Abstract
Background:
Postpartum depression (PPD) is a prevalent public health concern. Combustible cigarette use is associated with increased risk of PPD. While electronic cigarette (e-cigarette) use during pregnancy is linked to increased risk of depressive symptoms during pregnancy, the relationship between e-cigarette use and PPD is not well understood. We sought to examine the association of e-cigarette use with PPD.
Materials and Methods:
Using Pregnancy Risk Assessment Monitoring System 2016–2019 data, unadjusted and adjusted logistic regression analyses for PPD were conducted via three analyses where e-cigarette use (any vs. none) was retrospectively self-reported (1) in past 2-year, (2) prepregnancy (i.e., 3 months before pregnancy), and (3) during pregnancy (i.e., last 3 months of pregnancy). We conducted an additional past 2-year e-cigarette use analysis excluding those who used combustible cigarette and/or hookah. Covariates included age, race, ethnicity, combustible cigarette, and/or hookah use, prenatal care during the last trimester, health insurance coverage during pregnancy, physical abuse during pregnancy, income, and survey type.
Results:
Only unadjusted odds ratios from past 2-year e-cigarette use (1.63, 95% confidence interval [CI]: 1.42–1.87) and past 2-year e-cigarette use excluding individuals with cigarette and/or hookah use (1.78, 95% CI: 1.30–2.38) were statistically associated with PPD. No adjusted analyses were statistically significant.
Conclusion:
Any e-cigarette use, as compared to no use, does not appear to be an independent risk factor of PPD, though it may be a useful clinical marker of increased risk of PPD. Future studies are warranted to advance our knowledge of impact of e-cigarette use on PPD.
Keywords: pregnancy, perinatal, postpartum, e-cigarettes, depression, PRAMS
Introduction
Electronic cigarettes (e-cigarettes) are devices which deliver aerosols using heat powered by batteries, usually from liquids containing nicotine, flavorings, and other additives.1 Since they were first introduced in the U. S. market in 2007, e-cigarettes have gained a tremendous amount of popularity, including among women of reproductive age. In the United States, ∼3% of women aged 18–44 years old reported current e-cigarette use in 2014–2015,2 with young adults' use increasing quadratically since then.3 Due to the perceptions that e-cigarettes might help with cessation of combustible cigarettes (including some emerging evidence4 and opinions5) and that they pose a reduced level of harm when compared to combustible cigarettes,6 some people may initiate or maintain e-cigarette use during the perinatal period.
The association between e-cigarette use and postpartum depression (PPD) is currently unknown. However, combustible cigarette smoking during pregnancy is a known risk factor for PPD.7–9 While the exact mechanisms linking smoking during pregnancy to PPD are unknown, repeated exposure to nicotine (via regular smoking or regular use of nicotine-containing e-cigarettes) could contribute to the risk. Individuals with repeated exposure to nicotine can experience nicotine withdrawal symptoms, some of which show parallels with symptoms of PPD (e.g., low mood, anxiety, and anhedonia).10,11
An estimated 10%–15% of new mothers experience PPD.12,13 PPD can be debilitating for mothers and their children due to an increased risk of behavioral, cognitive, and social impairments for children of mothers with PPD.14 Evidence from one study that included a convenience sample shown that e-cigarette use before or during pregnancy is associated with depressive symptoms during pregnancy, as compared to those using only combustible cigarettes or no tobacco use15; though this observation has yet to be replicated. While the mechanisms by which dual use of combustible cigarettes and e-cigarettes may increase risk of depressive symptoms relative to combustible cigarettes alone is unknown, dual use (without significant reduction in smoking) may result in increased exposure to nicotine or toxicants. Additionally, in nonpregnant/postpartum individuals, results from a meta-analysis of 14 papers published between 2003 and 2017 (n = 16,406) indicated that e-cigarette use is associated with depressed mood.16 In this study, we aimed to examine the association of e-cigarette use and PPD using nationally representative health survey data from the United States (U.S.). We hypothesized that e-cigarette use would be associated with increased risk of PPD.
