Subscribe to RSS
Association between Prenatal Marijuana and Tobacco Smoke Exposures and Small for Gestational Age at BirthFunding K.K.V. was supported by the Care Innovation and Community Improvement Program at The Ohio State University.
Objective The aim of this study was to determine the association of prenatal marijuana exposure with and without tobacco smoke exposure and small for gestational age (SGA) at birth.
Study Design We conducted a secondary analysis of the prospective Lifestyle and Early Achievement in Families (LEAF) cohort enrolled from 2010 to 2015. We included singleton nonanomalous liveborn pregnancies. We assessed marijuana use inclusive of any pregnancy urine specimen with a Δ9-THC-COOH concentration of more than 15 ng/mL by mass spectrometry, self-report on questionnaire, and/or electronic health record; and self-reported maternal tobacco use. Because of the high co-frequency of marijuana with tobacco exposure in pregnancy and the known association between tobacco and fetal growth restriction, we modeled the exposure as: both marijuana and tobacco (hereafter “co-use”), only marijuana, only tobacco, and neither (reference). Incidence of SGA in each group was compared with the neither group. The primary outcome was SGA less than 10th percentile, and secondarily less than 5th percentile, using parity-specific definitions per 2017 US natality reference data.
Results Among 325 assessed mothers, 46% had neither exposure, 11% had only prenatal marijuana exposure, 20% only tobacco exposure, and 23% co-use exposure. A third (33%) of infants were SGA less than 10th percentile and 20% SGA less than 5th percentile. Marijuana exposure only was associated with an increased risk of SGA less than 10th percentile (43 vs. 26%; adjusted relative risk [aRR]: 1.66; 95% confidence interval [CI]: 1.02–2.69), and SGA less than5th percentile (30 vs. 13%; aRR: 2.26; 95% CI: 1.15–4.47). Tobacco was not associated with SGA less than 10th percentile, but was with SGA less than 5th percentile (26 vs. 13%; aRR: 2.01; 95% CI: 1.13, 3.56). Co-use was not associated with increased SGA risk in multivariate analysis, but was in sensitivity analysis when tobacco use was defined using a cotinine assay rather than self-report (SGA <10th percentile, aRR: 1.97; 95% CI: 1.24–3.15) and (SGA <5th percentile, aRR: 2.03; 95% CI: 1.09–3.78).
Conclusion Prenatal marijuana exposure in addition to tobacco may increase the risk of SGA. Given the rising prevalence of marijuana use in pregnancy, further research is warranted to understand how in utero marijuana exposure may impact fetal growth and birth weight with and without tobacco exposure.
Marijuana and tobacco are commonly used together in pregnancy.
Prenatal marijuana and tobacco exposure may increase the risk of a small for gestational age infant.
Further research is warranted to understand how in utero marijuana exposure impacts fetal growth.
Prenatal marijuana exposure in addition to tobacco exposure may increase the risk of SGA at birth.
This manuscript will be presented as a poster presentation (poster no.: 334) at the Society for Maternal Fetal Medicine Annual Meeting, February, 2022.
Received: 19 January 2022
Accepted: 03 June 2022
Article published online:
25 August 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
- 1 Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: summary of national findings, NSDUH series H-46, HHS publication no. (SMA) 13–4795. Rockville, MD: Substance Abuse and Mental Health Services Administration; ; 2013 2013
- 2 American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 637: Marijuana use during pregnancy and lactation. Obstet Gynecol 2015; 126 (01) 234-238
- 3 Volkow ND, Han B, Compton WM, McCance-Katz EF. Self-reported medical and nonmedical cannabis use among pregnant women in the United States. JAMA 2019; 322 (02) 167-169
- 4 Shiono PH, Klebanoff MA, Nugent RP. et al. The impact of cocaine and marijuana use on low birth weight and preterm birth: a multicenter study. Am J Obstet Gynecol 1995; 172 (1, Pt 1): 19-27
- 5 Kondracki AJ. Prevalence and patterns of cigarette smoking before and during early and late pregnancy according to maternal characteristics: the first national data based on the 2003 birth certificate revision, United States, 2016. Reprod Health 2019; 16 (01) 142
- 6 Duko B, Pereira G, Tait RJ, Nyadanu SD, Betts K, Alati R. Prenatal tobacco exposure and the risk of tobacco smoking and dependence in offspring: a systematic review and meta-analysis. Drug Alcohol Depend 2021; 227: 108993
- 7 Ko JY, Farr SL, Tong VT, Creanga AA, Callaghan WM. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol 2015; 213 (02) 201.e1-201.e10
- 8 Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001; 178: 101-106
- 9 Westfall RE, Janssen PA, Lucas P, Capler R. Survey of medicinal cannabis use among childbearing women: patterns of its use in pregnancy and retroactive self-assessment of its efficacy against 'morning sickness'. Complement Ther Clin Pract 2006; 12 (01) 27-33
