Perceptions, Characteristics, and Behaviors of Cigarette and Electronic Cigarette Use among Pregnant Smokers



      Smoking during pregnancy is a primary risk factor for adverse perinatal outcomes. Although electronic cigarette (e-cigarette) use has increased, reasons for and behaviors of use are not fully understood. The purpose of this study, composed exclusively of pregnant current smokers, was to describe perceptions of health risks associated with e-cigarette use among pregnant women, describe the use patterns of pregnant dual users (defined as those who simultaneously use conventional/combustible cigarettes and e-cigarettes), and examine smoking-related behaviors between conventional-only (defined as those smoking combustible cigarettes but not e-cigarettes) and dual users.


      Cross-sectional data from a larger study of pregnant conventional-only and dual users were analyzed. A brief survey measured perceptions of prenatal e-cigarette use and smoking behaviors. Analysis included descriptive statistics, bivariate analysis, and logistic and linear regression analysis.


      Among 176 pregnant smokers (38% dual users), more than one-half of participants believed e-cigarettes were harmful to women (56%) and posed harm to the fetus (53%). Among dual users, 41% used their e-cigarette daily, on average eight times per day. Eleven percent of dual users smoked a pack of cigarettes per day, compared with 5% of conventional-only smokers, and dual users scored significantly higher (p = .026) on the Penn State Cigarette Dependence Index. The most common e-cigarette liquid flavor was fruit (64%), and the most frequently reported e-cigarette nicotine concentration was 1–6 mg.


