ORIGINAL RESEARCH

Knowledge, Attitudes, and Practice of Electronic Cigarette

Use Among Pregnant Women
Katrina S. Mark, MD, Brooke Farquhar, Margaret S. Chisolm, MD, Victoria H. Coleman-Cowger, PhD,
and Mishka Terplan, MD, MPH

Objective: Electronic cigarettes (e-cigarettes) are a relatively recent

phenomenon, serving dual roles as an alternative vehicle for nicotine
T he harms of cigarette smoking in pregnancy are well
known. Higher rates of low birth weight babies, preterm
birth, stillbirth, and sudden infant death syndrome are a
delivery and a smoking-cessation tool. The purpose of this study was few of the many adverse outcomes associated with smoking
to determine pregnant women’s knowledge, attitudes, and practice (Dietz et al., 2010). Because of these known risks, the Ameri-
regarding electronic cigarettes. can Congress of Obstetricians and Gynecologists recommends
Study Design: A voluntary, anonymous survey was distributed to a that all obstetric care providers screen for tobacco use in
convenience sample of pregnant women presenting to a university- pregnancy and provide counseling regarding smoking cessa-
based outpatient clinic. After survey completion, participants re- tion (American Congress of Obstetricians and Gynecologists,
ceived information about smoking cessation and e-cigarettes. Data 2010, 2011).
were examined using χ 2 and Fisher exact tests and analysis of vari- As much of the harm of cigarette smoking is believed
ance. Stata was used for the analysis. to be from the combustion of tobacco products and the subse-
Results: Of the 326 surveys distributed, 316 were completed (97%). quent inhalation of substances such as carbon monoxide, a new
Of the 316 participants, 42 (13%) reported having ever used form of nicotine delivery system has been created called the
e-cigarettes. Only 2 (0.6%) reported current daily use. Ever users electronic cigarette (e-cigarette) (Breland et al., 2014; Hutzler
were slightly older (27.3 years vs 25.4 years; P = 0.007) and more et al., 2014). These products allow the user to inhale vapors typ-
likely to be current smokers (43% vs. 14%; P < 0.001) compared ically containing nicotine and avoid the harmful by-products
with women who had never used electronic cigarettes. Knowledge
of combustion found in traditional cigarettes (Breland et al.,
2014; Hajek et al., 2014). E-cigarettes are marketed as safer al-
of the harms of smoking was similar between the 2 groups. Overall,
ternatives to smoking (Breland et al., 2014). Although the Food
57% of all respondents believed that e-cigarettes contain nicotine,
and Drug Administration has not approved them as tools for
61% that e-cigarettes can be addictive, and 43% that e-cigarettes are
smoking cessation, studies have shown that many consumers
less harmful to a fetus than traditional cigarettes. Among ever users, use them for this purpose (Etter & Bullen, 2011; Breland
the most common reasons given for the use of e-cigarettes were the et al., 2014).
perception of less harm than traditional cigarettes (74%) and help In pregnancy, products of combustion are not the only
with smoking cessation (72%). danger of smoking. Some studies on smokeless tobacco have
Conclusions: Misconceptions about e-cigarettes are common among shown increased rates of preterm birth, low birth weight (Gupta
pregnant women, potentially motivating use that may pose risks to & Subramoney, 2004), and stillbirth (Gupta & Subramoney,
both maternal and child health. Screening and education regarding 2006; Wikstrom et al., 2010), suggesting that nicotine itself
e-cigarettes should be included in prenatal care. Future research in this may be playing a role in adverse pregnancy outcomes. Al-
area is necessary, including research examining pregnancy outcomes though nicotine replacement is often recommended in general
among women who use e-cigarettes. populations of smokers to assist with cessation, the U.S. Pre-
ventive Services Task Force has concluded that there is insuf-
Key Words: electronic cigarettes, e-cigarettes, pregnancy
ficient evidence to determine the safety of alternative nico-
(J Addict Med 2015;9: 266–272) tine delivery products in pregnancy (U.S. Preventive Services
From the University of Maryland (KSM, BF, MT), Johns Hopkins University Task Force, 2009). Even manufacturers and proponents of
School of Medicine (MSC), Battelle Public Health Center for Tobacco e-cigarettes caution that there is no evidence for the safety
Research (VHC-C), and Behavioral Health System Baltimore (MT), Bal- of their use in pregnancy (Blu Cigs, 2014; Hajek et al., 2014;
timore, MD.
Received for publication October 2, 2014; accepted February 28, 2015.
V2cigs, 2014).
The authors declare no conflicts of interest. Studies indicate that there has been a steady increase
Send correspondence and reprint requests to Katrina S. Mark, MD, Instruc- in use of e-cigarettes in the general population (Centers for
tor of Obstetrics, Gynecology and Reproductive Sciences, University of Disease Control and Prevention, 2013; Choi & Forster, 2013;
Maryland School of Medicine, 11 S Paca St, Ste 400, Baltimore, MD Breland et al., 2014; Chapman & Wu, 2014; Pepper & Brewer,
21201. E-mail: kmark@fpi.umaryland.edu.
Copyright C 2015 American Society of Addiction Medicine
2014). In a systematic review of patterns of e-cigarette use,
ISSN: 1932-0620/15/0904-0266 ever use rate was found to have increased from 1% to 6%
DOI: 10.1097/ADM.0000000000000128 between 2009 and 2011. Ten percent of high school students

