SHS [
24]. Partner smoking is a particular concern as the genetic effects from tobacco may pre-date conception [
25]. Exposure to SHS is reducing in most populations, however women may be at more risk within high prevalence populations.
In light of the potentially serious nature of these effects, it has been suggested that all types of smoking, nicotine and tobacco exposures are recorded and assessed [
26]. Several studies in Australia have focused on the overall practices of health professionals in asking and assessing pregnant women for tobacco smoking, and the type of care delivered to them [
27]. However no study, as far as we know, has focused on how often Australian clinicians ask or screen pregnant women about other types of smoking or nicotine-related exposures such as e-cigarettes, tobacco in other forms (potentially with cannabis or chewed), or exposure to SHS.
This study therefore had two aims: to survey Australian GPs and obstetricians about: (a) their practices of asking pregnant women about their use of e-cigarettes, forms of tobacco use other than regular cigarettes, cannabis use, and exposure to SHS, and (b) to compare differences in the responses of different clinicians’ groups. Practice location (rurality), and practice constituency (general population, or higher proportion of Aboriginal population) was hypothesised to have an impact on these clinician practices, because prevalence in rural and Aboriginal and Torres Strait Islander populations is usually higher that of the general or urban population.
4. Discussion
Australian General Practitioners and obstetricians reliably ask pregnant women about cigarette smoking, but less reliably ask about or screen for other exposures, such as cannabis smoking, e-cigarettes, chewing tobacco and second-hand smoke.
This was a cross-sectional national survey of 378 Australian GPs and obstetricians which analysed the reported frequency of enquiry about other types of smoking and exposures such as cannabis, nicotine through e-cigarettes, chewing tobacco, and second-hand smoke. Compared with the high percentages of these GPs and obstetricians (95%) asking pregnant women “Often-Always” about tobacco smoking, reported previously [
5], much fewer “Often-Always” asked about smoking other substances. Overall asking “Often-Always” progressively declined from cannabis (58%), cannabis with tobacco (38%), second-hand smoke (27%), e-cigarettes with nicotine (14%), e-cigarettes without nicotine (13%), and chewing tobacco (10%). The logistic regression showed variable associations with clinician type and the different exposures during pregnancy. Once controlling for other variables, the GPs responding to the online survey who belonged to the NFATSIH performed better than their GP and OBS colleagues from RANZCOG only in asking about cannabis.
4.1. Strengths and Weaknesses of the Study
This is the first study in Australia, as far as we know, to explore whether doctors ask about these other products that may be smoked or consumed. One strength of this study was that it was a national survey, with GPs and Obstetricians from all states and territories in Australia, covering urban, regional and remote areas. Data from RANZCOG indicates that 60% of their members are female, almost identical to our sample of RANZCOG respondents, and RACGP NFATSIH have a somewhat lower representation of female members at 53%, compared to 62% of our respondents.
The low response rates are a limitation, impacting on generalizability [
5]. However, surveys of medical practitioners may be less likely to be biased by low response rates. Participants are likely to represent those who might be more interested in this topic and be more likely to respond, thus the findings might represent higher estimates than what is practiced in general. The direction of bias is therefore likely to over-estimate prevalence. Thus, we feel that the prevalence of asking about these substances are conservative. The regressions are unlikely to be biased as the odd ratios are insensitive to prevalence. The inflated prevalence could reduce the power of the log regressions, so therefore any significant associations are less likely to be Type 1 errors.
The survey relied on self-report, so social desirability bias cannot be excluded. We did not ask about the use of hookah or other non-combustible forms of tobacco. We thus advise caution in interpretation on generalizability and representativeness due to these factors.
4.2. Strengths and Weaknesses in Relation to other Studies
There have been few similar studies. In a 2012 US study, 53% of 252 obstetricians and gynaecologists reported screening pregnant women at intake for noncombustible tobacco product use, “all or some of the time” [
29]. The survey asked these about products as one group and included: chewing tobacco, snuff/snus, e-cigarettes, and dissolvables, thus not differentiating between forms [
29]. In another study, only 14% of 776 US paediatricians and family medicine physicians reported screening adolescents for e-cigarette use, compared to 86% screening for tobacco use [
30].
4.3. Meaning of the Study
The RACGP has published comprehensive guidelines for smoking cessation, last updated in 2014 [
31]. They devote separate sections to smoking in pregnancy, Aboriginal and Torres Strait Islanders and culturally and linguistically diverse populations. RANZCOG published a “Women and Smoking” Statement as a literature review to provide advice to members about the management of smoking cessation in pregnancy, last updated in 2014 [
32]. Neither guideline covers how clinicians can ask about these other exposures, although the RACGP guidelines mentions the danger of SHS in pregnancy, and mentions chewing tobacco in reference to the Burmese community, but not Aboriginal or Torres Strait Islanders, nor reference to traditional, wild tobacco or
pituri use [
33]. E-cigarettes are mentioned by the RACGP as an unproven method for smoking cessation.
Currently in Australia, the sale and possession or use of electronic cigarettes containing nicotine is unlawful [
34]. Individuals can import nicotine liquid for personal use if a doctor writes a prescription. The Government, on 4 August 2016, called for public debate on exempting low dose nicotine liquid (3.6% or less) for e-cigarette use from their Schedule 7 regulation as a “dangerous poison” [
35]. In their interim report, the Therapeutic Goods Authority (TGA) declined to change the listing, and this position is currently being contested by Australian tobacco control experts and researchers [
36]. If nicotine liquid is approved in future by the TGA, this would allow wider availability for pregnant women.
4.4. Implications for Clinicians or Policymakers
Asking about and recording e-cigarette use, cannabis and SHS may enable monitoring of women and newborns for adverse effects, and be an entry point to advising women to reduce their exposures. After asking about tobacco, women could be asked: “What about any other types of smoking, use of e-cigarettes, cannabis or other ways of using tobacco? Do people smoke inside your home?” Changing provider practices to ask about these other exposures may take time. Inclusion of these other exposures in college and policy guidelines would be a first step, as would including these questions as part of routine antenatal care. Doctors may need training in how to ask about these other smoking, nicotine, vaping and tobacco exposures to ensure women are able to get assistance to reduce potential risks in pregnancy.
4.5. Unanswered Questions and Future Research
A more representative sample of clinicians, perhaps including other antenatal staff, would give a more accurate picture of frequency of screening for these products in pregnancy. If this could become a routine part of practice, then important exposures can be tracked and women offered timely advice and assistance to quit smoking, tobacco and nicotine use in all forms. Abstinence would be ideal, as exposure to these substances is not considered desirable during pregnancy for the health of mother and child.
Gillian S. Gould 1,*, 
, 
