Smoking during pregnancy is a well-established cause of illness and death in the offspring. There is evidence that nicotine e-cigarette use during pregnancy may be affecting perinatal outcomes.1,2
The US Surgeon General noted in 2014 that the evidence at that time was already ‘sufficient to provide appropriately cautious messages to pregnant women and women of reproductive age about the use of nicotine-containing products such as smokeless tobacco and electronic cigarettes, and newer forms of nicotine-containing tobacco products, as alternatives to smoking.’3
See Section 18.7.3.1 for the effects of e-cigarette use on the success in quitting smoking during pregnancy.
18.6.1.1 Animal studies of nicotine and e-cigarette exposure during pregnancy
During smoking by pregnant women, nicotine and other chemicals cross the placenta and enter the circulation of the developing baby.4 Nicotine from tobacco products adversely affects maternal and foetal health during pregnancy, contributing to poor outcomes including preterm delivery, still birth, neonatal apnoea, and sudden infant death syndrome.3,5 Nicotine exposure during pregnancy can also has lasting adverse consequences for brain and lung development.3
Laboratory and animal studies of e-cigarette emissions have identified potential effects of e-cigarettes on perinatal outcomes. Results from several rodent studies suggest that maternal e-cigarette exposure during pregnancy, regardless of nicotine content, is linked to poorer health outcomes in both the mother and the offspring.6,7 These include a decrease in pup (baby rodent) weights,8,9 foetal lung abnormalities10-12 and cognitive and behavioural defects in pups.7,13
One study has found narrowing of facial lengths, consistent with delayed facial growth in mouse pups exposed to e-cigarettes during pregnancy.14 Another has shown that development of pups’ blood vessels is affected by e-cigarette exposures in pregnant rats, with stronger effects when this exposure occurs mid to late gestation.13
Effects of e-cigarettes on rodent fertility are discussed below in Section 18.6.1.4.
18.6.1.2 E-cigarette use and poor pregnancy outcomes
Numerous longitudinal clinical studies have investigated the effects of e-cigarette use by mothers during pregnancy on the outcomes for babies.15-21 In five of these studies,15,17,18,20,21 e-cigarette use during pregnancy was associated with increased risk of having a small-for-gestational-age (SGA) baby, compared to babies from mothers who did not smoke or use e-cigarettes. Only the most frequent use (daily) of e-cigarettes was associated with these poor outcomes.18,19 SGA babies are in the lower 10th percentile of weight for their gestational age and at risk of conditions such as failure to thrive and hypoglycaemia (low blood sugar levels). SGA babies may have been affected by growth restriction during pregnancy, leading to increased risk of long-term health conditions later in life.22
Two studies have found that e-cigarette use by mothers during pregnancy was associated with increased risks of low birthweight and of preterm birth (before 37 weeks).18,19 One study that adjusted for pre-pregnancy smoking or e-cigarette use found that preterm birth and SGA remained a higher risk for e-cigarette use during pregnancy regardless of any use before pregnancy.15 Another longitudinal study found that birthweight and gestation at delivery did not differ between women who used e-cigarettes versus those that did not smoke or use e=-cigarettes during pregnancy.16 It is unclear why the results were different in this study compared to the others. A meta-analysis has concluded that use of e-cigarettes by pregnant women is associated with a 1.32 fold increased risk of small-for gestational age, 1.49 for low birthweight and a 1.4-fold increased risk of for preterm birth compared to those who do not use tobacco or e-cigarettes.2 Another study has found similar risks of babies being admitted to intensive care and Apgar scores (a measure of a baby’s health after birth).16
18.6.1.3 E-cigarette use during pregnancy and the health of infants
Although there are few studies and relatively small sample sizes, early findings indicate that women who use e-cigarette may have a lower chance of breastfeeding at discharge from hospital compared to women who do not smoke or use e-cigarettes.16 A later study, however, found no difference in breastfeeding rates between women who used e-cigarettes compared to those who did not smoke or use e-cigarettes.23
A case-control study of infant neurobehaviour found that infants of mothers who used e-cigarettes but not conventional cigarettes during pregnancy had a greater number of abnormal reflexes and decreased motor maturity compared to unexposed infants.24 Caution is needed in interpreting these results due to other differences between the two groups of women, which may have influenced neurobehavioural outcomes for these infants.24
18.6.1.4 E-cigarette use and fertility
While there are no major studies examining the effects of e-cigarette use on fertility, one cross-sectional study has found that e-cigarette use is associated with a lower sperm count in younger men (mean age of 19.0 years).25 This finding is consistent with the effects of conventional cigarettes on sperm count, but more extensive studies are needed that consider prior use of conventional cigarettes by people who use e-cigarettes.
There is evidence from animal studies that e-cigarette exposure can affect fertility. For mice exposed to e-cigarettes for 4 months (before and during pregnancy) there was a delay to the onset of first litters and impaired embryo implantation.26
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References
1. National Academies of Sciences Engineering and Medicine. Public health consequences of e-cigarettes. The National Academies Press, Washington, DC 2018. Available from: http://nationalacademies.org/hmd/Reports/2018/public-health-consequences-of-e-cigarettes.aspx.
2. Vallee A, Eid M, Feki A, and Ayoubi JM. Maternal vaping and pregnancy adverse outcomes: A systematic review and meta-analysis. Women and Birth, 2025; 38(5):101951. Available from: https://www.ncbi.nlm.nih.gov/pubmed/40651293
3. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta, GA: U.S. 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, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf.
