Elsevier

Addictive Behaviors

Volume 54, March 2016, Pages 52-58
Addictive Behaviors

Prevalence and correlates of a lifetime cannabis use disorder among pregnant former tobacco smokers

https://doi.org/10.1016/j.addbeh.2015.12.008Get rights and content

Highlights

  • In total, 14% of women met criteria for a lifetime cannabis use disorder (CUD).

  • A history of multiple psychiatric disorders and alcohol use disorder predicted CUD.

  • Greater quit attempts and lower weight management self-efficacy also predicted CUD.

Abstract

Background

Following tobacco and alcohol, cannabis is the most commonly used substance during pregnancy. Given the high prevalence of concurrent cannabis and tobacco use as well as the health consequences associated with prenatal substance use, we sought to document the relative contributions of psychosocial and psychiatric factors commonly associated with cannabis use in predicting a lifetime cannabis use disorder (CUD) among women who had quit smoking tobacco as a result of pregnancy.

Methods

Pregnant former tobacco smokers (n = 273) enrolled in a larger randomized controlled trial for postpartum tobacco relapse prevention completed semi-structured psychiatric interviews and self-reported demographic, pregnancy, health, psychosocial, and tobacco use factors during their third trimester of pregnancy.

Results

In total, 14% (n = 38) of women met criteria for a lifetime CUD. The strongest predictors of a lifetime CUD were a history of having multiple psychiatric disorders (OR = 36.44; 95% CI = 5.03–264.27; p < 0.001) followed by a lifetime alcohol use disorder (OR = 3.54; 95% CI = 1.27–9.87; p < 0.05). In addition, more frequent attempts to quit smoking tobacco (OR = 1.12; 95% CI = 1.01–1.25; p < 0.05) and lower self-efficacy about weight management after quitting smoking tobacco (OR = 0.78; 95% CI = 0.62–0.97; p < 0.05) also were significantly associated with a lifetime CUD.

Conclusions

Women with a history of both cannabis and tobacco dependence may represent a subset of women who need more specialized treatment during the perinatal period to improve substance use outcomes.

Introduction

Cannabis is the most commonly used illicit substance in the United States and is the only illicit substance for which there have been appreciable increases in the prevalence of use across the past decade (Ansell, E. B., et al., 2015, Caldeira, K. M., et al., 2012). A 2013 nationwide survey conducted by the Substance Abuse and Mental Health Services Administration, found that the number of Americans 12 years of age and older reporting daily cannabis use has nearly doubled since 2002, with current prevalence rates estimated to be 7.5% (SAMHSA, 2012). Cannabis also has the highest rates of past year dependence of any illicit substance, with 1.6% of users meeting criteria for a cannabis use disorder (CUD). Several factors, including changes in legal status, perceptions of low risk associated with use, and availability have been linked to the increased rates of cannabis use (Cerda, M., et al., 2012, Palamar, J. J., et al., 2014). Despite the growing societal acceptance of cannabis, the long-term consequences of cannabis use remain a general public health concern, and the high prevalence of cannabis use during pregnancy is of particular interest given the adverse effects on both maternal and fetal health.

Cannabis use is associated with significant health complications (Volkow, Baler, Compton, & Weiss, 2014). The acute effects of cannabis intoxication include euphoria, tachycardia, conjunctival congestion, and anxiety as well as slowed reaction time and impaired memory (Iversen, 2009). Although the acute effects of cannabis typically subside several hours following administration, prolonged cannabis use has been linked to chronic respiratory diseases, cognitive dysfunction, and behavioral problems. Smoking cannabis exposes users to carbon monoxide, bronchial irritants, tumor promotors, and carcinogens, which in turn increase risk for respiratory diseases (Ashton, 2001), severe respiratory symptoms (Macleod et al., 2015), and cardiovascular events (Volkow et al., 2014). Cannabis use also has lasting effects on cognition and the regulatory networks of the brain (Filbey, F. M., et al., 2009, Gilman, J. M., et al., 2014), which can lead to memory impairments, deficiencies in attention, slowed reaction time, poor impulse control and increased hostility as well as difficulties with information processing, perceptual coordination, and motor performance (Gunn et al., 2015).

