Use of electronic cigarettes (e-cigarette) and hookah is on the rise among adolescents . E-cigarette safety is a topic under heated debate, with proponents highlighting the potential benefit as a harm reduction product for current smokers, while public health officials express concern about the lack of data on long-term health risks . Recent data show that e-cigarette use is becoming more acceptable among middle and high school students , as the amount of these students who reported ever use of e-cigarettes doubled between 2011 and 2012 and continues to rise . Similarly, hookah use is increasing in high school students, where one study revealed that as many as 20 % of high school seniors have tried hookah [5, 6].
Considering the rise of e-cigarette and hookah use among young people, including females of reproductive age, questions emerge regarding the safety of use during pregnancy, and the immediate and long-term health risks for both mother and fetus. In other words, do pregnant and reproductive aged women consider e-cigarettes safer than, equivalent to, or higher risk than combustible tobacco cigarettes? Is this concordant or discordant from current recommendations and existing knowledge? By addressing these gaps in consumers’ knowledge can we enable informed decision regarding use, and potentially prevent long term and multigenerational exposures?
E-cigarettes deliver liquid nicotine, amongst other ingredients, as an aerosol produced by heating and vaporizing the liquid components through a battery charged atomizer. The composition of the liquid component varies and is often composed of flavoring substances, propylene glycol and glycerin . Scientific publications vary in the levels of carcinogens and harmful substances found in these devices due to variation among products made by different companies . However, e-cigarettes are marketed as smoking cessation devices  and as better alternatives to regular cigarettes . This perception of harm reduction in comparison to regular cigarettes may be prevalent due to the lack of FDA regulation on e-cigarette advertising.
While e-cigarettes are marketed as smoking cessation devices [10, 11], there are few studies supporting this claim [1, 12]. Due to known adverse effects of smoking on the fetus, pregnant women are counseled on smoking cessation. Presently there are no clear recommendations as to whether nicotine replacement therapy in pregnancy substantially increases the likelihood of successful cessation. Use of the nicotine patch as a method to quit smoking during pregnancy has not been shown to be effective, possibly due to higher metabolism of nicotine in pregnancy or lower adherence [13–16]. Recent data from a randomized controlled trial reveal that infants born to smoking mothers who used a nicotine containing patch for smoking cessation during pregnancy were less likely to have impaired development compared to those whose mothers received a placebo patch . The potential for pregnant women to utilize e-cigarettes due to the claims of their efficacy as cessation devices is a strong possibility. However, their efficacy amongst gravidae is unknown at present.
Hookah, also called “water pipe,” delivers tobacco smoke with various contents to the smoker [18, 19]. It consists of a head, body, water bowl, hose and mouthpiece and can be filled with tobacco of different flavors, which appeals to adolescent users [18, 20]. A piece of coal is lit and placed on top of the head. By inhaling through the mouthpiece, the tobacco smoke enters the water bowl and reaches the mouthpiece through the hose . Research suggests that smoking hookah delivers similar amounts of carbon monoxide as regular cigarette smoking [22, 23]. Further contents of hookah smoke comprise heavy metals such as arsenic, chromium and lead, as well as nicotine and tar . The rise in popularity of hookah bars reflects the increased prevalence of hookah use .
For decades the adverse effects of smoking during pregnancy have been widely studied and reported [25–27]. Yet our knowledge of the effects of prenatal nicotine use (rather than as a component of combustible tobacco smoke) mostly comes from studies using animal models. Adverse effects include altered offspring lung development, metabolism and neurobiology . Risks for hookah use in pregnancy have also been reported . Not only does hookah smoking during the first trimester of pregnancy almost triple the risk of a low birth weight baby, these neonates also exhibited lower APGAR scores and were more likely to suffer from pulmonary issues . Hence the effects of hookah smoke exposure should be taken seriously.
The health effects of electronic cigarettes, especially with regards to pregnancy, are still poorly understood [29–31]. With the rising popularity of e-cigarettes within the adolescent and young adult populations, it was our goal to determine the perception of risks of e-cigarette and hookah use in pregnancy. For this study we conducted focus groups with pregnant women who were participating in the CenteringPregnancy® model of prenatal care. Our primary objectives were to determine the perceived risks of e-cigarette and hookah use during pregnancy, as well as to determine if there is a stigma associated with e-cigarette use while pregnant. A secondary objective was to determine common terms and colloquialisms for e-cigarettes and their use.