Full length articlePrevalence and associated birth outcomes of co-use of Cannabis and tobacco cigarettes during pregnancy
Introduction
Cannabis is the most commonly used illicit drug globally and in the United States (World Health Organization (WHO), 2016), and rates of Cannabis use among US adults have risen significantly in the past 15 years (Hasin et al., 2015). In contrast, tobacco use has declined (WHO, 2015), although it remains one of the world's biggest public health threats, contributing to the deaths of approximately 7 million people each year (WHO, 2017). In the US general population, co-use of Cannabis and tobacco has increased significantly over the past decade (Schauer et al., 2015). Co-use of Cannabis and tobacco can refer to many different behavioral patterns, including use in the same episode, use within the same product (i.e., blunt or spliff smoking), or use within the same time-period (in the past month). Co-use of Cannabis and tobacco, relative to use of either Cannabis or tobacco alone, is associated with several concerning clinical correlates, including increased risk of Cannabis use disorder (CUD), exacerbation of mental health symptoms, and poorer cessation outcomes (Agrawal et al., 2012; Agrawal and Lynskey, 2009; Coleman-Cowger et al., 2017; Montgomery, 2015; Peters et al., 2012; Ramo et al., 2012). Preliminary evidence also suggests that co-use of Cannabis and tobacco may be associated with additive, or even multiplicative, adverse health consequences relative to tobacco use only (Coleman-Cowger et al., 2017; Peters et al., 2016).
With rates of co-use of marijuana and tobacco increasing significantly in the US, a critical question is how prevalent co-use is among vulnerable populations who may be especially susceptible to associated negative health implications, such as pregnant women. Among pregnant women in the 2005–2014 data from the US National Survey on Drug Use and Health, co-use of Cannabis and tobacco was significantly more prevalent than Cannabis only use (3.3% vs. 1.0%) but less common than tobacco only use (13.3%) (Coleman-Cowger et al., 2017). Co-use of Cannabis and tobacco was associated with being younger and Black or Hispanic, and having past month use of alcohol and other illicit drugs (Coleman-Cowger et al., 2017). In other studies, substance use during pregnancy is more common in women who are younger, less educated, single, unemployed (Havens et al., 2009), socioeconomically disadvantaged, have a partner who smokes (Giglia et al., 2007), or belong to a racial or ethnic minority group (El Marroun et al., 2008; Ko et al., 2015), as well as in multigravid women (i.e., women who have been pregnant more than once) and women with unplanned pregnancies (El Marroun et al., 2008). Although co-use of Cannabis and tobacco during pregnancy appears to be higher among certain subpopulations characterized by demographic characteristics and by behaviors associated with adverse health effects, research on co-use of Cannabis and tobacco among high risk populations of pregnant women is limited.
The negative health consequences of smoking tobacco during pregnancy are well-known (US Department of Health and Human Services (USDHHS), 2014) but the evidence base for the health consequences of smoking Cannabis during pregnancy is less robust (Gunn et al., 2016). Extant findings suggest links to reduced birth weight (though with smaller effects than those seen with tobacco use), increased risk of babies small for gestational age, increased risk of neonatal intensive care admission, poorer cognitive performance in adolescence, and maternal anemia (Gunn et al., 2016); however, the limitations of extant research are significant and include the small number of studies, small samples, underreporting of use, and inability to control for confounding effects of other substance use (Volkow et al., 2014). Two notable longitudinal studies of prenatal marijuana exposure (Fried and Makin, 1987; Richardson et al., 2002) found no association between Cannabis use during pregnancy and increased miscarriage rates, premature deliveries or any other complications, but did find differences in neonatal behaviors (i.e., increased tremors and startles and poorer habituation to visual stimuli) and neuropsychological outcomes at 10 years of age (i.e., effects on learning, memory, and impulsivity). Most studies on the effects of Cannabis use on birth outcomes did statistically control for tobacco smoking, showing the independent effects of Cannabis use on outcomes. To our knowledge, no studies have examined the unique research question of how tobacco and Cannabis interact synergistically to influence birth outcomes; i.e., does co-use of Cannabis and tobacco, relative to use of either one alone, compound adverse health consequences to the mother and developing fetus?
Existing studies on the health consequences of smoking Cannabis during pregnancy were initiated over 30 years ago. In the past two decades, 29 US states have implemented medicinal Cannabis laws and 8 states plus the District of Columbia have legalized adult recreational use of Cannabis. The impact of changing state and local policies legalizing Cannabis remains unclear, but there is some evidence that these policies contribute to greater Cannabis availability and the increasing perception that Cannabis use is harmless (Budney and Borodovsky, 2017; Schulenberg et al., 2017), both of which could lead to changing Cannabis use patterns among pregnant women. Because Cannabis and tobacco are so closely associated, changing Cannabis use patterns could have downstream effects on tobacco use patterns. Furthermore, exponential increases in tetrahydrocannabinol (THC) potency, the primary psychoactive constituent of Cannabis, over the past decade, combined with the fact that maternal tissues act as a reservoir for THC and other cannabinoids which results in prolonged fetal exposure, could make Cannabis difficult to quit during pregnancy (Budney and Borodovsky, 2017; Schulenberg et al., 2017). For all of these reasons, current research on the prevalence and associated birth outcomes of co-use of Cannabis and tobacco use is needed.
The purpose of this study is to: 1) describe the prevalence of co-use of Cannabis and tobacco cigarettes reported by a convenience sample of pregnant women presenting to two urban prenatal clinics; 2) outline correlates of co-use of Cannabis and tobacco cigarettes; and 3) compare birth outcomes between pregnant women who co-use Cannabis and tobacco cigarettes, who currently smoke tobacco cigarettes but do not use Cannabis, who currently use Cannabis but do not smoke tobacco cigarettes, and who do not currently use Cannabis or tobacco cigarettes.
Section snippets
Sample
This study's sample was recruited from two obstetric clinics in Maryland as part of a larger study to compare and validate screeners for illicit and prescription drug use during pregnancy. Pregnant women were enrolled in the study if they met the following criteria: 1) currently pregnant; 2) age 18 years or older; 3) able to speak and understand English sufficiently to provide informed consent; and 4) natural hair length at least 3 cm to allow for drug testing. Participants were compensated
Demographic characteristics
Table 1 outlines the demographic characteristics of the study participants. There were 500 participants enrolled into the study from two urban obstetrics clinics. Overall, the sample consisted primarily of African-American women (71.3%) who had never been married (65.3%), with an average age of 27.9 (SD = 5.2) years. Approximately 32% of the study sample reported having had a previous miscarriage or stillbirth. With regard to pregnancy intention, slightly over one-third of study participants
Discussion
There are several key findings from this study that highlight the importance of examining Cannabis and tobacco co-use during pregnancy. First, in this sample, the prevalence rate of Cannabis and tobacco cigarette co-use as well as the prevalence rate of Cannabis only use is higher than the prevalence of tobacco cigarette only use, which is notable given the focus on tobacco cessation in clinical practice. This cross-sectional finding of high Cannabis prevalence aligns with recent trend studies
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Acknowledgments
The research reported in this article is supported by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) grant under Award Number R01DA041328 (PI-Coleman-Cowger). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
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