266 J Addict Med r Volume 9, Number 4, July/August 2015

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J Addict Med r Volume 9, Number 4, July/August 2015 E-Cigarettes in Pregnancy

report having used an e-cigarette at least once, which was the agree.” Knowledge items related to traditional cigarettes were
highest rate among any age group (Chapman & Wu, 2014). In adapted from several sources, including smoking knowledge,
addition, although e-cigarettes are often promoted as a harm attitudes, and practices surveys (Delucchi et al., 2009). Items
reduction tool, between 9% and 12% of e-cigarette users have regarding e-cigarette use were adapted from the International
never smoked a traditional cigarette (Etter & Bullen, 2011; Tobacco Control Wave 8 survey (Adkinson et al., 2013; Inter-
Suftin et al., 2013; Breland et al., 2014). These and other national Tobacco Control Project, 2014). The third category
surveys suggest that people who believe e-cigarettes are safer included items regarding motivations for use. These items were
than traditional cigarettes are more likely to use them (Choi & presented in a multiple-choice format with the option of choos-
Forster, 2013; Breland et al., 2014). ing more than one answer. All respondents, including those
This study aims to identify the prevalence of e-cigarette who reported never using e-cigarettes, were asked to answer
use among pregnant women and to assess pregnant women’s questions regarding perceptions of e-cigarettes, presented in
knowledge about e-cigarettes and motivations for use. The au- yes/no and true/false formats.
thors hypothesized that e-cigarette users would be more likely
to perceive e-cigarettes as safe during pregnancy compared Data Preparation/Analysis
with nonusers of e-cigarettes. Data were entered into Microsoft Excel and analyzed
with Stata v.11 (College Station, TX). Participants who re-
METHODS ported any history of use of e-cigarettes were categorized as
e-cigarette users and contrasted with non–e-cigarette users.
Participants Hypothesis testing was performed using χ 2 testing or analysis
This study was conducted at the University of Maryland of variance analysis, except in comparisons with small cell
Women’s Health Center, which is a university-based prenatal counts. In these limited cases, Fisher exact testing was done.
care clinic where 93% of patients are publicly insured. The
study was approved by the University of Maryland Institu- RESULTS
tional Review Board. Inclusion criteria were English-speaking A total of 326 women were approached for enrollment
women presenting for prenatal care between June 2, 2014, and 316 women completed the survey, yielding a response
and July 21, 2014. Potential participants were identified by rate of 97%. All surveys that were returned were included.
clinic staff and approached by a member of the research team The median number of questions answered was 73%. Missing
to enroll in the study. An anonymous survey with questions variables were accounted for by being removed from the anal-
regarding demographic information, smoking history, knowl- ysis. Of those women who participated in the survey, 66.1%
edge of harms of cigarettes and e-cigarettes, and attitudes to- (209 of the 316) reported having ever heard of e-cigarettes,
ward electronic cigarettes was distributed to all women who 13% (42 of the 316) reported having any prior or current use
met inclusion criteria. As all eligible women presenting for of e-cigarettes (ever users), with 0.6% (2 of the 316) reporting
prenatal care during a given period were offered enrollment, current daily use. In comparing the e-cigarette ever user and
this was a sample of convenience. A cover letter was provided never user groups, those who reported ever using e-cigarettes
explaining that the study was anonymous and voluntary. No in- were slightly older (27.3 years vs 25.4 years; P = 0.007) and
centive was offered for participation in the study. Participants more likely to self-identify as white (33% vs 9%; P < 0.001).
returned their completed surveys to a member of the research There was no difference between the 2 groups in education
team in a sealed envelope. Once surveys were returned, the level, employment status, whether or not they lived with a
participants were given an information sheet explaining that smoker, age of first smoked a traditional cigarette, and gesta-
the safety of e-cigarette use in pregnancy has not yet been es- tional age at the time of survey administration (Table 1).
tablished and encouraging them to speak with their health care There was no difference in the knowledge of the harms of
provider about smoking cessation if applicable. cigarette use during pregnancy between the 2 groups (Table 2).
Almost all women in both groups answered “agree” or
Measures “strongly agree” with the statements “the hazards of smoking
Survey items were presented in 3 categories. The first have been clearly demonstrated” (90% vs 79%; P = 0.191),
category included demographic items such as age, gestational “when a pregnant woman smokes it harms her fetus” (93% vs
age, and race. These items were presented in multiple-choice 86%; P = 0.725), and “when a mother smokes, it is unhealthy
and fill-in-the-blank formats. Women were determined to be for her infant” (93% vs 89%; P = 0.976). Overall, 45% of
current smokers of traditional cigarettes if they had smoked respondents reported believing that e-cigarettes are less harm-
within the past 30 days. Women who smoked traditional ful to themselves than traditional cigarettes and 43% of them
cigarettes were asked if they had ever tried to quit, how many believed that they are less harmful to a baby. Ever users were
times they had previously tried to quit, and to rank how se- more likely than never users to believe that e-cigarettes are less
rious they currently were about quitting on a 10-point Likert harmful than traditional cigarettes to both themselves (78% v
scale. The second category included items related to traditional 31%, P < 0.001) and their babies (68% vs 31%; P < 0.001).
tobacco cigarette knowledge and use. These items were pre- Ever users were also more likely to believe that e-cigarettes
sented as a series of statements regarding the harms of smoking were cheaper than traditional cigarettes (61% vs 18%; P <
tobacco cigarettes. The respondent was asked to rate her level 0.001) (Table 3). There was no difference between ever users
of agreement with these statements on a 5-point Likert scale, and never users in the belief that they are fashionable. Overall
with responses ranging from “strongly disagree” to “strongly percentage of respondents who believed e-cigarettes contained


