WIC 371 Nicotine and Tobacco Use

Any use of products that contain nicotine and/or tobacco to include but not limited to cigarettes, pipes, cigars, electronic nicotine delivery systems (e-cigarettes, vaping devices), hookahs, smokeless tobacco (chewing tobacco, snuff, dissolvables), or nicotine replacement therapies (gums, patches).

Tobacco products, made with the dried leaves of the tobacco plant, contain a variety of harmful chemicals. The use of tobacco can lead to serious illnesses, including cancers, lung disease, and heart disease. Nicotine, one of the chemicals in tobacco, is highly addictive and associated with additional health risks (1). During pregnancy, the use of nicotine and/or tobacco products is harmful to both the mother and fetus, with potential consequences including low birth weight or even miscarriage (2). Nicotine can be found in breastmilk, therefore, the use of nicotine products may directly impact breastfed infants (3). Women, infants, and children living in a smoking environment also face adverse health outcomes that are outlined in risk #904 Environmental Tobacco Smoke Exposure.

Tobacco Smoking

Tobacco smoke is a toxic mix of more than 7,000 chemicals that cause immediate damage to the body. According to the Centers for Disease Control and Prevention (CDC), smoking remains the single largest preventable cause of death and disease in the United States. Cigarette smoking kills more than 480,000 Americans each year. (2)

According to 2018 CDC data, 14.1% of adult women in the US use tobacco products (4). In 2016, one in fourteen women who gave birth smoked cigarettes during pregnancy. The women most likely to smoke during pregnancy were aged 20-24, identified as non-Hispanic American Indian or Alaska Native, and whose highest level of educational attainment was high school or less (5). Additionally, CDC data from 2014 indicated that women who received WIC benefits were more likely to smoke before and during pregnancy than women who did not receive WIC benefits (6). There are no CDC data that report on the incidence of smoking among breastfeeding women.

Electronic Nicotine Delivery Systems (ENDS)

Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes are some of the many terms used to describe electronic nicotine delivery systems (ENDS) (7). ENDS are noncombustible tobacco products used to smoke or “vape” a solution that often contains nicotine. The solution, or “e-liquid”, is heated to create an aerosol that the user inhales (7). An individual’s level of exposure to nicotine depends on the amount of nicotine in the ENDS product, as well as on product characteristics, device operation, and the user’s inhalation pattern. Exhaled ENDS vapor has been shown to contain chemicals that can cause cancer, can harm the fetus, and are a source of indoor air pollution (8, 9, 10).

Data from the CDC’s 2015 Pregnancy Risk Assessment Monitoring System (PRAMS) for Oklahoma and Texas indicated that maternal use of ENDS was 10% before pregnancy and 7% around the time of conception. Among the women who reported using ENDS during the last 3 months of their pregnancy, over one-third said that the ENDS used contained nicotine while about a quarter said they were unsure of the nicotine content. Reported reasons for ENDS use around the time of pregnancy included curiosity, the perception that ENDS might help with quitting or reducing smoking, and the perception of reduced harm to the mother when compared to cigarette smoking. (11)

The CDC has stated that ENDS use is not safe for pregnant women (12). The continual innovation of novel ENDS makes health risk assessments difficult, and additional research is needed to fully understand ENDS’ safety, health effects, and cessation efficacy (13). Women who are pregnant or trying to become pregnant should consult with their health care provider on the risks that ENDS pose for both maternal and neonatal health (14, 15).

Smokeless Tobacco

According to the CDC, 0.5% of females 18 years and over used smokeless tobacco in 2016 (16). Smokeless tobacco products are either chewed or placed in between the cheek and gum or teeth. The tobacco can come as loose dried leaves or finely ground. While these products are meant to be alternatives to cigarettes, no form of smokeless tobacco is a safe substitute.

The following table summarizes the conditions associated with increased risk from nicotine and/or tobacco use for the mother and infant:

*See risk #142 Preterm or Early Term Delivery for more information about early delivery.

†See risk #141 Low Birth Weight and Very Low Birth Weight for more information about low birth weight.

‡See risk #345 Hypertension and Prehypertension for more information about preeclampsia.

