Maternal smoking and low breastfeeding rates are both major public health concerns relating to the postpartum period, with health implications for both the mother and her child [1-8]. While many mothers are able to quit smoking during pregnancy, a substantial proportion will return to smoking by six months postpartum [9]. The latest UK statistics show that, despite 81% of mothers initiating breastfeeding at birth, by six months only 1% of UK infants are still breastfed [10].

Studies have consistently reported associations between smoking behavior (abstinence) and breastfeeding patterns [11-15], with the intention to breastfeed acting as a precipitating factor for reducing postpartum return to smoking, and then the initiation and continuation of breastfeeding being positively associated with smoking abstinence postpartum [16,17]. The intention to return to smoking is one of the strongest predictors of the intention not to breastfeed and the early cessation (<3 months postpartum) of breastfeeding [13,18]. These associations may be partly explained by confounders like sociodemographic factors [19,20], but they may also be attributable to concerns regarding safety of smoking while breastfeeding. This is despite online information from both the American Pediatrics Association [21,22] and the National Health Service (NHS) [23] that promotes the continuation of breastfeeding even if the mother smokes.

A relatively new product that may be useful for preventing return to smoking or supporting cessation of smoking is the electronic cigarette (e-cig) [24]. E-cigs are handheld devices that produce an aerosolized mixture from a solution typically containing concentrated nicotine, flavoring chemicals and propylene glycol [25]. The user draws a deep breath and inhales the vaporized liquid (a process known as vaping), which creates a similar experience to smoking combustible tobacco [26]. Although we accept that the long-term health effects of e-cigs cannot be fully assessed given the relatively short time they have been available for use, the current research suggests that e-cigs are likely safer than smoking traditional cigarettes and their use is proposed as a harm reduction tool for smokers [27,28].

Online forums are a popular and accessible community for mothers to discuss, debate and share opinions on anything relating to motherhood [29]. A method of research known as infodemiology analyzes online discussions to inform public health research [30,31], and previous studies of this type have studied e-cigs [32,33], breastfeeding [34] and parental health-seeking behavior [35]. With the popularity of parenting forums and increased use of social media for health-seeking advice, this study analyzed parenting forum discussions to determine opinions on e-cig use.

Very little research thus far has examined the use of e-cigs amongst postpartum women, with the current research available focusing on the use of e-cigs in pregnancy. Therefore, we aimed to explore online forum users’ current attitudes, motivators and barriers to using e-cigs as a breastfeeding mother through the analysis of data extracted from online parenting forums.

An infodemiologiocal approach was taken for this research, which is the analysis of data on internet forum sites for public health research [30,31]. This research is the first to describe how women are accessing information about e-cig use during the postpartum period and is the first to provide evidence of women proactively using e-cigs to prevent returning to cigarette smoking and to aid smoking cessation, particularly as breastfeeding mothers. Women have concerns regarding the potential risks of using an e-cig and utilize online forums to discuss these risks with other women. This type of forum provides both positive and negative social support.

The themes show that women are accessing both lay and professional information on e-cig safety and their use via multiple sources, but this information is not necessarily being interpreted correctly, or it is being met with a degree of mistrust and uncertainty. There are conflicting opinions on the use of e-cigs while breastfeeding, mainly due to health concerns regarding what may be transferred from e-cig to the breastmilk, and then to the infant, as well as concerns about harm from secondhand vapor exposure.

There are limitations to this form of infodemiological research, with the use of online forum data forgoing the possibility of following up with individual users or seeking clarification on the meaning of their words, which increases the risk of bias during coding. It is also impossible to establish the validity of posts, like being completely confident that a user who identifies as a breastfeeding mother is, in fact, a breastfeeding mother. The transferability of these themes to the general postpartum population is limited due to both the exclusive participation of forum users and also that all the transcripts came from only two parenting forums. There is also no way to completely establish the authenticity of the users on the forum or whether they have connections within the e-cig or tobacco industry. On the other hand, the use of online data has several strengths, like that discussions are free from the response bias that may be present within interviews, and that forum data provides discourse that has been written with the intention of expressing and debating opinion for the purposes of discussion rather than research. The use of forum data provides in-depth qualitative data, and in other research, the use of a discussion analysis tool found that online interactions involving conflicting viewpoints promoted more discussion and critical thinking [59]. Our research is novel in both subject matter and approach, and therefore should be treated as an exploratory qualitative piece upon which further research can be built. Thus far, this is the only piece of work that considers the motivators, barriers and opinions of breastfeeding mothers using e-cigs postpartum.