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Mark et al. J Addict Med r Volume 9, Number 4, July/August 2015

TABLE 1. Characteristics of the Study Population Stratified by Ever Use of E-Cigarettes

E-Cigarette E-Cigarette
Overall Ever Users Never Users P
Mean age (SD), yrs 25.6 (5.5) 27.3 (6.2) 25.4 (6.2) 0.007
Mean gestational age (SD), wks 28.3 (8.3) 28.5 (7.9) 26.7 (8.4) 0.656
Educational level, n (%) 0.150
HS graduate 248 (79) 12 (29) 53 (19)
Not HS graduate 65 (21) 29 (71) 219 (81)
Hispanic, n (%) 0.622*
Yes 10 (3) 2 (5) 8 (3)
No 287 (97) 36 (95) 251 (97)
Race, n (%) <0.001*
African American 259 (82) 25 (60) 234 (85)
White 38 (12) 14 (33) 24 (9)
Other 19 (6) 3 (7) 16 (6)
Employment, n (%) 0.291
Employed 105 (42) 13 (34) 92 (43)
Unemployed 145 (58) 25 (66) 120 (57)
Ever smoked, n (%) <0.001*
Yes 135 (43) 41 (98) 94 (35)
No 179 (57) 1 (2) 178 (65)
Mean age when first smoked (SD), yrs 16.0 (3.6) 15.7 (3.7) 16.1 (3.6) 0.756
Household smokers, n (%) 0.189
Yes 118 (44) 21 (54) 97 (43)
No 149 (56) 18 (46) 131 (57)
Current smoker, n (%) <0.001
Yes 48 (15) 17 (43) 31 (14)
No 208 (66) 23 (58) 185 (86)
Tried to quit†, n (%) 0.539*
Yes 101 (89) 35 (92) 66 (87)
No 13 (11) 3 (8) 10 (13)
Mean number of quit attempts (SD)† 1.2 (3.0) 2.8 (3.2) 0.9 (2.9) 0.782
Nicotine replacement therapy†, n (%) 0.092*
Yes 24 (18) 11 (26) 13 (14)
No 112 (82) 31 (73) 81 (86)
Mean seriousness of trying to quit (SD)† 6.0 (4.4) 7.7 (3.4) 5.4 (4.6) 0.004
*Fisher exact test used for the analysis.
†Respondents who had never smoked cigarettes were excluded from the analysis.
HS, high school; SD, standard deviation.