Materials and Methods
Dataset
We analyzed the most recent available data from Pregnancy Risk Assessment Monitoring System (PRAMS), Phase 8 (2016–2019). PRAMS is an annual cross-sectional survey administered by state, territorial, or local health departments in partnership with the Centers for Disease Control and Prevention.17 Participants are mothers who are randomly selected via U.S. birth certificate data. Underrepresented groups, such as those who are at high-risk for adverse health outcomes (e.g., mothers with low-birth-weight infants) or mothers from minority groups, were oversampled to ensure adequate representation.9
Those selected receive a series of mailings, including the survey itself, via U.S. Postal Service over a 3–6 week period. The survey includes health-related maternal and infant questions in reference to the full perinatal period (i.e., before, during, and after pregnancy). If a selected individual does not respond to the mailed surveys, they are contacted by telephone to complete the same survey. Surveys are typically completed 2–6 months postpartum. For this analysis, we restricted the sample to those who gave birth to live infants and who had complete data for the variables described below.
Variables
PPD was assessed with two questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoy?” The response options to both questions were “always,” “often/almost always,” “sometimes,” “rarely,” and “never.” Following previously published definitions,18 respondents who selected “always” or “often/almost always” to one or both questions were categorized as having PPD, whereas other respondents (i.e., those who answered “sometimes,” “rarely,” or “never” to both questions) were categorized as not having PPD.
E-cigarette use was classified in three ways, all based on retrospective self-report (Supplementary Table S1): (1) Past 2-year e-cigarette use was defined as “any” or “none” per e-cigarette use during the 2 years before completing the survey including the perinatal period, (2) Pre-pregnancy e-cigarette use was defined as “any” or “none” per e-cigarette use in the 3 months immediately before pregnancy, and (3) During pregnancy e-cigarette use was defined as “any” or “none” per e-cigarette use during the last 3 months of pregnancy.
Covariates, selected a priori based on previous literature,12,18–20 included age (<20, 20–24, 25–29, 30–34, >34 years), race (White, Black, Asian, American Indian and Alaska Native, other), ethnicity (Hispanic, non-Hispanic), prenatal care during last trimester of pregnancy (any, none), insurance status during entire pregnancy (yes, no), physical abuse during pregnancy (yes, no), annual income level (≤$23,999; $24,000–$47,999; $48,000–$72,999; ≥$73,000), and method of study response (mail, telephone). Combustible cigarette and/or hookah use was also included as a covariate, using the same time points that were used for e-cigarette use including past 2-year combustible cigarette and/or hookah use (any, none), 3 months before pregnancy combustible cigarette and/or hookah use (any, none), and last 3 months of pregnancy combustible cigarette use and/or hookah use (any, none).
Statistical analyses
Descriptive statistics were computed to describe the study sample including frequencies (unweighted) and percentages (weighted). We analyzed for differences in respondent characteristics by e-cigarette use (any, none) using chi-square tests. For the primary analyses—to examine the association between any past 2-year e-cigarette use (exposure) and PPD (outcome)—we used unadjusted and adjusted logistic regressions with the covariates described above. Odds ratios (OR), adjusted odds ratios (AOR), and confidence intervals (95% CIs) were estimated. We tested assumptions of logistic regression and evaluated the fit of our models using the c-statistic and collinearity using Pearson's correlation coefficients. Bayes Factors were estimated for each analysis where a value of <0.33 indicates no evidence of an effect, between 0.34 and 3.0 indicates inconclusive evidence of an effect, and over 3.0 indicates evidence for an effect.21,22
To assess the robustness of our primary analyses, we conducted five sensitivity analyses: (1) pre-pregnancy e-cigarette use: any versus none in 3 months before pregnancy, adjusting for combustible cigarette and/or hookah use in the 3 months before pregnancy; (2) during pregnancy e-cigarette use: any versus none in the last 3 months of pregnancy, adjusting for combustible cigarette and/or hookah use in the last 3 months of pregnancy; (3) past 2 years e-cigarette use: any versus none in past 2 years, excluding those who reported any combustible cigarette and/or other hookah use in the past 2 years, (4) pre-pregnancy e-cigarette use: no use versus less than weekly versus weekly but less than daily versus daily versus more than once a day, and (5) during pregnancy e-cigarette use: no use versus less than weekly versus weekly but less than daily versus daily versus more than once a day. We performed complete case analyses which accounted for the complex survey design using procedures in SAS On Demand Academics Edition (Cary, NC). We conducted analyses with two-sided tests and alpha level = 0.05.
