Newspaper media representation of electronic cigarette use during pregnancy

ABSTRACT

Background

Smoking during pregnancy is associated with many adverse foetal outcomes, and electronic cigarettes (EC) have the potential to aid women to quit smoking in pregnancy. The mass media influence how people feel about products and treatments, so it is important to establish how they portray EC use during pregnancy.

Methods

UK newspaper articles which mentioned EC use during pregnancy were identified using the database Lexis Library. Articles were assigned a category (positive, negative or neutral), and an inductive thematic analysis was conducted to identify themes within the articles.

Results

Of the 55 newspaper articles, 16 (29%) were positive, 32 (58%) were negative and 7 (13%) were neutral. Four overarching themes were found within the 55 articles: ‘advice’, ‘impact on health of the foetus’, ‘uncertainty’ and ‘awareness’. Large increases in the frequency of articles reporting on EC were noticed between November 2015 and March 2016 and between February and March 2018.

Conclusions

The UK mass media mainly portray EC use during pregnancy as negative, which could impact women’s decisions to use these devices in pregnancy. More research is needed to investigate the true effectiveness of EC to aid smoking cessation in pregnancy.

Background

Smoking during pregnancy is thought to be the largest preventable cause of adverse outcomes in the child.¹ Low birth weight, birth defects, premature births, placental abruption, placental praevia and intrauterine growth retardation have all been linked to smoking during pregnancy.^2–6 Additionally, studies have shown that the offspring of women who smoked during pregnancy are at an increased risk of becoming overweight or obese, developing type 2 diabetes mellitus and developing higher blood pressure later in life.^7–9 Furthermore, nearly half of those who quit during pregnancy return to smoking by 6 months postnatally,¹⁰ thus continuing to impact the mother’s health and the child through exposure to second-hand smoke. The child is also at greater risk of becoming a smoker themselves when they are older.¹¹

In the UK, 10.8% of women smoke throughout their entire pregnancy; however, in certain areas, such as Blackpool, this figure can be as high as 27%.¹² Consequently, smoking cessation during pregnancy is a priority for public health interventions in the UK. The Tobacco Control Plan for England has set the target of reducing the prevalence of smoking in pregnancy to 6% or less by 2022.¹³

Nicotine replacement therapy (NRT) is available for pregnant women on the National Health Service (NHS) in the UK, and can include patches, gums and nasal sprays. Unfortunately, these smoking cessation strategies are often unsuccessful during pregnancy,^14–16 and those who fail to quit within the first trimester have decreased motivation to quit as their pregnancy progresses.¹⁷ For example, NRT has been found to be ineffective in pregnancy,^{14,  18,  19} possibly because the standard dose of nicotine is metabolized at a faster rate than in non-pregnant women.²⁰ Since traditional NRT is ineffective during pregnancy, alternative strategies are needed. The most popular method of quitting smoking in the general population in the UK is using an electronic cigarette (EC), with around 37% of people using them for quit attempts.²¹ It is predicted that EC will out-sell cigarettes by 2023.²²

Although research has addressed EC use in the general population, their use during pregnancy has not received as much focus. However, one US study showed that 53% of pregnant smokers had tried an EC,²³ indicating that they may be an acceptable method for attempting cessation. Furthermore, Public Health England (PHE) has stated that using an EC is likely to be 95% safer than traditional cigarettes.²⁴ Although this figure is derived from evidence from the general population, EC use is still more preferable to smoking by pregnant women.^{25,  26}

The media are an important source of information for the public as well as medical professionals regarding health and medical information.^{27,  28} They play a role in setting agendas and framing issues—influencing how people act and think about topics.²⁹ The media can also influence views about the importance of issues among the public and government policy makers,³⁰ as well as influencing health-related decision making in the public.^{31,  32} For example, when participants have been exposed to conflicting news coverage of EC, those who were exposed to negative headlines reported increased beliefs about harms and lower beliefs about benefits compared with those who were exposed to positive news headlines.³³ Therefore, portrayal of EC in the news can influence people’s beliefs about harms and benefits of EC use.

There is a need to understand how the use of EC in pregnancy is portrayed in the media, as this could potentially influence the attitudes and behaviours of pregnant smokers as well as healthcare professionals who may be offering smoking cessation advice.