TABLE 2. Perceived Risks of Smoking Traditional Cigarettes: Mean (SD) Likert Scores*
E-Cigarette E-Cigarette
Overall Ever Users Never Users P
“The hazards of smoking have been clearly demonstrated” 4.1 (1.1) 4.5 (0.9) 4.1 (1.1) 0.191†
“The hazards of second-hand smoking have been clearly 4.1 (1.2) 4.3 (1.0) 4.1 (1.2) 0.839†
demonstrated”
“If a person smokes a pack of cigarettes a day for more than 2.9 (1.4) 2.7 (1.5) 2.9 (1.4) 0.478†
20 years, there is little health benefit to quitting smoking”
“When a pregnant woman smokes, it harms her fetus” 4.4 (1.1) 4.6 (0.8) 4.3 (1.1) 0.725†
“If a mother smokes, it is unhealthy for her infant” 4.4 (1.1) 4.5 (0.9) 4.4 (1.1) 0.976†
*Based on a 5-point Likert scale.
†Fisher exact test used for the analysis.

nicotine was not significantly different between the 2 groups attempted to quit smoking (92% vs 87%; P = 0.539) or in the
(63% vs 55%; P = 0.381). There was no difference between the number of prior quit attempts (mean, 2.8 vs 2.6; P = 0.782).
ever user and never user groups in knowledge that e-cigarettes Almost twice as many e-cigarette users had previously tried
can be addictive (62% vs 60%; P = 0.836) and belief that pharmacologic agents to assist with smoking cessation (26%
e-cigarettes contain tobacco (29% vs 31%; P = 0.800). vs 14%; P = 0.092), although these numbers did not meet
Regarding smoking habits, e-cigarette ever users were statistical significance. Those who had ever used e-cigarettes
more likely to be current traditional cigarette smokers (43% vs did rate their seriousness about quitting smoking higher (7.7
14%; P < 0.001) (Table 1). Only one ever user of e-cigarettes vs 5.4; P = 0.004) compared with the never users.
had never used traditional cigarettes. Among those who had The most common reason endorsed for using
smoked traditional cigarettes, there was no difference between e-cigarettes was that they are less harmful to the users’ health
e-cigarette ever users and never users in having previously than traditional cigarettes (74%) and assistance with smoking

268 
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J Addict Med r Volume 9, Number 4, July/August 2015 E-Cigarettes in Pregnancy

TABLE 3. Knowledge of E-Cigarettes

E-Cigarette E-Cigarette
Overall, n (%) Ever Users, n (%) Never Users, n (%) P
E-cigarettes are less harmful to a baby <0.001
Yes 52 (43) 26 (68) 26 (31)
No 69 (57) 12 (32) 57 (69)
E-cigarettes are less harmful to me <0.001
Yes 54 (45) 28 (78) 26 (31)
No 65 (55) 8 (22) 57 (69)
E-cigarettes are cheaper <0.001
Yes 36 (31) 22 (61) 14 (18)
No 80 (69) 14 (39) 66 (83)
E-cigarettes are fashionable 0.088
Yes 21 (18) 10 (27) 11 (14)
No 95 (82) 27 (73) 68 (86)
E-cigarettes contain nicotine 0.381
Yes 117 (57) 24 (63) 93 (55)
No 89 (43) 14 (37) 75 (45)
E-cigarettes can be addictive 0.836
Yes 131 (61) 23 (62) 108 (60)
No 85 (39) 14 (38) 71 (40)
E-cigarettes contain tobacco 0.800
Yes 65 (31) 11 (29) 54 (31)
No 147 (69) 27 (71) 120 (69)

