Smoking when pregnant impacts on the health of mothers and unborn babies and also on children after birth and as they grow [1
]. In England, currently around 10.8% of women are smoking at the time they have their babies, but in some areas this is much higher (e.g., 26% in Blackpool) [5
]; rates are also much higher amongst younger and more deprived mothers [6
]. Women are particularly motivated to quit smoking during pregnancy. Around half of those who smoke report quitting with most doing so just before or on discovering they are pregnant [6
]; however, many find it difficult and try multiple times without success [8
], and rates of decline in smoking at time of delivery appear to have stalled more recently [5
]. Regrettably, most women who quit during pregnancy re-start smoking within 6 months of birth [10
]; this has negative impacts on their health and increases their children’s risk of being exposed to second-hand smoke. Additionally, smokers’ children are more likely to start smoking themselves [13
]. Pregnancy and the postpartum period, therefore, are crucially important times for helping women to quit as stopping for good improves both women’s and children’s health.
For non-pregnant smokers, e-cigarettes are now the most popular smoking cessation aid in England and are used in up to 40% of quit attempts [14
]. Outside of pregnancy, increasing e-cigarette use might explain decreasing rates of SSS uptake and use of other pharmacotherapies like nicotine replacement therapy (NRT); monitoring data in non-specialist SSS suggests that few clients are using e-cigarettes [15
] and as e-cigarettes mimic sensory aspects of smoking this may make them more appealing. There is some evidence that e-cigarettes work for smoking cessation [16
] and in 2014, 16,000–22,000 smokers who would not otherwise have quit are estimated to have quit long-term after using e-cigarettes [17
]. It is also possible that e-cigarettes could work for smoking cessation in pregnancy, and some pregnant women may already be using e-cigarettes for this, or to avoid postpartum smoking relapse [18
]. Recently, authoritative UK groups, including Public Health England (PHE), the Royal College of Physicians, the Smoking in Pregnancy Challenge Group, and the National Centre for Smoking Cessation and Training (NCSCT) who provide training for all SSS staff, have stated that they believe benefits from e-cigarettes are likely to be far greater than harms, including in pregnancy [19
]. However, safety concerns held by many women and health professionals may deter e-cigarette use and currently the prevalence of e-cigarette use in pregnancy and in the postpartum period is not known.
The World Health Organization recommends that all pregnant smokers should be routinely offered advice and psychosocial interventions for tobacco cessation [24
]. In the UK, National Health Service (NHS) Stop Smoking Services (SSS) support smokers to quit, and the UK National Institute for Health and Clinical Excellence (NICE) guidance recommends that pregnant women who smoke are referred for such support [25
]. Guidance is less specific, however, about how abstinent smokers should be supported after childbirth to avoid returning to smoking; only that relapse prevention should be offered [26
], and that women require support “throughout pregnancy and beyond” whilst acknowledging that no interventions are of proven efficacy [25
]. It is not clear how SSS have responded to this rather non-specific guidance on preventing return to smoking.
E-cigarette use in pregnancy could affect pregnant smokers’ use of NRT and perhaps of other interventions that SSS provide; NRT is offered to most pregnant women who attend SSS, but women already using e-cigarettes may be less likely to accept this. In addition, the recently published statements and guidance on e-cigarette use in pregnancy may be starting to influence SSS stance [19
]. Consequently, this mixed method study using a survey of SSS managers followed by qualitative interviews, attempts to identify whether and if so, how, SSS have needed to adapt or respond to e-cigarette use amongst pregnant women. Specifically, we sought English SSS managers’ views on e-cigarette use amongst pregnant women who seek SSS support, the cessation interventions SSS currently offer, how SSS attempt to prevent women returning to smoking postpartum and their views on using e-cigarettes in this context.