In addition to the general consequences of cannabis use, prenatal cannabis exposure presents specific problems for the developing fetus and has lasting effects on child development. Although prenatal cannabis use has been associated with reduced gestational length and a slowing of fetal growth, studies linking cannabis use during pregnancy to premature birth and low birth weight have been equivocal, with some studies reporting associations between prenatal cannabis use and decreased birth weight (El-Mohandes, A., et al., 2003, Gray, et al., 2010) and others reporting no relationship between prenatal cannabis use and low birth weight or premature birth (English, D. R., et al., 1997, Fergusson, D. M., et al., 2002). However, prenatal cannabis exposure consistently has been associated with disrupted sleep patterns (Dahl, R. E., et al., 1995, Scher, M. S., et al., 1988) and delayed cognitive development in early childhood (Day, et al., 1994) as well as with adolescent deficits in cognitive development (Fried, P. A. and Watkinson, B., 1990, Richardson, G. A., et al., 2002), attention (Fried, Watkinson, James, & Gray, 2002), and executive functioning (Fried, P. A., et al., 1998, Willford, J., et al., 2001). Prenatal cannabis exposure also has been associated with greater delinquent behaviors (Day, Leech, & Goldschmidt, 2011), higher rates of depression (Gray, Day, Leech, & Richardson, 2005) and anxiety (Leech, Larkby, Day, & Day, 2006) and later drug abuse (Day, Goldschmidt, & Thomas, 2006) among adolescents. Thus, cannabis use during the perinatal period has adverse consequences for both maternal and child health.

Despite the consequences of prenatal substance use, prenatal cannabis use is common. Cannabis is the third most commonly used substance during pregnancy following tobacco and alcohol (El Marroun, H., et al., 2008, Gilchrist, L. D., et al., 1996, Havens, J. R., et al., 2009). Although rates of cannabis use tend to decline during pregnancy (Bailey, J. A., et al., 2008, Gilchrist, L. D., et al., 1996), an estimated 11% of women continue to use cannabis during pregnancy, with over 16% of pregnant cannabis users reporting near daily use (Ko, Farr, Tong, Creanga, & Callaghan, 2015). Women who are younger, less educated, single, unemployed, socioeconomically disadvantaged, or belong to a racial or ethnic minority group are more likely to use cannabis during pregnancy (El Marroun, H., et al., 2008, Ko, J. Y., et al., 2015) as are multigravid women and women with unplanned pregnancies (El Marroun et al., 2008). Importantly, women who use tobacco and cannabis concurrently are at particular risk of continuing to use both substances during pregnancy (El Marroun, H., et al., 2008, Ko, J. Y., et al., 2015, Lester, B. M., et al., 2001), and women with a history of CUD are nearly three times more likely to continue using cannabis during pregnancy than are women without such a history (El Marroun et al., 2008).

Given the high concurrence between cannabis and tobacco use, the rates of prenatal cannabis use, and the specific health consequences of prenatal cannabis use, we sought to document the prevalence of a lifetime CUD among women who had quit smoking tobacco as a result of pregnancy and to examine the relative contributions of psychosocial and psychiatric factors commonly associated with cannabis use in predicting a lifetime CUD. We focused on demographic, pregnancy, health, psychosocial, and tobacco use factors as well as lifetime psychiatric disorders as predictors of a lifetime CUD. We hypothesized that factors related to greater nicotine dependence and more severe psychiatric problems would be most strongly related to a lifetime CUD among pregnant former tobacco smokers.

Section snippets

Participants and procedures

The procedures for this study were approved by the University of Pittsburgh Institutional Review Board, and participants provided written informed consent. Participants were part of a larger randomized controlled trial investigating the efficacy of a postpartum tobacco relapse prevention intervention that included a specialized focus on women's postpartum concerns about mood and weight (Levine, Marcus, Kalarchian, & Cheng, 2013). Participants were pregnant women who self-reported smoking

Statistical analysis

Differences in the study variables of interest were compared between women who completed the SCID-I/NP during pregnancy or postpartum. Women were categorized according to the absence or presence of a lifetime CUD. Independent samples t-tests and chi-square analyses initially were used to assess differences in demographic, pregnancy, health, psychosocial, and tobacco use factors as well as lifetime psychiatric disorders between women with and without a lifetime CUD. To correct for multiple

Results

Of the 300 women enrolled, 273 completed the SCID-I/NP and were included in the current analysis. Women included (n = 273) did not differ from those excluded (n = 27) on any of the psychosocial or psychiatric factors of interest (ps > 0.11). Moreover, women who completed the SCID-I/NP during pregnancy (n = 214) and those who completed the SCID-I/NP postpartum (n = 62) did not differ in demographic factors (ps > 0.10), pregnancy factors (ps > 0.39), health and psychosocial factors (ps > 0.06), tobacco use

