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Title: E-cigarettes : an acceptable alternative to smoking for breastfeeding mothers?
Author: Johnston, Emily
Awarding Body: University of Nottingham
Current Institution: University of Nottingham
Date of Award: 2020
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Despite many women quitting smoking during pregnancy, the majority will return to smoking by 12 months postpartum. Smoking postpartum carries substantial risks of morbidity and mortality for both mother and baby. Breastfeeding is a protective factor against some of the risks associated with smoking. However, mothers who smoke are less likely to intend to breastfeed, initiate breastfeeding at birth, or continue breastfeeding, than non-smoking mothers. Current explanations for this association include a possible physiological mechanism, a coincidental association due to shared demographics, or a fear of harm. E-cigarettes are an increasingly popular alternative to smoking, helping to prevent relapse in those trying to quit, and Public Health England, in an evidenced based review, estimate cite them to be at least 95% safer than smoking. While research has explored e-cigarette use during pregnancy, thus far, no study has considered how e-cigarettes may be being used in the postpartum period. Crucially, research has not explored if and how e-cigarettes are used by breastfeeding mothers. As e-cigarettes are likely to be far safer than cigarettes, with far fewer toxicants, they may be an appropriate alternative to smoking in the postpartum period. To explore possible future interventions using e-cigarettes to reduce postpartum smoking and increase the likelihood and duration of breastfeeding, research must first explore the acceptability and current use of e-cigarettes in relation to breastfeeding. This thesis includes three studies. The first study aimed to explore whether an association between smoking and breastfeeding currently existed within a sample of UK mothers, independent of demographic factors. This study used data from the Pregnancy Lifestyle Survey, which recruited 750 current and recent ex-smokers, e-cigarette users and dual users (both smoking and e-cigarette users) who self-completed questionnaires in early pregnancy, late pregnancy and at 3 months postpartum. In late pregnancy, 63.5% of women intended to breastfeed, 46.35% initiated breastfeeding, and 17.68% of women were breastfeeding at 3 months. Older mothers were more likely to initiate breastfeeding at birth (p = 0.02), and mothers with higher levels of education were more likely to intend to breastfeed (p<0.001), initiate breastfeeding (p<0.001) and be breastfeeding at three months (p=0.01). Ex-smokers were more likely to intend to breastfeed (p<0.01), initiate breastfeeding (p=0.04) and be breastfeeding at three months (p<0.01) than smoking/vaping mothers. When adjusted for age and education, smokers were less likely to breastfeed at birth (OR 0.48, 95% CI: .26 - .75), and at three months postpartum (OR .19, 95% CI: .09 - .37), compared to ex-smokers. Vapers were similarly less likely to initiate and intend to breastfeed, but this was not significant. A negative association between smoking and breastfeeding exists in the UK, irrespective of demographics. Interventions should consider the association is at least, in part, due to factors other than demographics. Due to only a small sample of vapers recruited, further research should explore the use of e-cigarettes and attitudes to vaping as a breastfeeding mother in more detail. The second study used infodemographic methods to explore the use of e-cigarettes postpartum, and opinions towards e-cigarette use when breastfeeding. This study used data obtained from online parenting forums. The study identified four themes using a template approach to thematic analysis; use; perceived risk; social support; and evidence. Women were using e-cigarettes to prevent returning to smoking postpartum, many having started using them during pregnancy to quit smoking. In regards to breastfeeding, women varied on their opinions as to the acceptability of e-cigarettes. However, overall, women were generally positive about their use. Women viewed the risks of using e-cigarettes using direct comparisons to the risks of smoking; using e-cigarettes was seen as a positive behaviour to avoid smoking. Social support was an important part of the discussion; some women felt judged for using e-cigarettes, which was primarily related to the use of nicotine. Some women thought that the use of nicotine was evidence of bad mothering and a morality issue as well as a safety issue. A key finding was the sources of evidence women used and were looking for. Some women had accessed peer-reviewed scientific sources but had misinterpreted the results of the studies they quoted. Some women used non-scientific sources such as blogs and media articles to form both positive and negative opinions on vaping. Many women felt there was not enough research on the long term use of e-cigarettes; this made them fearful that serious harm would be linked to e-cigarettes use in the future. One thing that united women who were both positive and negative about e-cigarette use were the shared opinion there wasn't enough advice and support for mothers who vaped and wanted to breastfeed. More advice and support needs to be available as part of usual care for women who do vape, to enable them to make informed decisions about breastfeeding their infants. The third study used an online survey to explore further the themes identified in the second study. This study recruited 149 women who either smoked, vaped, or smoked and vaped and had an infant aged 18 months or younger using social media advertisements and links on parenting forums. The survey asked women about their experiences and opinions on smoking/vaping breastfeeding using open-ended questions that were thematically analysed. The survey also included Likert scales following PPI feedback. Three main themes were identified: smoking, vaping and breastfeeding behaviours; barriers and facilitators for breastfeeding as a smoking or vaping mother; and barriers and facilitators for using e-cigarettes (and not smoking) postpartum. Women employed a series of behaviours to reduce perceived harm to their infant from breastfeeding as a smoker or vaper. For vaping mothers, this involved using only low or zero nicotine. Smoking and vaping mothers discussed maintaining a smoke-free home, ensuring the maintenance of proper hygiene, and timing feeds around their smoking/vaping behaviours. Vaping mothers reported being less cautious about vaping around their infants. Dual-use mothers reported vaping in the day and only smoking when they had either expressed enough milk they wouldn't need to feed their infant or when they had their partner home to care for the infant. Barriers and facilitators were not fixed and invariable. They included the mothers' beliefs on what was acceptable, the perceived safety of breastfeeding as a smoker/vaper, and access to social support. Barriers to breastfeeding as a smoker were often due to women's beliefs it was unacceptable and unsafe for them to breastfeed; this barrier was sometimes overcome by switching to vaping. However, a lack of support and advice from health care professionals about vaping and breastfeeding was a barrier. Barriers to using e-cigarettes included previous use resulting in adverse events (such as a cough, or not successfully quitting smoking) and a lack of consistent (if any) advice from health care professionals. Facilitators included wanting to improve health, pregnancy, good social support, saving money and not having the smells associated with smoking. Overall, women view e-cigarettes as acceptable for use when breastfeeding. Interventions should consider the use of e-cigarettes to prevent women from returning to smoking postpartum and improve confidence in breastfeeding. To support and encourage women to switch to vaping, training for health care professionals on the relative safety of e-cigarettes is required.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: WM Psychiatry