Results
Study sample
Participant characteristics stratified by past 2-year e-cigarette use are displayed in Table 1. Overall, 6.6% (n = 3,874) endorsed any e-cigarette use and 93.4% (n = 55,076) reported no e-cigarette use in the past 2 years. Greater prevalence of use was in those who were younger, White, non-Hispanic, use other forms of tobacco, experienced physical abuse, had lower incomes, and responded by mail.
Table 1.
Description of Survey Respondents by Any e-Cigarette Use Within Past 2 Years (n = 58,950); Pregnancy Risk Assessment Monitoring System, 2016–2019
| Characteristics, n (%) | Past 2-year e-cigarette usea |
p | |
|---|---|---|---|
| Any, n = 3,874 (6.6) | None, n = 55,076 (93.4)< | ||
| Prevalence and frequency of e-Cigarette use at subsequent time points | |||
| Use during the 3 months before pregnancy | Any use: 2,241 (58.1)b >Once a day: 763 (21.9) Once a day: 204 (4.6) 2–6 days a week: 289 (7.5) ≤1 day a week: 985 (24.9) |
1,638 (41.9) | Not assessedc |
| Use during the last 3 months of pregnancy | Any use: 703 (18.2) >Once a day: 226 (6.8) Once a day: 106 (2.1) 2–6 days a week: 103 (2.5) ≤1 day a week: 268 (6.8) |
3,193 (81.8) | |
| Postpartum depression (yes) | 796 (17.4) | 7,067 (11.4) | <0.01 |
| Age | |||
| <20 | 311 (8.0) | 1,835 (2.9) | <0.01 |
| 20–24 | 1,110 (30.0) | 9,400 (16.8) | |
| 25–29 | 1,218 (30.7) | 16,293 (29.7) | |
| 30–34 | 811 (21.0) | 17,065 (31.5) | |
| >34 | 424 (10.3) | 10,483 (19.1) | |
| Race | |||
| White | 3,183 (88.9) | 37,589 (76.3) | <0.01 |
| Black | 415 (7.4) | 110,937 (16.0) | |
| Asian | 47 (0.8) | 2,282 (3.0) | |
| American Indian and Alaskan Native | 156 (0.9) | 1,727 (0.6) | |
| Other | 73 (2.0) | 2,541 (4.1) | |
| Ethnicity: Hispanic | 346 (6.8) | 9,726 (14.8) | <0.01 |
| Tobacco use (yes)d | 3,027 (77.3) | 9,296 (16.0) | <0.01 |
| Prenatal care (yes)e | 3,782 (98.3) | 54,304 (98.6) | 0.27 |
| Health insurance coverage (yes)f | 3,743 (95.8) | 52,440 (93.3) | 0.60 |
| Physical abuse (yes)g | 322 (7.0) | 1,518 (2.5) | <0.01 |
| Income | |||
| $0 to $23,999 | 1,992 (50.4) | 18,729 (31.2) | <0.01 |
| $24,000 to $47,999 | 814 (22.1) | 10,647 (20.1) | |
| $48,000 to $72,999 | 431 (12.7) | 7,150 (14.1) | |
| ≥$73,000 | 461 (14.8) | 15,221 (34.6) | |
| Type of survey response | |||
| 2,853 (77.8) | 38,745 (74.1) | <0.01 | |
| Phone | 1,021 (22.2) | 16,331 (25.9) | |
Numbers are unweighted while percentages are weighted.