Overall there was no evidence that Stop Smoking Services had noticeably altered the support they provided to pregnant women following the emergence of e-cigarettes; the survey found that SSS rarely encountered pregnant women who used e-cigarettes, and the kinds of support they offered most frequently had not changed substantially since 2010–2011 [33
]. Most SSS supported pregnant women who vaped, but there was much uncertainty about whether e-cigarettes should be used in pregnancy at all and few SSS actively recommended their use. SSS managers were much more positive about the potential use of e-cigarettes in pregnancy when they were interviewed, which was after Public Health England and others released guidance on e-cigarettes [19
]. Nevertheless, managers still wanted more pregnancy-specific evidence on the safety of e-cigarettes during pregnancy, for e-cigarettes licensed as medications to be available, and for clear and consistent messages on e-cigarettes to be given to pregnant women whenever they received healthcare.
The study had a number of strengths, as well as some limitations. We identified a SSS and/or SSS manager for most areas of England, although there may have been SSS in other areas, so findings may not be representative of all services. However, by identifying services via commissioners, we took care to ensure that surveys were completed by those most knowledgeable about the local provision, and received responses from almost 70% of the services we contacted. Data were self-reported, and due to re-organisation, were occasionally for part years or estimated, but we believe that SSS managers would have taken care to provide the best information possible. As with all surveys, some questions may have been misinterpreted, but we piloted the survey with two SSS managers before distributing to the remainder, and this did not indicate any issues. We also provided additional information for questions where appropriate; for example, a screenshot of their database field for “unlicensed nicotine products”, and a definition of single and dual therapy NRT.
A particular strength of this study is that, to our knowledge, no others have investigated how specialist smoking cessation services have attempted to address e-cigarette use in pregnancy and postpartum. It was further strengthened by conducting follow up interviews with some services to gain more insight to their responses.
It is notable that in 2014–2015, SSS were encountering few pregnant women who reported using e-cigarettes, in spite of them being the most popular aid for smoking cessation amongst non-pregnant smokers during this period [14
]. There could be various explanations for this, for example, pregnant women using e-cigarettes may have already quit, or perhaps they don’t seek help and instead try to quit without support from SSS. Alternatively, they may be less likely to use e-cigarettes perhaps due to safety concerns [18
], or women may not admit to using them during pregnancy perhaps because of stigma [18
]. Interestingly, a study of general (rather than specialist) English SSS reported comparable e-cigarette figures to those from our survey for all clients attending SSS during the same period, and were similarly reluctant to advise e-cigarette use [15
Our survey found a lot of uncertainty amongst SSS managers about whether to advise pregnant women to use e-cigarettes, and how to help women postpartum to prevent return to smoking. This is noteworthy as SSS managers are likely be amongst the best informed about the latest recommendations for smoking cessation; although we didn’t ask about training or education in the survey, NICE, PHE and the Department of Health all recommend that anyone who helps people to quit should be NCSCT certified, and NCSCT provide general and pregnancy specific smoking cessation training free of charge. Commissioners of SSS insist that all advisors undertake this training. NCSCT also recommend that managers and commissioners complete the training. Irrespective of clinical scenario, few SSS were likely to advise e-cigarette use, but some of these survey responses are difficult to interpret. For example, where a SSS indicated they were unlikely to advise women to continue using e-cigarettes, we don’t know if they actively discouraged their use or if they did not address the issue at all (e.g., said nothing); however, our subsequent interviews indicate that overall this was more likely to be the latter. Most SSS did not have a formal policy regarding use in pregnancy; this, and their uncertainty about how they advise on e-cigarettes, is perhaps unsurprising, as there is currently no NICE guidance for e-cigarettes in pregnancy, and no specific NICE recommendations for postpartum relapse prevention other than providing ‘ongoing support’ and warning against second-hand smoke exposure [10
]. Although UK guidance or statements from the Smoking in Pregnancy Challenge Group, PHE, the Royal College of Physicians, and the NCSCT, endorse vaping amongst pregnant women who are unable or unwilling to quit smoking using traditional methods, most had only recently been published or have been published since this study [19
In the U.S., surveys of health professionals caring for pregnant women have indicated that many appear to have concerns about the use of e-cigarettes; obstetricians and gynecologists were uncertain about how to advise on e-cigarettes due to lack of guidance [35
], and of US family physicians who provided obstetric care, most respondents thought that e-cigarettes are unsafe to use during pregnancy [36
]. Many US quitline professionals also have negative beliefs about e-cigarettes outside of pregnancy [37
]. Our interviewees did not appear to have the same level of apprehension as those seen in the US studies; many told us that their SSS were starting to adopt a more positive attitude towards e-cigarettes in pregnancy, and that recent guidance had influenced them. However, several felt that some SSS commissioners had not yet taken this on board, and this was one of the main reasons for not recommending e-cigarettes, although many interviewees also said that they would like more specific evidence in pregnancy.
