Birth outcomes following intrauterine exposure to electronic nicotine delivery systems: a systematic review and meta-analysis
Abstract
Abstract Introduction Despite electronic nicotine delivery systems (ENDS) being used for smoking cessation during pregnancy, the relative consequences are still unclear. Here, we systematically reviewed and meta-analyzed birth outcomes associated with ENDS use. Methods This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. OVID (MEDLINE, EMBASE, PsycINFO) and PubMed databases were searched from inception until August 2025, for studies comparing outcomes from in utero exclusive ENDS exposure to non-exposed, exclusive nicotine replacement therapy–exposed, or exclusive combustible cigarette (CC)–exposed neonates. Results We included k = 22 studies with k = 10 independent samples. In ENDS-exposed vs non-exposed births, there were significantly greater odds of preterm birth (k = 3; moderate confidence) but not small for gestational age (SGA; k = 3; low confidence); these findings were less robust to sensitivity analysis. Additionally, there was no significant difference in SGA (k = 3; moderate confidence) or preterm birth (k = 3; high confidence) between CC-exposed and ENDS-exposed neonates; these findings were robust to sensitivity analysis. Analysis of continuous outcomes found lower birthweight in ENDS- vs non-exposed neonates (k = 4; moderate confidence) and lower birthweight in CC- vs ENDS-exposed neonates (k = 4; low confidence), and no difference in gestational age in either comparison (low confidence).…
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Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid.
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