TABLE 4. Perceived Benefits of E-Cigarettes awareness and use of e-cigarettes has been steadily increasing
(Centers for Disease Control and Prevention, 2013; Pepper
E-Cigarette Ever & Brewer, 2014), perhaps because of increased marketing of
Users, n (%) these products. In addition, the greater rates of use in this
E-cigarettes are not as bad for my health
sample of pregnant women may reflect the high motivation to
Yes 28 (74) minimize adverse pregnancy outcomes.
No 10 (26) The current study found that those women who used
E-cigarettes taste better e-cigarettes were slightly older and more likely to be white
Yes 21 (54) compared with women who had not used e-cigarettes. Previ-
No 18 (46)
E-cigarettes make it easier to cut down on the number ous studies in the general population have reported higher
of cigarettes that I smoke awareness of e-cigarettes in non-Hispanic whites (Pearson
Yes 28 (72) et al., 2012; King et al., 2013; Pepper & Brewer, 2014; Pep-
No 11 (28) per et al., 2014). There are 2 explanations for why this may
E-cigarettes can be smoked in places where cigarettes are banned
Yes 21 (55)
be the case. First, whites are more likely to smoke traditional
No 17 (45) cigarettes and e-cigarette users tend to have similar charac-
E-cigarettes may help me quit smoking teristics to other smokers (Centers for Disease Control and
Yes 27 (73) Prevention, 2011). Second, this may reflect targeted marketing
No 10 (27) to particular populations (Pepper et al., 2014).
Knowledge regarding the hazards of smoking traditional
cigarettes was similar between those who had ever used and
cessation (73%) (Table 4). Many ever users also felt that those who had never used e-cigarettes. Both groups were aware
e-cigarettes taste better than traditional cigarettes (54%). Over of the harms of smoking traditional cigarettes in general, and
half of the ever users (55%) agreed that the ability to use the fact that smoking poses a risk to both a fetus during preg-
e-cigarettes in some places where traditional cigarettes are nancy and an infant after birth. Overall, 45% of women be-
banned contributed to their motivations for use. lieved that e-cigarettes were less harmful to themselves and
43% believed them to be less harmful to their babies than
COMMENT traditional cigarettes. These findings are similar to previous
This study found that a large majority of pregnant women surveys that have found between 53% and 84% of respondents
had heard of e-cigarettes, 13% had ever used them, and 0.6% believe e-cigarettes to be less harmful, depending on the pop-
were current daily users. To our knowledge, this is the first ever ulation studied (Etter & Bullen, 2011; Choi & Forster, 2013).
report of the rates of use among a sample of pregnant women. Interestingly, ever users were more likely than never users
These rates are higher than those reported in the literature to believe that e-cigarettes are less harmful to themselves and
for the general population (Centers for Disease Control and their pregnancy, which is also consistent with previous findings
Prevention, 2013; Suftin et al., 2013; Breland et al., 2014; that those individuals who believe e-cigarettes to be less harm-
Chapman & Wu, 2014), which is consistent with findings that ful are more likely to use them (Choi & Forster, 2013). These


C 2015 American Society of Addiction Medicine 269

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Mark et al. J Addict Med r Volume 9, Number 4, July/August 2015