Past 2-year e-cigarette use is defined as any e-cigarette use in the 2 years before completing the survey.
“Any use” is the sum of the following options: more than once a day, once a day, 2–6 days a week, or 1 day a week or less.
Chi-square p-value for e-cigarette use was not assessed as this association is not applicable to this study.
Tobacco use defined as use of combustible cigarettes and/or hookah use within the 2 years before completing the survey.
Prenatal care defined as during the last trimester.
Health insurance coverage defined as during the entire pregnancy.
Physical abuse defined as incidence of physical abuse during pregnancy.
Any e-cigarette use in past 2 years and PPD
PPD was present in 17.4% (n = 796) of those who endorsed any use within the past 2 years and 11.4% (n = 7,067) who did not report use in the past 2 years. As displayed in Table 2, for unadjusted logistic regression, the odds of having PPD was 1.63 (95% CI: 1.42–1.87) higher in those who reported any e-cigarette use in the past 2 years versus those who reported no use. The odds ratio was no longer significant in adjusted analyses (AOR = 1.09, 95% CI: 0.98–1.29), providing inconclusive evidence for no greater odds of PPD in those who use e-cigarettes in the past 2 years (Bayes Factor = 0.34).
Table 2.
Unadjusted and Adjusted Odds Ratios for e-Cigarette Use with Postpartum Depression; Pregnancy Risk Assessment Monitoring System, 2016–2019
| Past 2-year use ORs (95% CI)a n = 57,045 | Pre-pregnancy use ORs (95% CI)b n = 3,879 | During pregnancy use ORs (95% CI)c n = 3,834 | Past 2-year use, no other tobacco use ORs (95% CI)d n = 44,737 | |
|---|---|---|---|---|
| Unadjusted OR for postpartum depression | ||||
| Any e-cigarette use (reference: none) | 1.63 (1.42–1.87) | 1.06 (0.81–1.38) | 1.14 (0.82–1.58) | 1.78 (1.30–2.38) |
| Adjusted OR for postpartum depression | ||||
| Any e-cigarette use (reference: none) | 1.09 (0.98–1.29) | 1.00 (0.76–1.32) | 1.03 (0.73–1.46) | 1.27 (0.88–1.84) |
| Age (reference: ≥35 years old) | ||||
| <20 | 2.03 (1.63–2.53) | 1.00 (0.56–1.81) | 1.01 (0.56–1.82) | 2.52 (1.94–3.29) |
| 20–24 | 1.45 (1.25–1.69) | 1.39 (0.86–2.24) | 1.40 (0.87–2.25) | 1.42 (1.18–1.70) |
| 25–29 | 1.16 (1.02–1.33) | 0.89 (0.55–1.44) | 090 (0.56–1.45) | 1.18 (1.00–1.38) |
| 30–34 | 1.06 (0.93–1.22) | 0.96 (0.58–1.60) | 0.96 (0.57–1.60) | 1.14 (0.98–1.33) |
| Race (reference: White) | ||||
| Black | 1.38 (1.23–1.54) | 1.14 (0.77–1.70) | 1.14 (0.77–1.69) | 1.38 (1.20–1.59) |
| Asian | 2.34 (1.88–2.92) | 1.21 (0.22–6.61) | 1.60 (0.36–7.22) | 2.57 (2.05–3.22) |
| American Indian and Alaskan Native | 0.97 (0.79–1.18) | 0.76 (0.40–1.45) | 0.76 (0.40–1.44) | 1.00 (0.78–1.30) |
| Other | 1.08 (0.83–1.43) | 0.26 (0.07–0.99) | 0.28 (0.008–1.00) | 1.03 (0.77–1.40) |
| Hispanic (reference: non-Hispanic) | 0.89 (0.77–1.02) | 1.07 (0.68–1.67) | 1.06 (0.68–1.67) | 0.85 (0.72–1.00) |
| Any tobacco use (reference: none) | 1.29 (1.15–1.44) e | 1.15 (0.82–1.61)f | 1.17 (0.83–1.64)g | —h |
| Any prenatal carei (reference: none) | 0.60 (0.43–0.81) | 1.41 (0.60–3.32) | 1.41 (0.60–3.32) | 0.56 (0.37–0.84) |