Methods

The database Lexis Library was searched using the search terms ‘pregnant’ or ‘pregnancy’ and ‘electronic cigarette’, ‘e-cig’, ‘e-cigarette’, ‘vape’, ‘vaper’ or ‘vaping’. The search included articles published up to 3 November 2018. All UK newspapers from all industries and all subjects were searched, representing a range of readership profiles, from tabloid (e.g. Sun, Mirror) to serious (e.g. Guardian, Times). The database also included online versions of the newspaper, e.g. Daily Mail and MailOnline.

All articles mentioning EC use in pregnancy, whether they were the focus of the article or just a passing mention, were included. Articles were excluded if they were duplicate articles; appeared in both print and online (in which case the print version was included); only mentioned other individuals using an EC around pregnant women or were letters. This resulted in a total of 55 articles included in the analysis.

A content and inductive thematic analysis was undertaken in order to systematically categorize content and to generate themes contained within the articles. This was an iterative process involving the rereading of articles. Because the focus of the study was to identify themes within the articles used in support or opposition to the use of EC in pregnancy, a code was assigned to each article as to whether they were ‘positive’, ‘negative’ or ‘neutral’ when referring to EC use in pregnancy. Next, a thematic analysis was carried out using the framework described by Braun and Clarke.³⁴ After rereading the articles, initial codes were generated inductively, and then refined through further coding and discussion among the researchers to generate four themes. Within a single article, there could be multiple themes, and a theme did not have to be the main focus of the article to be deemed present. To ensure reliability of the coding, one researcher (M.M.) coded all articles, and the other researcher (A.H.) coded 50%, which were chosen using a random number generator. The two researchers met to discuss their coding and refine coding labels.

Results

A total of 55 articles were included in the analysis, representing 29 different newspapers. Articles ranged in length from73 words to 3026 words. Of the 55 articles, 16 (29%) were positive, 32 (58%) were negative and seven (13%) were neutral. Judgements were made by considering the headline and the language used. Neutral articles tended to present more of a balanced viewpoint by discussing both sides of the argument. Some provided facts, such as information about a new trial of the safety of EC in pregnancy. The neutral articles discussed uncertainty around the long-term effects of EC use. EC use in pregnancy was the main topic in 15 (27%) of the newspaper articles, and 40 (73%) mentioned this as a sub-topic. Of the newspaper articles, 19 (35%) were from broadsheet newspapers and 36 (65%) were from tabloid newspapers.

Despite searching from inception to November 2018, no articles containing the search terms were published before 10 January 2013. The first newspaper article was published in January 2013, and of the 55 newspaper articles, the majority were published in the last 3 years (n = 43, 78%). Six were published in 2013, two were published in 2014, four were published in 2015, 14 were published in 2016, five were published in 2017 and 24 were published in 2018.

The thematic analysis identified four main themes: advice, impact on health of the foetus, uncertainty and awareness. Among the 55 articles, 39 (71%) contained the theme ‘advice’, 31 (56%) contained the theme ‘impact on health of the foetus’, 21 (38%) contained the theme ‘uncertainty’ and 14 (25%) contained the theme ‘awareness’. Fig. 1 highlights the ideas and themes contained within a thematic map. There were no apparent differences in the themes contained within broadsheet newspapers versus tabloid newspapers.

Fig. 1.

Thematic map of the ideas and themes found within newspaper articles mentioning EC use and pregnancy.

Advice

Within this theme, articles expressed an opinion about whether a woman should or should not use an EC during pregnancy, stating this either explicitly or implicitly. This theme contained three ideas: pregnant women should use an EC; pregnant women should not use an EC and pregnant women should be warned about EC.

One prominent idea was that pregnant women should use an EC during pregnancy if they cannot give up tobacco, with all but one, positive articles specifically stating that pregnant women should ‘switch’ to EC instead of tobacco. It was usually implied or stated that this should be done in an attempt to completely quit smoking tobacco. Articles would either mention that this is common practise in the UK already or that women should be encouraged to ‘switch’.

‘PREGNANT women who smoke should be encouraged to switch to e-cigarettes, health officials claim’

(Daily Mail (London), 6 February 2018)

Of the negative articles, 23 (72%) of them advised that pregnant women do not use EC, with three citing the opinion of an expert in this topic area while others stated that this was the recommendation of the time which the newspaper was written. All three of these articles which cited expert opinion advising against EC use were published before 2017. These articles stated EC should not be used during pregnancy because the devices expose pregnant women to nicotine. These articles would either state explicitly that EC should not be used during pregnancy or implicitly that EC are not suitable for use during pregnancy.

