Between 2001 and 2013, marijuana use among US adults more than doubled, many states legalized marijuana use, and attitudes toward marijuana became more permissive. In aggregated 2007-2012 data, 3.9% of pregnant women and 7.6% of nonpregnant reproductive-aged women reported past-month marijuana use. Although the evidence is mixed, human and animal studies suggest that prenatal marijuana exposure may be associated with poor offspring outcomes (eg, low birth weight, impaired neurodevelopment). The American College of Obstetricians and Gynecologists recommends that pregnant women and women contemplating pregnancy be screened for and discouraged from using marijuana and other substances. Whether marijuana use has changed over time among pregnant and nonpregnant reproductive-aged women is unknown

Brown, Qiana

Hasin, Deborah S.

Martins, Silvia S.

Shmulewitz, Dvora

Wall, Melanie M.

English

Columbia University Academic Commons

Copyright 2016 American Medical Association. All rights reserved.LettersRESEARCH LETTERTrends inMarijuana Use Among PregnantandNonpregnant Reproductive-AgedWomen,2002-2014Between 2001 and 2013, marijuana use among US adultsmore than doubled, many states legalized marijuana use,and attitudes toward marijuana became more permissive.1In aggregated 2007-2012data,3.9%ofpregnantwomenand 7.6% of nonpregnantreproductive-aged womenreported past-month mari-juana use.2 Although the evi-dence ismixed, humanandanimal studies suggest that prena-tal marijuana exposuremay be associated with poor offspringoutcomes (eg, lowbirthweight, impairedneurodevelopment).3The American College of Obstetricians and Gynecologists rec-ommends that pregnant women and women contemplatingpregnancy be screened for and discouraged from using mari-juana and other substances.4 Whether marijuana use haschanged over time among pregnant and nonpregnant repro-ductive-agedwomen is unknown.Methods | The Columbia University Medical Center institu-tional review board waived review of this study. Informedoral consent was obtained from each participant. Data fromwomen aged 18 through 44 years from the annual NationalSurvey on Drug Use and Health (NSDUH) from 2002 through2014 were analyzed. The surveys used in-person audiocomputer-assisted self-interviews (ACASI) about substanceuse and other behaviors in nationally representative samplesof the noninstitutionalized US population; average responserates since 2002 were 75%.5 Among participants reportinglifetime use of marijuana or hashish, recency of use wasassessed with the question: “How long has it been since youlast used marijuana or hashish?” Responses included “withinthe past 30 days,” “more than 30 days ago but within the past12 months,” and “more than 12 months ago.”5 Among preg-nant and nonpregnant women, log-Poisson regression(SUDAAN [RTI International], version 11.0.1) was used to esti-mate and test trends in the adjusted prevalences of past-month and past-year marijuana use over time, controlling forcomplex survey design, age, race/ethnicity, family income,and education. Differences in trends over time were exam-ined by pregnancy status and age (18-25 years and 26-44years). Results were considered statistically significant ata P value of less than .05 (2-sided).Results |Of the 200510women analyzed, 29.5%were aged 18through 25 years and 70.5% were aged 26 through 44 years;61.0%werewhite, 13.7%black, 17.2%Hispanic, and8.1%otherrace/ethnicity; 59.2%had some college education; 55.9%hadannual family incomes less than$50000;and5.3%(n = 10587)were pregnant.Among all pregnant women, the adjusted prevalence ofpast-month marijuana use increased from 2.37% (95% CI,1.85%-3.04%) in 2002 to 3.85% (95% CI, 2.87%-5.18%) inViewpointRelated articleTable. Trends in Prevalence ofMarijuana Use in Pregnant and NonpregnantWomen, 2002-2014aMarijuana Use Among WomenAdjusted Prevalence, No. (%) [95% CI]bPrevalence Ratio (95%CI)eP Value for Differencein Prevalence Ratiosf2002 (n = 15 284)c 2014 (n = 15 318)dPast monthg.64Pregnant 40 (2.37) [1.85-3.04] 43 (3.85) [2.87-5.18] 1.62 (1.09-2.43)Nonpregnant 1531 (6.29) [6.02-6.57] 1673 (9.27) [8.90-9.65] 1.47 (1.38-1.58)Past year.73Pregnant 134 (8.64) [7.32-10.19] 115 (11.63) [9.78-13.82] 1.35 (1.05-1.72)Nonpregnant 2809 (12.37) [12.05-12.70] 2824 (15.93) [15.48-16.40] 1.29 (1.23-1.35)a Data were from the US National Survey on Drug Use and Health (NSDUH).bAdjusted prevalence estimates are from the linear predicted prevalencemodeldescribed in footnote a of the Figure.c Sample sizes in 2002: pregnant women, n = 797; nonpregnant women,n = 14 487.d Sample sizes in 2014: pregnant women, n = 735: nonpregnant women,n = 14 583.e Prevalence ratios were the ratio of the adjusted prevalence estimates from2014 divided by the adjusted prevalence estimates from 2002; ratios and 95%CIs were from log-Poisson regressions. CIs for prevalence ratios that did notinclude 1.00within the lower and upper levels indicated statistically significantincreasing trends in marijuana use.f The test for difference in prevalence ratios was the P value of thepregnancy × year interaction in the log-Poisson regression. This test indicatedwhether the ratio of the prevalence ratios for pregnant vs nonpregnantwomen differed significantly from 1.00. Nonsignificant P values (P  .05)indicated insufficient evidence to conclude that the prevalence ratios differ.g Past-monthmarijuana use was defined as responding “within the past 30days” to the question, “How long has it been since you last usedmarijuana orhashish?” Past-year marijuana use was defined as responses of “within the past30 days” or “more than 30 days ago but within the past 12 months” to theaforementioned question. Preprocessing of missing variables by predictivemean neighborhood imputation and recoding was done prior to public releaseof the NSDUH data sets.5 Because the analyses used the imputed variables ofNSDUH, there were nomissing data.jama.com (Reprinted) JAMA Published online December 19, 2016 E1Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User  on 12/20/2016Copyright 2016 American Medical Association. All rights reserved.2014 (prevalence ratio [PR], 1.62 [95% CI, 1.09-2.43])(Table). The adjusted prevalence of past-month marijuanause was highest among those aged 18 to 25 years, reaching7.47% (95% CI, 4.67%-11.93%) in 2014 (Figure), significantlyhigher (P = .02) than among those aged 26 to 44 years(2.12% [95% CI, 0.74%-6.09%]). However, increases overtime did not differ by age (P = .76). Past-year use was higheroverall, reaching 11.63% (95% CI, 9.78%-13.82%) in 2014,with similar trends over time.In nonpregnant women, prevalences of past-month use(2014:9.27%[95%CI, 8.90%-9.65%]) andpast-yearuse (2014:15.93% [95% CI, 15.48%-16.40%]) were higher overall, withsimilar trends over time. Increases over time in past-monthmarijuana use did not differ by pregnancy status (P = .64).Discussion | Among pregnant women, the prevalence of past-month marijuana use increased 62% from 2002 through2014. Prevalence was highest among women aged 18 to 25years, indicating that young women are at greater risk forprenatal marijuana use. Study limitations are noted. Self-reported marijuana use may lead to underreporting due tosocial desirability and recall biases. However, use of ACASIhelps reduce such biases,5 and the increases over timeobserved in this study are consistent with increases over timein marijuana-related outcomes shown in other studies thatdid not rely on self-reports, supporting the validity of thefindings.6 Additionally, future studies should address dose,frequency of use, and clinical outcomes.These results offer an important step toward under-standing trends in marijuana use among women of repro-ductive age. Although the prevalence of past-month useamong pregnant women (3.85%) is not high, the increasesover time and potential adverse consequences of prenatalmarijuana exposure3 suggest further monitoring andresearch are warranted. To ensure optimal maternal andchild health, practitioners should screen and counsel preg-nant women and women contemplating pregnancy aboutprenatal marijuana use.Qiana L. Brown, PhD, MPH, LCSWAaron L. Sarvet, MPHDvora Shmulewitz, PhDSilvia S. Martins, MD, PhDMelanie M. Wall, PhDDeborah S. Hasin, PhDAuthor Affiliations: Columbia University, New York, New York.Corresponding Author:Deborah S. Hasin, PhD, Department of Psychiatry,Columbia University Medical Center, 1051 Riverside Dr, No. 123, New York, NY10032 (deborah.hasin@gmail.com).Published Online:December 19, 2016. doi:10.1001/jama.2016.17383Author Contributions:Dr Brown had full access to all of the data in the studyand takes responsibility for the integrity of the data and the accuracy of the dataanalysis.Concept and design: All authors.Acquisition, analysis, or interpretation of data: Brown, Shmulewitz, Wall,Sarvet, Hasin.Figure. Year-to-Year Prevalencea of Past-MonthMarijuana Useb Among Pregnant and NonpregnantWomen, Overall and by Age, 2002-2014c188101214166420Adjusted Prevalence of Past-MonthMarijuana Use, % (95% CI)188101214166420Adjusted