Nutrition

The research on tobacco use and its impact on nutritional status has focused on cigarette smoking. Cigarette smoking causes a generalized upward shift in hemoglobin concentration and hematocrit, which lowers the effectiveness of anemia screening tools. Therefore, pregnant women who smoke may require additional iron supplementation even if their hemoglobin/hematocrit results show they are not anemic. (See risk #201 Low Hematocrit/Low Hemoglobin for more information about cut-offs for determining iron deficiency for women who smoke.) Smoking also increases oxidative stress and affects metabolism. Vitamin C is the only micronutrient with a Dietary Reference Intake (DRI) specific to individuals who smoke, with the recommendation of consuming an additional 35 mg per day compared to those who do not (23). Research indicates that those who smoke have lower concentrations of certain nutrients (i.e., B-carotene, vitamin B-12, vitamin B-6 and folic acid), but due to the observational nature of the research, the exact cause remains unclear (24). Additional research is needed to determine smoking’s effect on micronutrients and if additional DRI recommendations for other micronutrients are needed for those who smoke.

Smoking Cessation<

Pregnancy offers an opportunity to quit smoking because pregnant women are highly motivated to take actions to protect the health of their babies. Around 50% of women who smoked during the three months before they conceived quit during pregnancy. However, of those who did quit during pregnancy, about 50% of them returned to smoking after the baby was born. (25)

Research has shown that both dosage (number of cigarettes smoked in a day) and timing of maternal smoking (during particular trimesters) are associated with neonatal birth weight. Women who stopped smoking before their third trimester gave birth to infants with similar weights to those infants who were never exposed to smoking. Therefore, efforts for smoking cessation should not only be made in the early stages of pregnancy, but should continue throughout pregnancy with an emphasis on the health benefits for the infant if smoking stops before the third trimester. (26)

Nicotine replacement therapy (NRT) is used as an aid for smoking cessation. NRT delivers small doses of nicotine, most commonly using nicotine gum or transdermal nicotine patches. Little research has been conducted to prove the effectiveness and safety for pregnant or postpartum women who engage in NRT (27).

The optimal cessation intervention for a pregnant tobacco user is behavioral, as the safety and efficacy of neonatal nicotine exposure while using NRT has not been established. If a behavioral smoking cessation intervention alone is unsuccessful, the American College of Obstetricians and Gynecologists recommends that NRT only be considered in conjunction with a behavioral intervention and with close monitoring by a health care provider (27). ENDS are often marketed as smoking cessation devices. However, due to the differences between products (e.g. tank sizes, nicotine amounts, etc.), it is difficult for health organizations and researchers to determine how effective all ENDS are for helping people to quit smoking (25). The FDA does not approve of using ENDS to help people quit smoking (28).

Breastfeeding

In 2001, the American Academy of Pediatrics removed nicotine from its list of contraindicated substances during breastfeeding, indicating that the benefits of breastfeeding while smoking outweigh the alternative of smoking and formula feeding (29). Therefore, maternal use of nicotine and tobacco should not prohibit a mother from breastfeeding her child (30 31). Breastfeeding while smoking may help reduce some of the harmful effects of prenatal smoking on infants, including acute respiratory illness and asthma (32, 33). However, women who smoke cigarettes are less likely to initiate breastfeeding than those who do not, possibly revealing that there is a psychosocial factor responsible for lower rates of breastfeeding among women who smoke cigarettes (31, 34). This is an opportunity for WIC staff to inform participants of the health benefits and to encourage them to breastfeed despite their use of tobacco.

Nicotine has been found to have multiple effects on breastmilk. Nicotine can transfer to an infant through breastmilk (3). Nicotine lowers prolactin levels (35, 36), which has been associated with reduced breastmilk supply (37, 38) and reduced milk fat content (3). Additional changes in milk composition and flavor due to maternal smoking may contribute to an infant’s early weaning from breastmilk (39).

Smoking in the presence of an infant or child can expose them to secondhand smoke, which has negative health outcomes (30). (See risk #904 Environmental Tobacco Smoke Exposure for more information.) If a woman chooses to continue her nicotine and tobacco use while breastfeeding, she should not do it in the presence of the infant (30, 31). Additionally, it is recommended that a breastfeeding woman who uses nicotine should first breastfeed her infant and then use the product (8, 30, 40). This timing will help minimize the amount of nicotine in her breastmilk the next time she breastfeeds (8, 30, 40).

Self-reporting of a diagnosis by a health care provider should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.