| Health insurance coveragej (reference: no) | 1.05 (0.85–1.29) | 0.85 (0.40–1.81) | 0.86 (0.41–1.84) | 1.05 (0.83–1.35) |
| Any physical abusek (reference: none) | 2.72 (2.26–3.27) | 3.24 (2.10–5.00) | 3.22 (2.09–4.97) | 2.82 (2.15–3.69) |
| Income (reference: ≥$73,000) | ||||
| $0–$23,999 | 2.17 (1.89–2.48) | 1.86 (1.13–3.09) | 1.85 (1.12–3.08) | 2.26 (1.94–2.65) |
| $24,000–$47,999 | 1.84 (1.61–2.11) | 1.34 (0.79–2.29) | 1.34 (0.79–2.29) | 1.97 (1.69–2.30) |
| $48,000–$72,999 | 1.17 (1.01–1.36) | 0.98 (0.54–1.79) | 1.01 (0.56–1.82) | 1.13 (0.96–1.34) |
| Mail Survey (reference: phone) | 1.25 (1.13–1.39) | 1.11 (0.79–1.54) | 1.11 (0.80–1.53) | 1.24 (1.10–1.40) |
Bolded numbers indicate statistical significance.
In this primary analysis, e-cigarette use is defined as self-report any use within the 2 years before survey completion.
In this sensitivity analysis, prepregnancy e-cigarette use is defined as use during the 3 months before pregnancy.
In this sensitivity analysis, during pregnancy e-cigarette use is defined as use during the last 3 months of pregnancy.
In this sensitivity analysis, e-cigarette use is defined as self-report any use within the 2 years before survey completion and was restricted to those who reported no use of combustible cigarettes or hookah.
Any tobacco use is defined as any combustible cigarette and/or hookah use within the past 2 years for primary analysis.
Any tobacco use defined as combustible cigarette and/or hookah use within the 3 months prior pregnancy.
Any tobacco use defined as combustible cigarette and/or hookah use during the last 3 months of pregnancy.
Anyone with tobacco use (combustible cigarette and/or hookah use) during the 2 years before survey completion was excluded for this analysis.
Any prenatal care is defined as prenatal care during the last trimester.
Health insurance is defined as self-reported coverage during the entire pregnancy.
Physical abuse is defined as self-reported physical abuse during the entire pregnancy.
CI, confidence interval; OR, odds ratio.
Sensitivity analyses
Pre-pregnancy e-cigarette use: among those who reported e-cigarette use in the 3 months before pregnancy, 18.0% (n = 479) had PPD compared to 17.2% (n = 311) of those who did not report e-cigarette use in the 3 months before pregnancy. There were no statistically significant differences in the odds of PPD by e-cigarette use group in the unadjusted (OR = 1.06; 95% CI: 0.81–1.18) or adjusted (AOR = 1.00, 95% CI: 0.76–1.32) analyses; offering inconclusive evidence (Bayes Factor = 0.34, 0.33; respectively).
During pregnancy e-cigarette use: among those who reported e-cigarette use in the last 3 months of pregnancy, 19.3% (n = 176) had PPD versus 17.4% (n = 617) of those who did not use e-cigarettes in the last 3 months of pregnancy. There were no statistically significant differences in the odds of PPD by e-cigarette use group in the unadjusted (OR = 1.14; 95% CI: 0.82–1.58) and the adjusted (AOR = 1.03, 95% CI: 0.73–1.46) analyses; indicating inconclusive evidence (Bayes Factor = 0.50, 0.41; respectively).