Discussion

Women with a history of CUD as well as those who use cannabis and tobacco concurrently are at elevated risk of continuing to use both substances during pregnancy and postpartum (El Marroun, H., et al., 2008, Ko, J. Y., et al., 2015, Lester, B. M., et al., 2001). Given the adverse effects of prenatal cannabis use, we aimed to document rates of CUD and to identify characteristics of women who may be likely to use cannabis during the perinatal period by examining psychosocial and psychiatric

Role of funding sources

This work was supported by NIDA (R01 DA021608 to MDL) and NHLBI (T32 HL07560 to RLE). Neither NIDA nor NHLBI had a role in the design and conduct of the study, collection, management, analysis or interpretation of the data, preparation of the manuscript for publication, or decision to submit the manuscript for publication.

Contributors

MDL developed the concept for the study. RLE, MPG, and JLG conducted the literature review and wrote the initial draft of the manuscript. RLE conducted the statistical analysis under the advice of MDL. All authors contributed to the critical revision of the manuscript for important intellectual content and have approved the final manuscript.

Conflict of interest

No conflict declared.

References (74)

  • M. Eisen et al.

    Evaluation of substance use outcomes in demonstration projects for pregnant and postpartum women and their infants: Findings from a quasi-experiment

    Addictive Behaviors

    (2000)
  • H. El Marroun et al.

    Demographic, emotional and social determinants of cannabis use in early pregnancy: The generation R study

    Drug and Alcohol Dependence

    (2008)
  • R. Elk et al.

    Cessation of cocaine use during pregnancy: Effects of contingency management interventions on maintaining abstinence and complying with prenatal care

    Addictive Behaviors

    (1998)
  • D.M. Fergusson et al.

    Maternal use of cannabis and pregnancy outcome

    British Journal of Obstetrics and Gynaecology

    (2002)
  • P.A. Fried et al.

    Differential effects on cognitive functioning in 9- to 12-year olds prenatally exposed to cigarettes and marihuana

    Neurotoxicology and Teratology

    (1998)
  • L.D. Gilchrist et al.

    Drug use among adolescent mothers: Prepregnancy to 18 months postpartum

    The Journal of Adolescent Health

    (1996)
  • Gray et al.

    Prenatal marijuana exposure: Effect on child depressive symptoms at ten years of age

    Neurotoxicology and Teratology

    (2005)
  • B.C. Haberstick et al.

    Prevalence and correlates of alcohol and cannabis use disorders in the United States: Results from the national longitudinal study of adolescent health

    Drug and Alcohol Dependence

    (2014)
  • M. Haney et al.

    Predictors of marijuana relapse in the human laboratory: Robust impact of tobacco cigarette smoking status

    Biological Psychiatry

    (2013)
  • J.R. Havens et al.

    Factors associated with substance use during pregnancy: Results from a national sample

    Drug and Alcohol Dependence

    (2009)
  • S.L. Leech et al.

    Predictors and correlates of high levels of depression and anxiety symptoms among children at age 10

    Journal of the American Academy of Child Psychiatry

    (2006)
  • M.D. Levine et al.

    Strategies to avoid returning to smoking (STARTS): A randomized controlled trial of postpartum smoking relapse prevention interventions

    Contemporary Clinical Trials

    (2013)
  • B.A. Moore et al.

    Tobacco smoking in marijuana-dependent outpatients

    Journal of Substance Abuse

    (2001)
  • S.M. Mullins et al.

    The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare

    Journal of Substance Abuse Treatment

    (2004)
  • J.J. Palamar et al.

    Correlates of intentions to use cannabis among US high school seniors in the case of cannabis legalization

    The International Journal on Drug Policy

    (2014)
  • M.E. Passey et al.

    Tobacco, alcohol and cannabis use during pregnancy: Clustering of risks

    Drug and Alcohol Dependence

    (2014)
  • E.N. Peters et al.

    Psychiatric, psychosocial, and physical health correlates of co-occurring cannabis use disorders and nicotine dependence

    Drug and Alcohol Dependence

    (2014)
  • C.S. Pomerleau et al.

    The female weight-control smoker: A profile

    Journal of Substance Abuse

    (1993)
  • P.A. Ratner et al.

    Twelve-month follow-up of a smoking relapse prevention intervention for postpartum women

    Addictive Behaviors

    (2000)
  • G.A. Richardson et al.

    Prenatal alcohol and marijuana exposure: Effects on neuropsychological outcomes at 10 years

    Neurotoxicology and Teratology

    (2002)
  • H.H. Severson et al.