4. Luck W, Nau H, Hansen R, and Steldinger R. Extent of nicotine and cotinine transfer to the human fetus, placenta and amniotic fluid of smoking mothers. Developmental Pharmacology and Therapeutics, 1985; 8(6):384-95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4075937
5. England LJ, Bunnell RE, Pechacek TF, Tong VT, and McAfee TA. Nicotine and the developing human: a neglected element in the electronic cigarette debate. American Journal of Preventive Medicine, 2015; 49(2):286-93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25794473
6. Byrne S, Brindal E, Williams G, Anastasiou K, Tonkin A, et al. E-cigarettes, smoking and health. A Literature Review Update. CSIRO, Australia, 2018. Available from: https://researchnow.flinders.edu.au/en/publications/e-cigarettes-smoking-and-health-a-literature-review-update.
7. Mescolo F, Ferrante G, and La Grutta S. Effects of e-cigarette exposure on prenatal life and childhood respiratory health: a review of current evidence. Frontiers in Pediatrics, 2021; 9:711573. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34513764
8. Orzabal MR, Lunde-Young ER, Ramirez JI, Howe SYF, Naik VD, et al. Chronic exposure to e-cig aerosols during early development causes vascular dysfunction and offspring growth deficits. Translation Research, 2019; 207:70-82. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30653941
9. Griffith JA, Schafner KJ, Garner KL, DeVallance E, Lewis SE, et al. Maternal electronic cigarette inhalation exposure during gestation: impacts on prolactin and xanthine oxidase. Cardiovascular Toxicology, 2025; 25(8):1095-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/40528126
10. Orzabal MR, Naik VD, Lee J, Hillhouse AE, Brashear WA, et al. Impact of E-cig aerosol vaping on fetal and neonatal respiratory development and function. Translation Research, 2022; 246:102-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35351623
11. Orzabal MR, Naik VD, Lee J, Wu G, and Ramadoss J. Impact of gestational electronic cigarette vaping on amino acid signature profile in the pregnant mother and the fetus. Metabolism Open, 2021; 11:100107. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34355157
12. Ozekin YH, Saal ML, Pineda RH, Moehn K, Ordonez-Erives MA, et al. Intrauterine exposure to nicotine through maternal vaping disrupts embryonic lung and skeletal development via the Kcnj2 potassium channel. Developmental Biology, 2023; 501:111-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37353105
13. Mills A, Nassabeh S, Hurley A, Shouldis L, Chantler PD, et al. Influence of gestational window on offspring vascular health in rodents with in utero exposure to electronic cigarettes. The Journal of Physiology, 2024; 602(17):4271-89. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39106241
14. Kishinchand R, Boyce M, Vyas H, Sewell L, Mohi A, et al. In utero exposure to maternal electronic nicotine delivery system use demonstrate alterations to craniofacial development. The Cleft Palate Craniofacial Journal, 2024; 61(8):1389-97. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36916055
15. Wang X, Lee NL, and Burstyn I. Smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a 2016 U.S. national sample. Preventive Medicine, 2020; 134:106041. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32105682
16. McDonnell BP, Dicker P, and Regan CL. Electronic cigarettes and obstetric outcomes: a prospective observational study. BJOG, 2020; 127(6):750-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32036628
17. Cardenas VM, Cen R, Clemens MM, Moody HL, Ekanem US, et al. Use of electronic nicotine delivery systems (ENDS) by pregnant women I: Risk of small-for-gestational-age birth. Tobacco Induced Diseases, 2019; 17:44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31516487
18. Kim S and Oancea SC. Electronic cigarettes may not be a "safer alternative" of conventional cigarettes during pregnancy: evidence from the nationally representative PRAMS data. BMC Pregnancy Childbirth, 2020; 20(1):557. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32967660
19. Regan AK, Bombard JM, O'Hegarty MM, Smith RA, and Tong VT. Adverse birth outcomes associated with prepregnancy and prenatal electronic cigarette use. Obstetrics & Gynecology, 2021; 138(1):85-94. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34259468
20. Shittu AAT, Kumar BP, Okafor U, Berkelhamer SK, Goniewicz ML, et al. Changes in e-cigarette and cigarette use during pregnancy and their association with small-for-gestational-age birth. American Journal of Obstetrics & Gynecology, 2022; 226(5):730 e1- e10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34864040
21. Cardenas VM, Ali MM, Fischbach LA, and Nembhard WN. Dual use of cigarettes and electronic nicotine delivery systems during pregnancy and the risk of small for gestational age neonates. Annals of Epidemiology, 2020; 52:86-92 e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32805398
22. Australian Institute of Health and Welfare. Australia's mothers and babies. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/baby-outcomes/birthweight-adjusted-for-gestational-age.
23. Hamilton WN, Masud N, Kouambo C, and Tarasenko YN. Perinatal smoking and e-cigarette use and their relationship with breastfeeding: PRAMS 2015-2020. Breastfeeding Medicine, 2023; 18(11):855-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37902988
24. Froggatt S, Reissland N, and Covey J. The effects of prenatal cigarette and e-cigarette exposure on infant neurobehaviour: A comparison to a control group. EClinicalMedicine, 2020; 28:100602. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33294816
25. Holmboe SA, Priskorn L, Jensen TK, Skakkebaek NE, Andersson AM, et al. Use of e-cigarettes associated with lower sperm counts in a cross-sectional study of young men from the general population. Human Reproduction, 2020; 35(7):1693-701. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32558890
26. Wetendorf M, Randall LT, Lemma MT, Hurr SH, Pawlak JB, et al. E-cigarette exposure delays implantation and causes reduced weight gain in female offspring exposed in utero. Journal of the Endocrine Society, 2019; 3(10):1907-16. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31598571