Past 2-year e-cigarette use excluding those who reported use of combustible cigarettes and/or hookah: excluding those who reported use of combustible cigarettes and/or hookah, 14.8% (n = 97) had PPD among those who reported using e-cigarettes in the past 2 years compared to 10.4% (n = 5,141) of those who reported no use of e-cigarettes in the past 2 years. In the unadjusted logistic regression, e-cigarette use was significantly associated with higher odds of PPD (OR = 1.78, 95% CI: 1.30–2.38). For the adjusted logistic regression, the direction of the effect indicated a potential association with PPD, but the 95% CI was compatible with there being no effect (AOR = 1.27, 95% CI: 0.88–1.84); the Bayes Factor (0.81) also indicating inconclusive evidence.
Lastly, in the analyses of prepregnancy and during pregnancy e-cigarette use variables as ordinal variables, the unadjusted logistic regression findings were not statistically significant (Supplementary Table S2). Further, for adjusted analyses, prepregnancy use of e-cigarettes was not associated with PPD. For use during pregnancy, the model had poor fit indices and, thus, not reported here.
Discussion
This study examined the relationship between e-cigarette use and PPD in a nationally representative sample of mothers in the United States. Overall, in the adjusted models, there were no statistically significant associations between any e-cigarette use, as compared to no e-cigarette use, and PPD where e-cigarette use during the past 2 years before completion of the survey (which occurred at 2–6 months postpartum), 3 months before pregnancy, or the last 3 months of pregnancy was considered. However, unadjusted logistic regression, where any e-cigarette use (vs. no use) during the past 2 years showed a statistically significant difference such that e-cigarette use was associated with greater odds of PPD. This outcome was also found when respondents with other combustible cigarette and/or hookah use were excluded from the unadjusted logistic regression analysis. For analyses of e-cigarette use during the 3 months before pregnancy or the last 3 months of pregnancy, neither the unadjusted nor the AOR were statistically significant. This suggests that those who use e-cigarettes are more likely to experience PPD, but both PPD and e-cigarette use may be independently related to other characteristics, including but perhaps not limited to those described in the sensitivity analyses. Moreover, we defined e-cigarette use broadly (any use compared to no use) and, therefore, it is possible these observations are underestimating the association between e-cigarette use and PPD.
While our study is among the first to explore the association between e-cigarette use and PPD, other research has examined this association during pregnancy. Specifically, in a sample of 1,365 women recruited at a low-income, urban clinic, Rollins et al. observed a higher prevalence of depressive symptoms during pregnancy among those who reported e-cigarette use with or without other tobacco use (n = 54; 32.5%) compared to those who used combustible cigarettes without e-cigarette use (n = 372; 18.9%) or compared to those who did not use any nicotine (n = 939; 10.1%).15 It is possible that our results were inconsistent due to the differences in the samples (i.e., a U.S. nationally representative sample vs. a convenience sample from a single site in one Northeastern state in the United States), measurement and timing of e-cigarette use (i.e., assessment of up to 2 years before survey completion vs. assessment of up to 3 months before pregnancy), and/or in the primary outcome (i.e., depressive symptoms during postpartum vs. during pregnancy). More broadly, the evidence for the use of e-cigarettes during pregnancy as a harm reduction approach is still developing. Whether or not e-cigarettes contribute to the development of PPD, the overall evidence related to the potential of e-cigarettes to reduce harms of combustible cigarette use is still insufficient to make recommendations for or against using e-cigarettes during pregnancy.23
Combustible cigarette use is an established risk factor for PPD.7–9 E-cigarette use is also associated with depressive symptoms in nonpregnant/postpartum individuals per a meta-analysis done by Liu et al.16 Heterogeneity in the underlying studies precluded a sensitivity analysis, so it is not known if that association is also explained by underlying factors associated with people who use e-cigarettes or with e-cigarettes per se. Further, the postpartum period and associated mood changes are markedly different from a nonpregnancy state, in that the postpartum period is associated with a higher overall risk of depressive symptoms. A final possible implication of these observations is that while adjusted analyses indicate that e-cigarette use in the previous 2 years is not an independent risk factor for PPD, it may be a useful clinical marker to identify individuals who may be at high risk for PPD based on the unadjusted analyses. That is, while our observations indicate that any e-cigarette use within the previous 2 years is not causally related to PPD, it may be a proxy for risk of PPD and clinicians may consider using this as an indicator for individuals who should receive additional screening for PPD.
