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MEDIA RELEASE - Vaping emerges as new concern in New Zealand infant deaths
Maternal vaping is emerging as a potential risk factor for sudden unexpected death in infancy (SUDI), according to New Zealand researchers who say their findings highlight the need to reassess public health messaging around vaping in pregnancy and bed sharing. Smoking during pregnancy by mothers and sharing the bed with their baby are recognised major risk factors for SUDI, especially when they occur together. In New Zealand smoking in pregnancy has decreased, but SUDI rates remain the same.
A recent study of a series of 101 SUDI deaths in New Zealand during 2022 and 2023 had detailed information about maternal nicotine exposure and the infant's sleep environment for 66 cases. Findings showed that smoking and/or vaping was reported in nearly three-quarters of these cases, while nearly 70 percent of infants had died while directly bed sharing.
Maternal vaping was reported in half of the SUDI cases involving direct bed sharing, compared with one in five cases where direct bed sharing was not reported.
“The interaction between maternal smoking and bed sharing is well established,” said lead author Professor Ed Mitchell, of Waipapa Taumata Rau – University of Auckland. “What is new and concerning is that vaping may be showing a similar pattern of risk as smoking, especially when combined with bed sharing. This raises the possibility that the effects of nicotine itself, rather than how nicotine is delivered, may be contributing to infant vulnerability.”
The researchers stress that the study does not prove that vaping causes SUDI. “Uncertainty is not reassurance,” says co-author Professor Barry Taylor, of the University of Otago – Ōtākou Whakaihu Waka.
“When the possible consequence is an infant death, a precautionary approach is warranted while the evidence develops.”
The researchers say the findings raise a fundamental question about current pregnancy advice. “Vaping has been widely approached as a safer alternative to smoking and a smoking cessation aid, including in pregnancy. Our findings suggest we need to consider all nicotine exposure during pregnancy, particularly when it is combined with bed sharing,” says Professor Mitchell.
In a related policy analysis published in the journal Acta Paediatrica, the same authors argue that pregnancy requires a different approach to nicotine policy from that used for non- pregnant adults. “Nicotine crosses the placenta, reduces foetal blood flow and lowers birthweight,” explains Professor Taylor. “We suspect that vaping may also produce the same infant ‘arousal defect’ seen with tobacco exposure.”
The researchers recommend a pregnancy-specific approach with nicotine-free the goal and coordinated support for women to achieve this across addiction services, pregnancy care, SUDI prevention and family support. “Every woman who vapes or smokes during pregnancy needs support that meets them where they are in terms of their circumstances and confidence,” says co-author Stephanie Cowan, of Change for Our Children. “The aim is to help every woman move towards cessation as early as possible in pregnancy, because that is how both mother and infant are protected.”
In the SUDI cases studied, 84.8 percent of deaths occurring during direct bed sharing involved maternal smoking or vaping. The researchers say more research is needed urgently to establish the specific risks associated with vaping during pregnancy. In the meantime, they argue that vaping, like smoking, should be discouraged in pregnancy and women supported to be nicotine-free as early as possible as the new health norm.
Expert Reaction
These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.
Associate Professor Kelly Burrowes, Auckland Bioengineering Institute, University of Auckland.
"I support the precautionary approach taken by the authors. We have known for a long time that smoking during pregnancy is harmful, including increasing the risk of SUDI. There is now growing evidence that vaping is not harmless either. Studies are reporting cardiovascular and vascular effects from vaping, and emerging evidence in pregnancy has associated vaping with outcomes including preterm birth, low birth weight and babies being small for gestational age.
"However, it is important not to overstate what this particular SUDI study can tell us. It is a case series without a comparison group, so it cannot establish that vaping causes SUDI or tell us how much vaping independently increases the risk. Smoking, vaping, dual use and infant sleep practices can also overlap, making their individual effects difficult to separate.
"Overall, I think these findings provide further reason to discourage vaping during pregnancy and to investigate its potential role in SUDI more urgently. Ideally pregnancy should be smoke-, vape- and nicotine-free, while people who smoke during pregnancy should continue to be supported with evidence-based cessation treatment.”
Associate Professor Gergely Toldi, Liggins Institute, University of Auckland & consultant neonatologist, Starship Children’s Health
"The reported high rates of SUDI in NZ are indeed very concerning. The increasing proportions of Māori and Pacific infants affected call for urgent, culturally appropriate communication of health advice and safety netting for whānau with a small pēpi.
"Safe sleep principles from birth to 11 months of age cannot be overemphasized, and direct bed sharing should be discouraged by all possible means.