      Characterizing perceptions and behaviors of e-cigarette use during pregnancy is foundational for future research to explore the association between product use and maternal and infant outcomes.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Adkison S.E.
        • O'Connor R.J.
        • Bansal-Travers M.
        • Hyland A.
        • Borland R.
        • Yong H.H.
        • Fong G.T.
        Electronic nicotine delivery systems: International tobacco control four-country survey.
        American Journal of Preventive Medicine. 2013; 44: 207-215
        • Ashford K.
        • Wiggins A.
        • Butler K.
        • Ickes M.
        • Rayens M.K.
        • Hahn E.
        E-cigarette use and perceived harm among women of childbearing age who reported tobacco use during the past year.
        Nursing Research. 2016; 65: 408-414
        • Ashford K.
        • Wiggins A.
        • Rayens E.
        • Assef S.
        • Fallin A.
        • Rayens M.K.
        Perinatal biochemical confirmation of smoking status by trimester.
        Nicotine & Tobacco Research. 2017; 19: 631-635
        • Bhandari N.R.
        • Day K.D.
        • Payakachat N.
        • Franks A.M.
        • McCain K.R.
        • Ragland D.
        Use and risk perception of electronic nicotine delivery systems and tobacco in pregnancy.
        Women's Health Issues. 2018; 28: 251-257
        • Bhanji S.
        • Andrades M.
        • Taj F.
        • Khuwaja A.K.
        Factors related to knowledge and perception of women about smoking: A cross sectional study from a developing country.
        BMC Women's Health. 2011; 11: 16
        • Bowker K.
        • Orton S.
        • Cooper S.
        • Naughton F.
        • Whitemore R.
        • Lewis S.
        • Ussher M.
        Views on and experiences of electronic cigarettes: A qualitative study of women who are pregnant or have recently given birth.
        BMC Pregnancy and Childbirth. 2018; 18 (Ussher): 233
        • Centers for Disease Control and Prevention (CDC)
        Fast facts and fact sheets: Smoking and tobacco use fast facts and fact sheet.
        Date: 2019
        Date accessed: June 12, 2019
        • Centers for Disease Control and Prevention (CDC)
        Health effects of cigarette smoking fast facts and fact sheet.
        • Dawkins L.
        • Corcoran O.
        Acute electronic cigarette use: Nicotine delivery and subjective effects in regular users.
        Psychopharmacology (B). 2014; 231: 401-407
        • Dempsey D.A.
        • Benowitz N.L.
        Risks and benefits of nicotine to aid smoking cessation in pregnancy.
        Drug Safety. 2001; 24: 277-322
        • Drake P.
        • Driscoll A.K.
        • Mathews T.J.
        Cigarette smoking during pregnancy: United States, 2016. NCHS Data Brief, no 305.
        National Center for Health Statistics, Hyattsville, MD2018 (Available:)
        Date accessed: December 6, 2019
        • England L.J.
        • Tong V.T.
        • Koblitz A.
        • Kish-Doto J.
        • Lynch M.M.
        • Southwell B.G.
        Perceptions of emerging tobacco products and nicotine replacement therapy among pregnant women and women planning a pregnancy.
        Preventive Medicine Reports. 2016; 4: 481-485
        • Etter J.F.
        Levels of saliva cotinine in electronic cigarette users.
        Addiction. 2014; 109: 825-829
        • Fallin A.
        • Miller A.
        • Assef S.
        • Ashford K.
        Perceptions of electronic cigarettes among Medicaid-eligible pregnant and postpartum women.
        Journal of Obstetric, Gynecologic & Neonatal Nursing. 2016; 45: 320-325
        • Fiore M.C.
        • Jaén C.R.
        • Baker T.B.
        • Bailey W.C.
        • Benowitz N.L.
        • Curry S.J.
        • Henderson P.N.
        Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. U.S. Department of Health and Human Services, Public Health Service.
        Date: 2008
        Date accessed: October 6, 2019
        • Foulds J.
        • Veldheer S.
        • Yingst J.
        • Hrabovsky S.
        • Wilson S.J.
        • Nichols T.T.
        • Eissenberg T.
        Development of a questionnaire for assessing dependence on electronic cigarettes among a large sample of ex-smoking E-cigarette users.
        Nicotine & Tobacco Research. 2014; 17: 186-192
        • Gaalema D.E.
        • Higgins S.T.
        • Bradstreet M.P.
        • Heil S.H.
        • Bernstein I.M.
        Using NicAlert strips to verify smoking status among pregnant cigarette smokers.
        Drug and Alcohol Dependence. 2011; 119: 130-133
        • Kahr M.K.
        • Padgett S.
        • Shope C.D.
        • Griffin E.N.
        • Xie S.S.
        • Gonzalez P.J.
        • Stotts A.L.
        A qualitative assessment of the perceived risks of electronic cigarette and hookah use in pregnancy.
        BMC Public Health. 2015; 15 (Stotts): 1273
        • Kapaya M.
        • D’Angelo D.V.
        • Tong V.T.
        • England L.
        • Ruffo N.
        • Cox S.
        • King B.A.
        Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth—Oklahoma and Texas, 2015.