1. American Lung Association [Internet]. Chicago (IL): American Lung Association. Nicotine. 2019 Feb 12 [cited 2019 Mar 22]. Available from: https://www.lung.org/stop-smoking/smoking-facts/nicotine.html

2. U.S. Department of Health and Human Services [Internet]. Washington (DC): U.S. Department of Health and Human Services, 2015. The health consequences of smoking—50 years of progress: a report of the Surgeon General. 2015 July [cited 2017 Apr 20]. [24 pages]. Available from: https://www.surgeongeneral.gov/library/reports/50-years-of-progress/consumer-guide.pdf.

3. Morrison B, Wambach K. Women’s health and breastfeeding. In: Wamback K and Riodan J, editors. Breastfeeding and human lactation. 5th edition. Boston (MA): Jones and Bartlett Learning; c2016. Chapter 15; p 594.

4. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Tobacco product use and cessation indicators among adults: United States, 2018. Morb Mortal Wkly Rep. 2019 Nov 15 [cited 2020 Jul 30];68(45). Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm.

5. Drake P, Driscoll AK, Mathews TJ. Cigarette smoking during pregnancy: United States, 2016. NCHS Data Brief, no 305. Hyattsville, MD: National Center for Health Statistics. 2018 [cited 2019 May 15] Available from: https://www.cdc.gov/nchs/data/databriefs/db305.pdf.

6. Curtin SC, Mathews TJ. Smoking prevalence and cessation before and during pregnancy: Data from the birth certificate, 2014. National vital statistics reports, vol 65 no 1. Hyattsville (MD): National Center for Health Statistics. 2016 [cited 2019 May 21] Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_01.pdf.

7. U.S. Food & Drug Administration [Internet]. Washington (DC): US FDA, 2019. Vaporizers, e-cigarettes, and other electronic nicotine delivery systems (ENDS). 2019 Feb 05 [cited 2019 Mar 1]. Available from: https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm.

8. Grana R, Benowitz N, Glantz SA. E-cigarettes: a scientific review. Circulation. 2014 [cited 2019 Mar 27];129(19): 1972-86. Available from: https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.114.007667.

9. Bahl V, Lin S, Xu N, Davis B, Wang YH, Talbot P. Comparison of electronic cigarette refill fluid cytotoxicity using embryonic and adult models. Reprod Toxicol. 2012 Dec [cited 2019 Mar 27];34(4): 529-37. Available from: https://www.sciencedirect.com/science/article/pii/S0890623812002833.

10. Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health. 2014 Jul [cited 2019 Mar 27];217(6): 628-37. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24373737.

11. Kapaya M, D’Angelo DV, Ton VT, et al. 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 2010 Mar 1 [cited 22 Mar 2019]; 68(8): 189-94. Available from: https://www.cdc.gov/mmwr/volumes/68/wr/mm6808a1.htm.

12. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. About electronic cigarettes. 2020 24 Feb [2020 July 27]. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html

13. U.S. Department of Health and Human Services [Internet]. 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, 2016. E-cigarette use among youth and young adults: a report of the Surgeon General. 2016 July [cited 2019 Apr 20]. [24 pages]. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/index.htm.

14. Siu AL. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015 [cited 2019 Mar 27];163(8): 622-634. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26389730.

15. American Academy of Pediatrics [Internet]. Washington (DC): American Academy of Pediatrics, 2017. ENDS fact sheet for physicians. Available from: https://www.aap.org/en-us/Documents/5AsENDSfactsheet.pdf.

16. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Smokeless tobacco use in the United States. 2018 Aug 29 [cited 2019 Mar 12]. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/use_us/index.htm.

17. U.S. Department of Health and Human Services [Internet]. Washington (DC): U.S. Department of Health and Human Services, 2001. Women and smoking: a report of the Surgeon General. [cited 2019 Apr 17]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44303/.

18. U.S. Department of Health and Human Services [Internet]. Bethesda (MD): National Institutes of Health, National Cancer Institute. Smoking and your baby. [cited 2019 June 24] Available from: https://women.smokefree.gov/pregnancy-motherhood/quitting-while-pregnant/smoking-your-baby.

19. U.S. Department of Agriculture [Internet]. Washington (DC): USDA Food and Nutrition Service, 2013. Substance use prevention: Screening, education, and referral resource guide for local WIC agencies. [cited 2019 June 20]. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/ResourceManual%20rev%204-17-18.pdf.

20. Zacharasiewicz A. Maternal smoking in pregnancy and its influence on childhood asthma. ERJ Open Res. 2016 July [cited 2019 May 15];2(3): 00042-2016. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5034599/.