Some of our findings are similar to those seen outside of pregnancy; a survey of SSS practitioners wanted more evidence and licensed products before recommending them [15
]. Interviews with generic SSS staff also show that they have faced challenges similar to the ones we identified for pregnancy specific services to becoming more e-cigarette friendly, including the role of local public health commissioners [38
]. However, as more guidance has become available, commissioner attitudes may have started to change, at least for general smokers. A recent survey of tobacco control leads found that 75% of respondents said their SSS now supported smokers who want to use e-cigarettes to aid their quit attempt, and none reported discouraging e-cigarette use although questions were framed differently to our survey and were aimed at general SSS rather than pregnancy specific SSS [39
Since 2010–2011 there has been a steady decline in the number of pregnant women setting quit dates with SSS, mirroring the data seen for all smokers [40
], and it has been suggested that e-cigarettes are a key reason for decline in general SSS attendance [15
]. However, in spite of this, overall rates of smoking at time of delivery continues to fall in England; 13.7% of women reported smoking at delivery in 2010–2011, whereas this was 10.8% in 2017–2018, but whether any of this fall is due to women quitting using e-cigarettes is unknown [5
]. Our survey gives a snapshot for one year at a time of great change amongst SSS; cuts to smoking cessation budgets had been reported in 39% of local authorities, with over half of services having some form of recommissioning or reconfiguration [41
]. Therefore, it is interesting that in spite of these changes in organisation, and the widespread availability of e-cigarettes, the type of support offered had changed little since 2010/2011 [33
]. As many SSS face further cuts this may not continue; in 2017, 74% of local authorities reported still having some form of specialist SSS (e.g., for pregnant smokers) [39
It is possible that women may find e-cigarettes more satisfying than NRT and so be more likely to use them, but there may also be ways to encourage women to use NRT more effectively. For example, as safety of both is likely to be a concern to pregnant women in particular [43
], informing them of the relative harms of both NRT and e-cigarettes compared with cigarettes needs to be more widely disseminated, particularly by health professionals. From the data provided, it appears that SSS have few concerns about supplying dual NRT despite little evidence on safety or effectiveness, and yet they had a much more cautious approach to e-cigarettes. Currently only one-third of smokers who do not use e-cigarettes believe they are less harmful than cigarettes [14
], and so pregnant women may be discouraged from using them due to perceived safety issues. Surveys and qualitative research on e-cigarettes amongst pregnant women indicate that they generally perceive e-cigarettes to be safer than smoking, but they have uncertainty about absolute safety [18
] and some women reported getting mixed messages from health professionals [34
]. Although many had tried e-cigarettes, few women reported using them during pregnancy [47
Now that guidance, particularly in the UK, is more positive about use of e-cigarettes for smoking cessation, including in pregnancy, some SSS are starting to feel more confident in providing advice on their use, but there are still inconsistencies and many still express uncertainties. As there is still a lack of specific evidence in this area, more research, particularly on safety (including harms relative to smoking and to NRT treatment) and effectiveness in pregnancy is needed; at least one randomized controlled trial is currently underway [52
]. Findings from this research and other studies in pregnancy and postpartum will assist SSS and other health professionals to tailor their advice.