misconceptions about safety may be perpetuated by providers. quitting. Eighty-nine percent of women in the current study
A recent survey of practicing obstetricians found that 40% of who smoked traditional cigarettes had attempted to quit at least
obstetric providers do not screen their patients for e-cigarette once previously, with an average of 2.7 quit attempts. Almost
use and 13.5% of obstetricians believe that there are no twice as many e-cigarette ever users had previously used other
adverse health risks to e-cigarette use in pregnancy (England pharmacologic agents to aide with smoking cessation (26%
et al., 2014). vs 14%; P = 0.09). Although these numbers did not meet
Despite being promoted as safer, e-cigarettes are not statistical significance, it is likely that this is due to small
federally regulated and the contents of them are not only sample size and this represents a true difference. Three quarters
highly variable, but also often not well disclosed (Duffy & of the respondents viewed e-cigarettes as a tool for cessation.
Jenssen, 2014; Franck et al., 2014; Hutzler et al., 2014; Weaver These numbers are similar to previous reports in nonpregnant
et al., 2014). A study analyzing 28 different vapors used in populations, which show that 44.5% to 77% of respondents
e-cigarettes found substances such as ethylene glycol, a chemi- believed that e-cigarettes can help them stop smoking (Etter &
cal used in antifreeze that has been banned in tobacco cigarettes Bullen, 2011; Choi & Forster, 2013).
because of its toxic nature (Hutzler et al., 2014). Formalde- Unfortunately, these beliefs about e-cigarettes as a smok-
hyde and acetaldehyde have also been found in trace amounts ing cessation tool do not coincide with the evidence. Studies
(Hutzler et al., 2014; Weaver et al., 2014). The health risks of regarding the ability of e-cigarettes to assist with smoking ces-
these vapors have not been well studied, particularly in preg- sation have shown modest effects at best (Bullen et al., 2013;
nancy. Acetaldehyde is particularly concerning as it increases Hajek et al., 2014). In a randomized controlled trial, the rate
the addictive properties of nicotine (Hilts, 1994; Belluzzi of abstinence from cigarette use at 6 months was 7.3% in e-
et al., 2005). cigarette users, which was not significantly different from those
Although many of the substances in e-cigarette vapors who used nicotine patches or placebo (Bullen et al., 2013). The
are unstudied, one that is well known to cause adverse effects Food and Drug Administration has not approved e-cigarettes
on pregnancy outcomes is nicotine (Gupta & Subramoney, for use in smoking cessation in any population (US Food and
2004, 2006; American Congress of Obstetricians and Gyne- Drug Administration, 2014a, 2014b), and the American Heart
cologists, 2010; Wikstrom et al., 2010; US Department of Association has recently published a Policy Statement cau-
Health and Human Services, 2014). Rates of preterm labor, tioning against the use of e-cigarettes for smoking cessation as
low birth weight, stillbirth, and sudden infant death syndrome their benefits are unproven and long-term safety data are not
are higher in women who use smokeless tobacco when com- yet available (Bhatagnar et al., 2014).
pared with nonsmokers, and in some cases may even be higher E-cigarettes have been the subject of much recent debate
than in smokers (Gupta & Subramoney, 2004, 2006; American because of the possibility that, rather than assisting people
Congress of Obstetricians and Gynecologists, 2010; Wikstrom in quitting smoking, these products may actually be promot-
et al., 2010;). In addition to contributing to poor pregnancy ing the initiation of cigarette use or “renormalizing” smoking
outcomes, nicotine exposure in utero may have long-term neg- (Franck et al., 2014; Pepper & Brewer, 2014). A recent study
ative effects on fetal brain development (US Department of on perceptions found that both users and nonusers believed
Health and Human Services, 2014). The amount of nicotine them to be more socially acceptable than traditional cigarettes
delivered from e-cigarettes is variable, but some studies have (Trumbo & Harper, 2013). In the current study, only one per-
shown blood nicotine levels to be elevated equivalent to that son who had smoked e-cigarettes had never smoked tobacco
of cigarette smoking (Vansickel & Eissenberg, 2013; Breland cigarettes. This may be due to the sample surveyed and the
et al., 2014; Dawkins & Concoran, 2014). As other nicotine relatively recent introduction of e-cigarettes to the market.
replacement therapies are not yet determined to be safe in preg- The vast majority of respondents in the current study were
nancy (U.S. Preventive Services Task Force, 2009; American African American, and previous studies have shown lower
Congress of Obstetricians and Gynecologists, 2010; Coleman rates of awareness among this population (Pepper & Brewer,
et al., 2010), e-cigarettes should also not yet be regarded as 2014). Other studies have reported between 9% and 12% of
such. those who have used e-cigarettes have never used traditional
In the current survey, an unexpectedly high percentage cigarettes (Centers for Disease Control and Prevention, 2013;
of women were unaware that e-cigarettes may contain nicotine. Suftin et al., 2013).
Sixty-six percent of those who had used e-cigarettes and 55% The most common motivations for use endorsed by
of those who had not endorsed a statement that e-cigarettes e-cigarette ever users were smoking cessation and perceived
contain nicotine. Although some e-cigarettes are in fact mar- risk reduction. However, many respondents also reported that
keted as nicotine-free, a study determining the contents of they thought the e-cigarettes tasted better were fashionable,
e-cigarettes found low levels of nicotine in many of these prod- and were less expensive. In addition, many thought that
ucts as well (Hutzler et al., 2014). The finding in this study the ability to smoke e-cigarettes in places where traditional
that 43% of all pregnant women are unaware that e-cigarettes cigarettes are banned made them more appealing. The current
can contain nicotine indicates that these women may be un- study finding that all of these positive perceptions were
knowingly exposing themselves and their infants to harm. In significantly more common among e-cigarette ever users is
addition, if pregnant women are unaware of the potential risks similar to previous reports in a nonpregnant population (Choi
of e-cigarettes, they may be less motivated to quit smoking. & Forster, 2013). This raises the concern that pregnant women
Although complete cessation of smoking is the optimal who may otherwise be motivated to quit smoking might be less
choice for all pregnant women, many women have difficulty inclined to do so because of the perceived non–health-related

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J Addict Med r Volume 9, Number 4, July/August 2015 E-Cigarettes in Pregnancy

benefits of e-cigarettes. Also, because not all respondents were Centers for Disease Control and Prevention. Electronic cigarette use among
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