21. Wickstrom, R. Effects of nicotine during pregnancy: human and experimental evidence. Current neuropharmacology. 2007 [cited 2019 Mar 8]; 5: 213-22. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656811/.

22. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention. Smokeless tobacco: health effects. 2018 Jan 29 [cited 2019 Mar 12]. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/health_effects/index.htm.

23. Institute of Medicine [Internet]. Washington (DC): National Academy of Sciences. Dietary reference intakes for vitamin c, vitamin e, selenium, and carotenoids. 2000 [cited 2019 Mar 1]; [about 507 pages]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25077263.

24. Cogswell ME, Weisberg P, Spong, C. Cigarette smoking, alcohol use and adverse pregnancy outcomes: implications for micronutrient supplementation. Journal of Nutrition. 2003 May 1 [cited 2019 Mar 1];133(5): 1722S–31S. Available from: https://doi.org/10.1093/jn/133.5.1722S.

25. U.S. Department of Health and Human Services [Internet]. Washington (DC): U.S. Department of Health and Human Services, 2020. Smoking cessation: a report of the Surgeon General. 2020 [cited 2020 July 27]. [700 pages]. Available from: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf

26. Harrod CS, Reynolds RM, Chasan-Taber L, et al. Quantity and timing of maternal prenatal smoking on neonatal body composition: the health start study. Journal of Pediatrics. 2014 Oct [cited 2019 Mar 27];165(4): 707-12. Available from: https://doi.org/10.1016/j.jpeds.2014.06.031.

27. American College of Obstetricians and Gynecologists [Internet]. Committee Opinion No 721: Smoking cessation during pregnancy. Washington (DC): American College of Obstetricians and Gynecologists, 2017c. 2017 Oct [cited 2019 Mar 17]. Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Smoking-Cessation-During-Pregnancy.

28. Centers for Disease and Control and Prevention [Internet]. Atlanta (GA): Centers for Disease and Prevention. E-cigarettes and pregnancy. 2019 Feb 25 [cited 2019 Mar 25]. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/substance-abuse/e-cigarettes-pregnancy.htm.

29. American Academy of Pediatrics. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001 Sept [cited 2019 April 30];93(1): 137. Available from: https://pediatrics.aappublications.org/content/108/3/776.

30. U.S. Department of Agriculture [Internet]. Washington (DC): USDA Food and Nutrition Service, 2010. Infant nutrition and feeding: a guide for use in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). 2019 April [cited 2019 Aug 7]. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/Infant_Feeding_Guide_Final_508c_0.pdf

31. American Academy of Pediatrics [Internet]. Washington (DC): American Academy of Pediatrics, 2012. Policy statement: Breastfeeding and the use of human milk. [cited 2019 June 20] Available from: www.pediatrics.org/cgi/doi/10.1542/peds.2011-3552.

32. Karmaus W, Dobai AL, Ogbuanu I, et al. Long-term effects of breastfeeding, maternal smoking during pregnancy, and recurrent lower respiratory tract infections on asthma in children. Journal of Asthma. 2008 Oct [cited 2019 Mar 22];45(8):688-95. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700345/.

33. Woodward A, Douglas RM, Graham NM, et al. Acute respiratory illness in Adelaide children: breast feeding modifies the effect of passive smoking. J Epidemiol Community Health 1990 Sept [cited 2019 April 30];44(3): 224–30. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060647/.

34. Amir LH, Donath SM. Does maternal smoking have a negative physiological effect on breastfeeding? The epidemiological evidence. Birth. 2002 [cited 2019 Mar 1];29:112-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12000412.

35. Centers for Disease Control and Prevention [Internet]. Atlanta (GA): Centers for Disease Control and Prevention, 2018. Breastfeeding: tobacco and e-cigarettes. 2018 Jan 24 [cited 2018 Mar 21]. Available from: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/tobacco-and-e-cigarettes.html.

36. Andersen AN, Lund-Andersen C, Larsen JF et al. Suppressed prolactin but normal neurophysin levels in cigarette smoking breast-feeding women. Clin Endocrinol (Oxf). 1982 [cited 2019 Mar 1]; 17:363-8. Available from: https://www.researchgate.net/publication/19788598_Milk_production_by_mothers_of_premature_infants.