‘E-cigarettes are also not suitable for pregnant women because nicotine passes through the placenta’

(Daily Mail (London), 29 October 2013)

Following on from the previous idea that pregnant women should not use EC, a third of the negative articles go as far as to warn women about EC use during pregnancy, highlighting potential dangers to their unborn child. These articles would often use words such as ‘warn’ or ‘caution’.

‘Pregnant women warned “e-cigarettes could harm your unborn baby” ’

(mirror.co.uk, 11 February 2016)

Impact on health of the foetus

Articles described whether the use of an EC during pregnancy is safe. These articles often cited scientific studies as their source of evidence, which seemed to discover an association between EC use during pregnancy and an adverse outcome for the foetus. Experts in this topic area were also often cited as the article’s source of evidence. This theme contained three ideas: EC are harmful to a foetus; EC are just as bad as or worse than tobacco for the foetus and EC are safer for a foetus than tobacco.

One idea which frequently appeared was that EC use is harmful to the foetus. Four of these articles mentioned increases in risk of specific conditions, such as sudden infant death syndrome, stillbirth and asthma. These articles attributed the increase in risk, to the nicotine found in EC. Others implied that vaping was not safe for the foetus because EC smoke contains harmful chemicals. These articles concluded that vaping during pregnancy is not safe.

‘Vaping in pregnancy increases a child’s risk of asthma, new research suggests. Ecigarettes may cause the potentially life-threatening lung condition even if they do not contain nicotine, a study found’

(MailOnline, 11 September 2017)

One idea captured within this theme was that EC are just as bad as or worse than tobacco during pregnancy. This idea only appeared in newspapers from February 2016 and was always stated with uncertainty, referencing a recent scientific study carried out in the USA on mice.

‘A ground-breaking study reveals the devices [e-cigarettes] could even be as dangerous as normal cigs for mums-to-be’

(The Sun (England), 12 February 2016)

In contrast, the idea that EC were a safer alternative to tobacco appeared quite frequently. This was either mentioned with certainty or uncertainty. Articles would often use phrasing such as ‘better’, ‘less toxic’ and ‘safer’ when referring to EC. While stating that EC use during pregnancy is safer than smoking tobacco, all articles explicitly or implicitly mentioned that it is best not to smoke anything at all.

‘[Vaping] is certainly safer than smoking traditional cigarettes because the unborn child is exposed to fewer toxins. But the best choice for a pregnant smoker is, of course, to neither smoke nor vape’

(The Sun (England), 7 February 2018)

Uncertainty

Articles highlight the lack of studies in this topic area, stating that more research is needed. Often, this idea appears after the article mentions the theme advice, adding uncertainty to the advice given, whether it is positive or negative.

‘Janet Fyle, policy adviser with the Royal College of Midwives, said any research into the issue on the effects of vaping on the unborn child would be welcome. “We have to say the jury is still out on e-cigarettes,” she said’

(The Sunday Herald (Glasgow), 4 September 2016)

Awareness

Articles express the need for women to better understand the risks or benefits of EC use during pregnancy, often concluding that pregnant women are misinformed about EC use during pregnancy.

Those articles that encourage EC use during pregnancy imply that women think the devices are more dangerous than is true; sometimes highlighting the need for women to be given the correct advice and for women to positively change their perceptions. All but one positive article mentioned that pregnant women should be encouraged to use an EC instead of tobacco, highlighting how women do not understand the benefits of using these devices enough to use one. PHE is often cited as the source of information in these articles.

‘Hazel Cheeseman, director of policy at Ash, said pregnant woman also need to be more confident using e-cigarettes as an alternative to smoking… “Women need to have confidence in these products that they are a safer alternative, if they are going to be encouraged to use them sufficiently.” ’

(Belfast Telegraph Online, 27 March 2018)

Within this theme, half of the articles were positive about EC use during pregnancy, and highlighted how women falsely perceive the devices to be more dangerous than they are. However, some articles emphasized the dangers of EC use during pregnancy, and implied that women do not appreciate the risk associated with this. These articles implied a need to negatively change women’s perceptions regarding EC use during pregnancy, to which findings from recent studies are cited as a means of doing so.