    Reducing maternal smoking and relapse: Long-term evaluation of a pediatric intervention

    Preventive Medicine

    (1997)
  • D.S. Svikis et al.

    Attendance incentives for outpatient treatment: Effects in methadone- and nonmethadone-maintained pregnant drug dependent women

    Drug and Alcohol Dependence

    (1997)
  • D.S. Timberlake et al.

    Progression from marijuana use to daily smoking and nicotine dependence in a national sample of U.S. adolescents

    Drug and Alcohol Dependence

    (2007)
  • K. Yonkers et al.

    Motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice: A randomized trial for treatment of hazardous substance use in pregnancy and after delivery

    General Hospital Psychiatry

    (2012)
  • D.J. Allsop et al.

    Quantifying the clinical significance of cannabis withdrawal

    PloS One

    (2012)
  • C.H. Ashton

    Pharmacology and effects of cannabis: a brief review

    British Journal of Psychiatry

    (2001)
  • J.A. Bailey et al.

    Men's and women's patterns of substance use around pregnancy

    Birth

    (2008)
  • Cited by (12)

    • Marijuana and tobacco co-use among a nationally representative sample of US pregnant and non-pregnant women: 2005–2014 National Survey on Drug Use and Health findings

      2017, Drug and Alcohol Dependence
      Citation Excerpt :

      Although the health consequences of smoking marijuana during pregnancy are less clear, marijuana use during pregnancy has been linked to reduced birth weight (though with smaller effects than those seen with tobacco smoking), increased risk of babies small for gestational age, maternal anemia, and poorer cognitive performance in adolescence (Gunn et al., 2016; Hall, 2015; Volkow et al., 2014). Though the distinct health effects of co-use of marijuana and tobacco during pregnancy have not been fully elucidated, co-use of these substances may be associated with continued use of both substances during pregnancy (Emery et al., 2016) and heightened risk for adverse health consequences relative to use of just one, as is suggested in the general population. Marijuana is the most commonly used illicit drug during pregnancy, with 5.5% of pregnant women reporting past month use in 2014 (SAMHSA, 2015aSubstance Abuse and Mental Health Services Administration [SAMHSA], 2015a).

    • Marijuana use and its effects in pregnancy

      2016, American Journal of Obstetrics and Gynecology
      Citation Excerpt :

      Interestingly and in contrast to our findings, these investigators did not observe a similar increase in adverse effects in cousers,3 conflicting with previous research examining maternal tobacco use and neonatal outcomes.5,39 Consistent with prior studies, we similarly observed a significant rate of co-use of marijuana and tobacco smoking.10,40 While many prior studies adjust for cigarette smoking in their statistical analysis, few stratify results by smoking status.3

    • Prenatal tobacco and marijuana co-use: Sex-specific influences on infant cortisol stress response

      2020, Neurotoxicology and Teratology
      Citation Excerpt :

      However, despite high rates of prenatal TOB + MJ co-use, only a small number of studies have investigated maternal and offspring health risks related to MJ + TOB co-use in pregnancy. These studies have revealed increased maternal and neonatal morbidity—including increased rates of pre-eclampsia and preterm birth and decreased birthweight and head circumference—as well as increased rates of maternal prenatal psychiatric and substance use disorders in co-users vs. sole or non-users (Chabarria et al., 2016; Coleman-Cowger et al., 2018; Coleman-Cowger et al., 2017; Emery et al., 2016; Gray et al., 2010). An emerging literature has also highlighted links between prenatal MJ + TOB exposure and altered offspring neurobehavior across development.

    • Prenatal tobacco and marijuana co-use: Impact on newborn neurobehavior

      2018, Neurotoxicology and Teratology
      Citation Excerpt :

      In non-pregnant populations, MJ + TOB co-use was associated with worse health outcomes, including increased risk of both MJ and TOB use disorders, poorer MJ and TOB cessation outcomes, increased psychiatric conditions, and increased respiratory dysfunction (Agrawal et al., 2012; Peters et al., 2012; Peters et al., 2014; Rabin and George, 2015). In pregnant women, MJ + TOB co-use was associated with increased maternal (e.g., asthma and pre-eclampsia) and neonatal health risks (preterm birth, decreased birthweight and head circumference), increased risk for maternal psychiatric and alcohol use disorders, increases in other drug and poly-tobacco use, and difficulty with TOB cessation (Chabarria et al., 2016; Coleman-Cowger et al., 2017; Emery et al., 2016; Gray et al., 2010). The impact of MJ + TOB on fetal development may be mediated by THC/cannabinoids and nicotine.

    View all citing articles on Scopus
    View full text