        Morbidity and Mortality Weekly Report. 2019; 68 (King): 189-194
        • Kurti A.N.
        • Redner R.
        • Lopez A.A.
        • Keith D.R.
        • Villanti A.C.
        • Stanton C.A.
        • Higgins S.T.
        Tobacco and nicotine delivery product use in a national sample of pregnant women.
        Preventive Medicine. 2017; 104: 50-56
        • Lopez A.A.
        • Redner R.
        • Kurti A.N.
        • Keith D.R.
        • Villanti A.C.
        • Stanton C.A.
        • Higgins M.E.
        Tobacco and nicotine delivery product use in a US national sample of women of reproductive age.
        Preventive Medicine. 2018; 117 (Roberts): 61-68
        • Mark K.S.
        • Farquhar B.
        • Chisolm M.S.
        • Coleman-Cowger V.H.
        • Terplan M.
        Knowledge, attitudes, and practice of electronic cigarette use among pregnant women.
        Journal of Addiction Medicine. 2015; 9: 266-272
        • Marufu T.C.
        • Ahankari A.
        • Coleman T.
        • Lewis S.
        Maternal smoking and the risk of still birth: Systematic review and meta-analysis.
        BMC Public Health. 2015; 15: 239
        • McCubbin A.
        • Fallin-Bennett A.
        • Barnett J.
        • Ashford K.
        Perceptions and use of electronic cigarettes in pregnancy.
        Health Education Research. 2017; 32: 22-32
        • Mei-Dan E.
        • Walfisch A.
        • Weisz B.
        • Hallak M.
        • Brown R.
        • Shrim A.
        The unborn smoker: Association between smoking during pregnancy and adverse perinatal outcomes.
        Journal of Perinatal Medicine. 2015; 43: 553-558
        • National Academies of Sciences, Engineering, and Medicine
        Public health consequences of e-cigarettes.
        The National Academies Press, Washington, DC2018
        • Nichols T.R.
        • Birnbaum A.S.
        • Birnel S.
        • Botvin G.J.
        Perceived smoking environment and smoking initiation among multi-ethnic urban girls.
        Journal of Adolescent Health. 2006; 38: 369-375
        • Peterson L.A.
        • Hecht S.S.
        Tobacco, e-cigarette and child health.
        Current Opinion in Pediatrics. 2017; 29: 225-230
        • Siu A.L.
        Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: US Preventive Services Task Force recommendation statement.
        Annals of Internal Medicine. 2015; 163: 622-634
        • St. Helen G.
        • Havel C.
        • Dempsey D.A.
        • Jacob III, P.
        • Benowitz N.L.
        Nicotine delivery, retention and pharmacokinetics from various electronic cigarettes.
        Addiction. 2016; 111: 535-544
        • Tong V.T.
        • England L.J.
        • Rockhill K.M.
        • D'Angelo D.V.
        Risks of preterm delivery and small for gestational age infants: Effects of nondaily and low-intensity daily smoking during pregnancy.
        Paediatric and Perinatal Epidemiology. 2017; 31: 144-148
        • U.S. Department of Health and Human Services (USDHHS)
        The health consequences of smoking—50 years of progress: A report of the surgeon general.
        US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2014 (Printed with corrections, January 2014. Available:)
        • U.S. Department of Health and Human Services (USDHHS)
        E-cigarette use among youth and young adults. A report of the surgeon general.
        US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2016 (Available:)
        • Wagner N.J.
        • Camerota M.
        • Propper C.
        Prevalence and perceptions of electronic cigarette use during pregnancy.
        Maternal and Child Health Journal. 2017; 21: 1655-1661
        • Weaver S.R.
        • Kim H.
        • Glasser A.M.
        • Sutfin E.L.
        • Barrington-Trimis J.
        • Payne T.J.
        • Loukas A.
        Establishing consensus on survey measures for electronicvnicotine and non-nicotine delivery system use: Current challenges and considerations for researchers.
        Addictive Behaviors. 2018; 79 (Loukas): 203-212


      Andrea McCubbin, MPH, is the Director of Perinatal Research Operations for the Perinatal Research and Wellness Center at the University of Kentucky College of Nursing. Her research interests include the impact of tobacco use on perinatal health, and interventions for cessation.


      Amanda Wiggins, PhD, is a lecturer and statistician for the University of Kentucky College of Nursing. She is the Director of Data Management and Outcomes for UK's BREATHE team. Her scholarly work primarily focusses on tobacco, adolescent healths, and perinatal research.


      Janine Barnett, MSN, is the Nurse Research Coordinator for the Perinatal Research and Wellness Center at the University of Kentucky College of Nursing. She has also worked as a labor and delivery nurse, childbirth educator, and obstetric clinic instructor.


      Kristin Ashford, PhD, WHNP-BC, FAAN, is the Director of the Perinatal Research and Wellness Center, a Professor, Associate Dean of Undergraduate Faculty Affairs, and Women's Health Nurse Practitioner at the University of Kentucky College of Nursing.