"Smoking and vaping are another serious risk factor. It is important to realise that vaping is not an acceptable alternative when it comes to SUDI risk. I welcome the suggestion that complete nicotine cessation should be encouraged in NZ during pregnancy, breastfeeding and in households with a small pēpi less than one year of age instead of recommending vaping as an acceptable alternative."
Dr Charlotte Oyston, Faculty of Medical and Health Sciences, Obstet, Gynaecol & Reprod Science, University of Auckland
"If you smoke, one of the best things you can do for your baby’s health is to become smokefree, ideally before becoming pregnant. Smoking in pregnancy increases the chance of almost every pregnancy complication including miscarriage, stillbirth, early (preterm) birth, low birthweight, and sudden unexpected death in infancy (cot death). Harmful chemicals in cigarettes damage the way the placenta works, and the nicotine in cigarettes (and vapes) crosses the placenta to the baby, and has the potential to impact on baby’s development.
"Vapes might have seemed like a good alternative to cigarettes. They contain fewer toxic chemicals and have had much less negative press around their harmful impacts. However, they still contain nicotine, they are still addictive, and as more
research becomes available, we see more evidence that they cause significant harm. Vaping in pregnancy is associated with increased chance of baby’s being born growth restricted (small), and preterm. This new paper written by Edwin Mitchell and colleagues now demonstrates vaping as a risk factor for Sudden Unexpected Death in Infancy (SUDI).
"It is best to stop smoking or vaping before becoming pregnant, BUT we know that reducing and stopping during pregnancy (and staying smoke/vape free after) is also beneficial. It is important for the household/whānau to be smokefree, as it is much harder for the pregnant person/mother to stop smoking if their friends and family continue to smoke; furthermore, secondhand smoke is directly harmful to mums and babies.
"Because nicotine is so addictive, smoking or vaping can be hard to stop. Lots of supports are freely available to support pregnant people and their whānau/family to become smokefree. Nicotine replacement therapy is an option; this contains only nicotine, but not the other harmful chemicals found in cigarettes or vapes. This can be used to become nicotine-free, reducing the amount of nicotine taken on a path towards stopping entirely."
Dr Lucy Hardie, Research Fellow & Lecturer, School of Population Health, University of Auckland
"The findings of these studies are very concerning. Science has been playing catch-up with widespread rates of vaping, and new studies reporting associations of harm should be taken seriously.
"Assumptions have been made about the health impacts of vaping, mainly because they are often framed in relation to the devastating health impacts of, and a solution to, smoking.
"However, we need to acknowledge that these products come with a new set of potential dangers and accept that we risk the health of our future generations without proper regulation to reduce and prevent vaping alongside smoking and other nicotine products, such as pouches."
Chris Bullen, Professor of Public Health Department of General Practice and Primary Care, School of Population Health, University of Auckland
“Mitchell and colleagues hypothesise that exposure to nicotine from vaping during pregnancy could be a potential new risk SUDI factor requiring further investigation, specifically the association of vaping with SUDI and bed sharing. Their analysis of a series of SUDI cases found almost three quarters occurred while bed sharing, with 85% of the mothers of these infants reporting smoking and/or vaping in the pregnancy.
“While it is not possible to tell from their study if the relationship with bedsharing, vaping and SUDI is one of causation or merely association, they are right to be concerned, both about the failure of years of public health messaging about the risks of bed sharing to translate into practice for many parents, and also the very high proportion of the infants exposed to smoking and/or vaping during pregnancy.
“The common factor to smoking and vaping is nicotine. In an opinion piece, the same authors point to evidence that nicotine exposure can be harmful to the developing fetus. Their call for greater attention to be paid in public messaging and clinical practice not just to smokefree pregnancies but more broadly to nicotine-free pregnancies is a reasonable one, given the high stakes at play.
“The challenge is for this messaging to reach and translate into action in the women of childbearing age who are most at risk, among whom smoking and vaping often commence at a young age, pregnancies may be unplanned, and years of messaging about safe bedsharing practices has failed to have an impact.”
Research Associate Professor Andrew Waa, Co-Director of ASPIRE Aotearoa tobacco control research centre, University of Otago
“These studies demonstrate that we must exercise the precautionary principle and protect babies from exposure to nicotine. While we are still learning what the mechanisms are linking smoking and vaping to SUDI, we do know that vaping causes harm to babies.
“Traditionally we have had success supporting mothers to quit smoking while pregnant but relapse after birth has always been a challenge, particularly if other family members continue to smoke. We need to ensure that government polices protect families from using cigarettes and vapes, rather than making them more available. We also need to make sure mothers and families are supported to quit both cigarettes and vapes.”
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