‘Are they safer than cigarettes? The answer’s not there but they don’t appear to be. “Our findings should open people's eyes by showing that this is something that potentially can be harmful if used during pregnancy” ’

(Scottish Daily Mail, 12 February 2016)

Discussion

Main findings of this study

This study was the first to analyse how EC use in pregnancy is portrayed in the UK newspaper media. As the popularity of EC has increased, coverage in UK newspapers has also increased, with the majority of articles appearing in the last 3 years, and none prior to 2013. Less than a third portrayed EC use in pregnancy as positive. Over half portrayed it as a negative behaviour. Within the articles, four main themes were identified: advice (articles that provide an opinion on whether pregnant women should or should not use an EC); impact on health of the foetus (articles discussing the safety for the foetus of the mother using an EC); uncertainty (articles highlighting the lack of research in this topic area) and awareness (articles which mention the need to change pregnant women’s perceptions about EC).

What is already known on this topic

EC are the most popular method of quitting smoking in the UK,²¹ but little is known about how effective they are in pregnancy. Since EC do not burn tobacco, their vapour does not contain carbon monoxide or tar. As relatively new products, long-term evidence on EC is not yet available. However, based on evidence so far, carried out in the general population, leading UK health and public health organizations state that EC are far less harmful than tobacco cigarettes. These devices are thought to be 95% safer than smoking tobacco,²⁴ even in pregnancy.²⁶ The Royal College of Physicians also concluded that although the effects of maternal use of EC on the foetus are unknown, they are likely to be as safe as NRT, on the grounds of the very low levels of toxins in vapour.³⁵ Qualitative studies suggest they are useful for smoking cessation in pregnancy.³⁶

One previous study³³ has found that conflicting news headlines about EC can influence beliefs about harms and benefits of the devices. A study exploring media representations of EC in general found that the theme ‘Healthier Choice’ was the most commonly occurring and that the percentage of articles that mentioned risk and uncertainty decreased over time.³⁷

There are no studies exploring the media representation of EC use during pregnancy, but one study looked at discussions of vaping during pregnancy on an online forum and found distinct views that EC were a suitable harm reduction tool, or that EC are dangerous and should be avoided.³⁸

What this study adds

This is the first study to give an indication of how EC use during pregnancy is portrayed in the UK media. In the UK, 40% of people read printed newspapers as their source of news and 37% of people use the internet (excluding social media).³⁹ It is therefore evident that the newspaper media plays a large role in informing the public, so any opinions portrayed about EC use during pregnancy will reach many people. The fact that the majority of the articles portrayed EC use in pregnancy as a negative behaviour is important in terms of the potential these devices play in harm reduction. Messages portrayed in the media are likely to influence people’s beliefs about harms and benefits of EC use in pregnancy, and consequently may influence behaviours. Conflicting information may deter pregnant smokers from switching to a less harmful product if they are unable to quit using traditional methods. The findings highlight the need to accurately educate and support pregnant smokers, as well as health professionals, about all possible harm reduction efforts. Although NRT is the preferred treatment for quitting smoking in pregnancy, if a pregnant smoker chooses to use an EC she should not be discouraged from doing so.²⁶ The negative portrayals in the media could influence the views people have about EC, irrespective of what the evidence suggests, or what official guidelines say.

Limitations of this study

First, only one database (Lexis Library) was used to conduct the search; however, this is the most comprehensive database for searching newspapers, but it does not include BBC News Online, which is a popular source of news for people in the UK. Second, this study only considered newspapers within the UK. Other countries’ media may portray EC use during pregnancy differently. Third, it is not possible to determine the effect that the news stories have on perceptions and behaviours among pregnant smokers or health professionals.

Conclusions

The UK mass media mainly portray EC use during pregnancy as negative, which could impact women’s views of these products and subsequent decisions to use or not use these devices in pregnancy for stopping smoking. More research is needed to investigate the true effectiveness of EC to aid smoking cessation in pregnancy, as well as the long-term effects.

Funding

This work was supported by Medical Research Council [grant number MR/K023195/1] for the UK Centre for Tobacco and Alcohol Studies, which includes funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council and the Department of Health under the auspices of the UK Clinical Research Collaboration. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Max Moyse, Medical student

Abby Hunter, PhD