Prevalence and correlates of a lifetime cannabis use disorder among pregnant former tobacco smokers
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.
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Co-occurrence of mental illness and substance use among US pregnant individuals, 2012-2021
2024, Psychiatry ResearchMarijuana 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 DependenceCitation 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 GynecologyCitation 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 TeratologyCitation 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 TeratologyCitation 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.