Prevalence of Past-MonthMarijuana Use, % (95% CI)YearPregnant womenA2002 2004 2006 2008 2010 2012 2014OverallAge18-25 yAge26-44 yLinear predicted–adjusted prevalenceYear-to-year–adjusted prevalenceYearNonpregnant womenB2002 2004 2006 2008 2010 2012 2014OverallAge18-25 yAge26-44 ya Year-to-year–adjusted and linear predicted–adjusted prevalence estimateswere from log-Poisson regressions. Models controlled for race/ethnicity(non-Hispanic white, non-Hispanic black, Hispanic, and other non-Hispanicminorities), family income ($0-$19 999, $20000-$49999,$50000-$74 999,$75000), age (18-25 years, 26-34 years, 35-44 years),education (<high school, high school, some college), year (year was categoricalin the year-to-year model, and continuous in the linear predictedmodel),pregnancy status, pregnancy × year interaction, covariate × pregnancyinteractions, and complex survey design. Error bars indicate 95% CIs and areonly shown for overall year-to-year–adjusted prevalence estimates.Percentage of variability in dichotomousmarijuana use explained by themodel with year as a continuous variable was 6% (McFadden pseudo-R2);the ratio of the pseudo-R2 statistics for themodels with year as a continuousvs categorical variable was 0.98, indicating strong evidence for a linear trend.b Past-monthmarijuana use was defined as responding “within the past30 days” to the question, “How long has it been since you last usedmarijuanaor hashish?”c Data were from the US National Survey on Drug Use and Health. Sample sizeacross all years combined: pregnant women (n = 10 587), nonpregnantwomen (n = 189923).LettersE2 JAMA Published online December 19, 2016 (Reprinted) jama.comDownloaded From: http://jama.jamanetwork.com/ by a University of Memphis User  on 12/20/2016Copyright 2016 American Medical Association. All rights reserved.Drafting of the manuscript: Brown, Martins, Hasin.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Brown, Shmulewitz, Wall, Sarvet, Hasin.Administrative, technical, or material support: Brown, Hasin.Conflict of Interest Disclosures: All authors have completed and submitted theICMJE Form for Disclosure of Potential Conflicts of Interest and none werereported.Funding/Support: This work was supported by grants T32DA031099 (DrsBrown and Hasin [program director]), R01DA037866 (Dr Martins), andR01DA034244 (Dr Hasin) from the National Institute on Drug Abuse and theNew York State Psychiatric Institute (Hasin, Wall).Role of the Funder/Sponsor: The funding organizations and sponsoringagencies had no further role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, orapproval of themanuscript; and decision to submit themanuscript forpublication. The Substance Abuse andMental Health Data Archive provided thepublic use data files for the US National Survey on Drug Use and Health, whichwas sponsored by the Office of Applied Studies of the Substance Abuse andMental Health Services Administration.1. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of marijuana use disorders inthe United States between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72(12):1235-1242.2. Ko JY, Farr SL, Tong VT, Creanga AA, CallaghanWM. Prevalence and patternsof marijuana use among pregnant and nonpregnant women of reproductiveage. Am J Obstet Gynecol. 2015;213(2):201.e1-201.e10.3. Calvigioni D, Hurd YL, Harkany T, Keimpema E. Neuronal substrates andfunctional consequences of prenatal cannabis exposure. Eur Child AdolescPsychiatry. 2014;23(10):931-941.4. American College of Obstetricians and Gynecologists Committee onObstetric Practice. Committee opinion no. 637: marijuana use during pregnancyand lactation.Obstet Gynecol. 2015;126(1):234-238.5. Center for Behavioral Health Statistics and Quality. 2014 National Survey onDrug Use and Health: Methodological Summary and Definitions. Rockville, MD:Substance Abuse andMental Health Services Administration; 2015.6. Hasin DS, Grant B. NESARC findings on increased prevalence of marijuanause disorders-consistent with other sources of information. JAMA Psychiatry.2016;73(5):532.Lettersjama.com (Reprinted) JAMA Published online December 19, 2016 E3Downloaded From: http://jama.jamanetwork.com/ by a University of Memphis User  on 12/20/2016

Trends in Marijuana Use Among Pregnant and Nonpregnant Reproductive-Aged Women, 2002-2014

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Trends in Marijuana Use Among Pregnant and Nonpregnant Reproductive-Aged Women, 2002-2014

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