This work has improved our understanding of how and why women use e-cigs in the postpartum. For the first time we are able to understand and explore what evidence women are accessing to inform themselves about e-cigs and how this information is then interpreted. It also provides the first evidence of women perceiving their use of e-cigs postpartum to be preventative of a return to smoking. We are also better able to understand the concerns women have around the impact of e-cigs on infant health, in particular that a misattribution of nicotine as the most harmful substance transferred to infants via a smoking mother’s milk is sometimes an obstacle to the use of e-cigs postpartum.

Previous research has highlighted that some women perceive that smoking affects the quality of their breastmilk in a way that is detrimental to their infant’s health [15,60] despite the previous decade of recommendations from professional health bodies encouraging women who do smoke to continue breastfeeding [23]. This current research helps us better understand the fears women have in relation to e-cig use, most notably in relation to the perceived lack of consistent, evidence-based information about e-cig safety and the effects of nicotine transferring through breastmilk. By addressing these concerns, we could improve the acceptability of using a vape alternative for women who are breastfeeding and also smoke, while minimizing harm to the mother and infant and reducing their fears regarding their child’s exposure to vape constituents via breastmilk.

Prior work using forum data considering e-cig use during pregnancy [31] identified three distinct themes explaining the ways in which forum users debated the use of e-cigs while pregnant: (1) quitting (nicotine) abruptly and completely is unsafe; (2) vaping is the lesser of two evils; and (3) vaping is not worth the risk. The authors concluded that women perceived their addiction to cigarettes as more than just a nicotine addiction, and that the behavioral aspects of smoking were also important, hence the potential for e-cigs. In our forum transcripts, women reported using e-cigs either to prevent returning to smoking or to quit smoking after having already relapsed. Returning to smoking, or perceived likelihood of returning to smoking, was often triggered by the demands of motherhood, perceived stress or the feeling of needing some personal time. It is interesting that some women are choosing an e-cig for similar reasons that have previously been identified for why women return to smoking traditional cigarettes, including smoking for relief and nostalgia for their former self [61]. Although evidence is limited, it is suggestive that women who use e-cigs during pregnancy are still likely to return to cigarette smoking, with one qualitative study partly attributing this to a lack of professional consensus within healthcare on the safety of e-cigs [62]. Lack of consistent and transparent information from professional health sources is a significant barrier to e-cig use postpartum, an issue that needs to be addressed given the success some women have reported on using e-cigs to prevent a return to smoking.

In our study, women also displayed mixed views on e-cig safety. The majority of users accepted that e-cigs were probably safer than cigarettes; however, there was a lot of skepticism and mistrust of the evidence for this. Health bodies such as PHE and the NHS were classed as biased due to their targets of reducing cigarette smoking, and comparisons were made regarding previous health recommendations that have since proven to be detrimental. Women were accessing scientific journals to learn more about e-cigs; however, it was often mistranslated. News media stories are often shared among online groups if a headline is particularly provocative, and even when these stories were discredited users felt that these fears must be based on something. Lack of evidence or mistrust of the current evidence appears to be a barrier for the use of e-cigs as a harm reduction tool during the postpartum period, which often gives rise to the thought process that it is better to deal with the familiar than risk the unknown. This skepticism is not confined to e-cigs, as previous research has identified that some women believe NRT patches to be harmful and that smoking is preferable to using them [63].