37. Vio F, Salazar G, Infante C. Smoking during pregnancy and lactation and its effects on breast-milk volume. Am J Clin Nutr. 1991 [cited 2019 Mar 1]; 54:1011-6. Available from: https://www.researchgate.net/publication/21197821_Smoking_during_pregnancy_and_lactation_and_its_effects_on_breast-milk_volume.

38. Hopkinson JM, Schanler RJ, Fraley JK, Garza C. Milk production by mothers of premature infants: influence of cigarette smoking. Pediatrics. 1992 [cited 2019 Mar 1];90:934-8. Available from PubMed; PMID: 1437437.

39. Primo CC, Ruela PBF, Brotto LDdA, et al. Effects of maternal nicotine on breastfeeding infants. Revista Paulista de Pediatria. 2013 [cited 2019 Mar 1];31(3): 392-97. Available from: https://dx.doi.org/10.1590/S0103-05822013000300018.

40. Napierala M, Mazela J, Merritt TA, et al. Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review. Environmental Research. 2016 Nov [cited 2019 July 3];151: 321-38. Available from: https://www.sciencedirect.com/science/article/pii/S0013935116303437.

WIC staff can provide the following nutrition services to women who use nicotine and/or tobacco:

• Administer State or local agency substance use screening methods. For more information, please see: WIC Substance Use Prevention resource, Chapter 5: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide
• Provide a safe and supportive environment when discussing nicotine and/or tobacco use. For more information on techniques for delivering effective messages, please see: WIC Substance Use Prevention resource, Chapter 6: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide.
• Consider all potential nicotine and/or tobacco delivery methods participants may be using.
• Explain the importance of eliminating or reducing the amount of tobacco and/or nicotine use, especially before the third trimester if pregnant.
• Explain that ENDS have variable amounts of nicotine and are not safer alternatives to cigarettes.
• Encourage fruit and vegetables that are high in vitamin C intake to achieve adequate antioxidant and vitamin C consumption.
• Highlight WIC foods, especially 100% juice that are good sources of vitamin C and other important nutrients.
• Encourage high iron fruits and vegetables. If the participant is taking an iron supplement, provide recommendations for minimizing gastro-intestinal side effects and foods that can improve iron bioavailability. For more information, please see: https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/.
• Offer the following suggestions to minimize secondhand smoke exposure to the infant (30, 35):
  • Avoid smoking in infant’s presence.
  • Smoke outside.
  • Ask other smokers to avoid smoking around the infant or other children.
  • Have smoke-free rules for the car and home.
  • Change clothes and wash hands after smoking and prior to handling the infant.
• Refer to a state quit line (1-800-QUIT-NOW), text-based program (text QUIT to 47848) or a local in-person smoking cessation program.
• Refer to their health care provider to discuss the health implications of using NRT while pregnant or breastfeeding.

WIC staff can provide the following nutrition services to breastfeeding women who use nicotine and/or tobacco:

• Provide breastfeeding promotion and support and inform participants of the health benefits of human milk for infants of mothers who smoke.
• Utilize the participant-focused WIC Breastfeeding Support website topic articles that can be found at: https://wicbreastfeeding.fns.usda.gov/breastfeeding-and-alcohol-drugs-and-smoking.
• Recommend mothers to refrain from smoking/vaping until right after a feeding so that nicotine level will have time to decrease before the next feeding.
• Counsel women who use NRT to time its use for after breastfeeding and to not use at night.
• Provide anticipatory guidance about the possible effect of nicotine on breast milk supply.

Additional Resources available to WIC Staff:

• See risk #904 Environmental Tobacco Smoke Exposure for more information.
• WIC participant handbook: https://wicworks.fns.usda.gov/resources/give-your-baby-healthy-start-tips-pregnant-women-and-new-mothers
• WIC Infant Nutrition and Feeding Guide: https://wicworks.fns.usda.gov/resources/infant-nutrition-and-feeding-guide
• FDA Tobacco Products Labeling: https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm.
• WIC Substance Use Prevention resource: https://wicworks.fns.usda.gov/resources/wic-substance-use-prevention-guide
• Centers for Disease Control and Prevention – Electronic Cigarettes: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm
• American Academy of Pediatrics - Resources on E-cigarettes: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Pages/Resources-on-E-cigarettes.aspx
• Smoking & Your Baby: https://women.smokefree.gov/pregnancy-motherhood/quitting-while-pregnant/smoking-your-baby