Although our observations are strengthened by the use of a validated nationally representative data, the following limitations should be considered. First, due to sample size limitations and limitations in the type of data collected in PRAMS, we had to crudely classify our sample by any e-cigarette use compared to no e-cigarette use. We were not able to account for how regularly or heavily e-cigarettes were used, or what type/s of e-cigarette products were used (e.g., nicotine levels, flavors, device characteristics). It is possible that those who use e-cigarettes more frequently or who use e-cigarettes with certain characteristics (e.g., higher nicotine levels) may be at increased risk of PPD. Next, this was a cross-sectional study, which does not allow for the temporality between the e-cigarette use and PPD to be assessed. In other words, it is possible that those who were at less risk of experiencing PPD may have had a lower chance of using e-cigarettes during the perinatal period. Another limitation is that the data were self-reported. Due to social stigma related to both e-cigarette use and PPD, participants may have underreported either or both variables, therefore, biasing our results toward the null. Additionally, e-cigarette use was not biochemically confirmed and PPD was not measured with a clinical diagnosis. Further, due to the available survey data, we were only able to assess the use of three nicotine/tobacco products (e-cigarettes, combustible cigarettes, and hookah). It is possible the use of other types of nicotine/tobacco (e.g., cigarillos, smokeless tobacco, nicotine replacement therapy) may have influenced our results. Finally, these data were collected from 2016 to 2019. While these are the most recent data available, the landscape of tobacco/nicotine use is continually changing including the development of novel e-cigarette and other tobacco/nicotine products as well as changes in regulation related to e-cigarette and other products. Continued future investigations of the relationship of e-cigarettes and PPD is necessary. Specifically, prospective observational studies are needed that assess detailed information about e-cigarette and combustible tobacco use, with biochemical confirmation of use, throughout the perinatal period to measure risk of clinically diagnosed PPD while taking numerous confounders into consideration (e.g., affect, socioeconomic status, and history of depression). This type of study design would allow for stronger information to help determine a potential causal relationship between the two variables of interest.
In summary, e-cigarette use is increasingly common during pregnancy.24 Our results indicate that self-report of any (vs. no) e-cigarette use in the 2 years before childbirth, 3 months before pregnancy, and last 3 months of pregnancy is not associated with self-reported PPD after adjusting for known confounders. Given the growing prevalence of e-cigarettes (Bandi et al., 2021) plus the emerging evidence suggests e-cigarettes may help with smoking cessation during pregnancy (Hajek et al. 2022), additional research is needed to replicate these results using prospective study designs, biochemical confirmation of e-cigarette use, detailed characterization of use (e.g., frequency of use, device characteristics), and clinical confirmation of PPD within larger and more diverse samples.
Supplementary Material
Acknowledgment
We extend our thanks to Dr. Philip Smith for his input on the statistical analyses and to the PRAMS Working Group for their approval and input on this project.
Authors' Contributions
B.C. wrote the first draft of the manuscript and completed the analyses. A.M.A. conceived the study idea. A.M.A. and M.L.B. mentored B.C. All authors contributed to the development of the analysis plan, interpretation of results, revision of the manuscript, and approval of the final draft of the manuscript.
Ethics Approval
The methodology and protocol for the PRAMS data have been approved by the Centers for Disease Control and Prevention's (CDC) Institutional Review Board. This specific analyses has been approved by the PRAMS working group. The University of Arizona's Institutional Review Board review the project and determined oversight was not needed due to the use of de-identified publicly available data.
Disclaimer
The content is solely the responsibility of the author(s) and does not necessarily represent the official views of the NIH or the FDA.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
E.E.D. effort was supported by R01DA046360 from the National Institute on Drug Abuse (NIDA), FDA Center for Tobacco Products (CTP). N.P. was supported by R00DA045749.
Supplementary Material
References
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