Uncertainty regarding e-cig safety often led to women discussing the concept of risk either in terms of comparison to smoking or in justifying the perceived risk. This individual assessment of risk is not unique to e-cig use and is attributed to a knowledge deficit between professionals and the lay public [64]. The risk assessment formed by lay people is complex, situationally influenced and reflects their personal values [65], and all of this is particularly relevant when considering the morality of motherhood and the negative attitudes some women hold towards vaping while breastfeeding. For example, the negative attitude towards government-backed advice on risk is assumed to be due to perceived exclusion from science-led and political decision-making [66]. With this in mind, involving women in discussions about e-cig use and safety within usual postnatal visits could help them make an informed choice on e-cig use.

This knowledge deficit could explain the reliance on unverified evidence from social media, news publications or web content found within this study. These sources of information are written to inform a general population but are also written to be read with ease, so this may be why women are engaging more with this type of evidence. There is also a reliance on others for information, with women seeking support and advice from health care professionals but also from other mothers. It is unsurprising that new mothers would seek information that is easy to access and easy to read, but the use of online forums also provides anonymity, which provides some form of protection of self while receiving or giving information [67]. Therefore, despite judgement from other mums, the ability to remain anonymous allows a mother to still have some perceived control over how those around her perceive her morally and ethically.

The concept of risk is a subjective one, and while there was much discussion of it, this risk was not defined apart from discussions on nicotine. There were suggestions of harm drawn from media conclusions, but risk itself was often discussed as a general term. Other lifestyle behaviors such as alcohol and caffeine consumption were often used as a comparison to justify this risk concept, with forum users suggesting that if these behaviors were acceptable for mothers then vaping was also acceptable. However, the risks of nicotine exposure to the baby were one of the defined examples of risk. There were unsubstantiated attributions that nicotine caused SIDS, fears of infants becoming addicted to nicotine and being forced to experience withdrawal once breastfeeding ceased, and concerns that using e-cigs to manage the mother’s mental health needs (such as stress) would lead to children who grew up exposed to unhealthy coping mechanisms. The exposure of infants to nicotine was also the subject of judgement. Some women would argue that a mother asking if it was acceptable to vape was actually asking if it was acceptable to feed her baby nicotine, suggesting that the nicotine became a deliberate exposure rather than a byproduct of the breastmilk. This concern regarding nicotine acted as a barrier to the use of e-cigs postpartum, and although some women acknowledged the known harmful substances in cigarettes, their primary concern seemed to be nicotine. Harmful effects from nicotine are not fully understood but are likely to be minimal compared to the effect of other compounds. Although it is accepted as an extremely addictive substance [68], there are far more worrying compounds within cigarette smoke, which research suggests are either not present in e-cigs or are present at significantly lower levels [69]. There is still limited empirical data on the safety and composition of e-cig vapor; however, there has been some promising toxicity testing that has evaluated the chemical nature of the vapor generated from e–cigarettes [69]. Despite the identification of certain toxicants within e-cig vapor, these levels are <1% of the levels present in cigarette smoke. E-cigs therefore have potential as a harm reduction tool, as confirmed by the PHE report [70].

This research closely relates to the “good mother” social construct [71], as shown with the various justifications of perceived risk, or the moralized stances against the use of any nicotine-containing products by a breastfeeding mother. The role of the mother is one that is subject to historical and cultural experiences, and social networks provide a framework to help make sense of culturally defined experiences and responsibilities [72]. The use of an online forum varies slightly from this by bringing together women from various socioeconomic backgrounds, ages, experiences and cultures to discuss breastfeeding. Therefore, the social constructs of a “good mother” are more explicit, particularly for infant feeding [73], whereby a “good mother” is synonymous with a breastfeeding mother without considering any cultural or environmental context [71]. The justification of risk here is similar to that of mothers who justify smoking by claiming that it is for their baby’s sake [74], that is, it is better for the baby to have a mother who isn’t stressed or is more alert.

In conclusion, this study has shown women hold a mixture of views on the acceptability of vaping as a mother, but some women are using (or are interested in using) e-cigs in the postpartum period. They are seeking, and need, more reliable information to facilitate their use, especially when breastfeeding. Therefore, we need further research that considers how women could have opportunities to ask and receive advice, perhaps by opening a dialogue on e-cigs between mothers and health care providers which could potentially reduce rates of maternal smoking and increase breastfeeding rates.