- 10 Gnofam M, Allshouse AA, Stickrath EH, Metz TD. Impact of marijuana legalization on prevalence of maternal marijuana use and perinatal outcomes. Am J Perinatol 2020; 37 (01) 59-65
- 11 Skelton KR, Hecht AA, Benjamin-Neelon SE. Recreational cannabis legalization in the US and maternal use during the preconception, prenatal, and postpartum periods. Int J Environ Res Public Health 2020; 17 (03) E909
- 12 Bolhuis K, Kushner SA, Yalniz S. et al. Maternal and paternal cannabis use during pregnancy and the risk of psychotic-like experiences in the offspring. Schizophr Res 2018; 202: 322-327
- 13 El Marroun H, Bolhuis K, Franken IHA. et al. Preconception and prenatal cannabis use and the risk of behavioural and emotional problems in the offspring; a multi-informant prospective longitudinal study. Int J Epidemiol 2019; 48 (01) 287-296
- 14 Fried PA, Smith AM. A literature review of the consequences of prenatal marihuana exposure. An emerging theme of a deficiency in aspects of executive function. Neurotoxicol Teratol 2001; 23 (01) 1-11
- 15 Metz TD, Borgelt LM. Marijuana use in pregnancy and while breastfeeding. Obstet Gynecol 2018; 132 (05) 1198-1210
- 16 Venkatesh KK, Leviton A, Fichorova RN. et al. Prenatal tobacco smoke exposure and neurological impairment at 10 years of age among children born extremely preterm: a prospective cohort. BJOG 2021; 128 (10) 1586-1597
- 17 Leemaqz SY, Dekker GA, McCowan LM. et al; SCOPE Consortium. Maternal marijuana use has independent effects on risk for spontaneous preterm birth but not other common late pregnancy complications. Reprod Toxicol 2016; 62: 77-86
- 18 Klebanoff MA, Wilkins DG, Keim SA. Marijuana use during pregnancy and preterm birth: a prospective cohort study. Am J Perinatol 2021; 38 (S 01): e146-e154
- 19 Oberbarnscheidt T. Pharmacology of Marijuana. In: Miller N. ed. Journal of addiction research and therapy. 2016
- 20 Brar BK, Patil PS, Jackson DN, Gardner MO, Alexander JM, Doyle NM. Effect of intrauterine marijuana exposure on fetal growth patterns and placental vascular resistance. J Matern Fetal Neonatal Med 2021; 34 (20) 3330-3334
- 21 Conner SN, Bedell V, Lipsey K, Macones GA, Cahill AG, Tuuli MG. Maternal marijuana use and adverse neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol 2016; 128 (04) 713-723
- 22 Warshak CR, Regan J, Moore B, Magner K, Kritzer S, Van Hook J. Association between marijuana use and adverse obstetrical and neonatal outcomes. J Perinatol 2015; 35 (12) 991-995
- 23 El Marroun H, Hudziak JJ, Tiemeier H. et al. Intrauterine cannabis exposure leads to more aggressive behavior and attention problems in 18-month-old girls. Drug Alcohol Depend 2011; 118 (2-3): 470-474
- 24 Abraham M, Alramadhan S, Iniguez C. et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS One 2017; 12 (02) e0170946
- 25 ElSohly MA, Mehmedic Z, Foster S, Gon C, Chandra S, Church JC. Changes in cannabis potency over the last 2 decades (1995-2014): analysis of current data in the United States. Biol Psychiatry 2016; 79 (07) 613-619
- 26 Chabarria KC, Racusin DA, Antony KM. et al. Marijuana use and its effects in pregnancy. Am J Obstet Gynecol 2016; 215 (04) 506.e1-506.e7
- 27 Godleski SA, Shisler S, Eiden RD, Huestis MA. Co-use of tobacco and marijuana during pregnancy: pathways to externalizing behavior problems in early childhood. Neurotoxicol Teratol 2018; 69: 39-48
- 28 Berg CJ, Stratton E, Schauer GL. et al. Perceived harm, addictiveness, and social acceptability of tobacco products and marijuana among young adults: marijuana, hookah, and electronic cigarettes win. Subst Use Misuse 2015; 50 (01) 79-89
- 29 Solomon L, Quinn V. Spontaneous quitting: self-initiated smoking cessation in early pregnancy. Nicotine Tob Res 2004; 6 (Suppl. 02) S203-S216
- 30 Warner TD, Roussos-Ross D, Behnke M. It's not your mother's marijuana: effects on maternal-fetal health and the developing child. Clin Perinatol 2014; 41 (04) 877-894
- 31 Klebanoff MA, Fried P, Yeates KO. et al. Lifestyle and Early Achievement in Families (LEAF) study: design of an ambidirectional cohort study of prenatal marijuana exposure and child development and behaviour. Paediatr Perinat Epidemiol 2020; 34 (06) 744-756
- 32 Foltz RL, McGinnis KM, Chinn DM. Quantitative measurement of delta 9-tetrahydrocannabinol and two major metabolites in physiological specimens using capillary column gas chromatography negative ion chemical ionization mass spectrometry. Biomed Mass Spectrom 1983; 10 (05) 316-323
- 33 Huang W, Moody DE, Andrenyak DM. et al. Simultaneous determination of delta9-tetrahydrocannabinol and 11-nor-9-carboxy-delta9-tetrahydrocannabinol in human plasma by solid-phase extraction and gas chromatography-negative ion chemical ionization-mass spectrometry. J Anal Toxicol 2001; 25 (07) 531-537
- 34 Kim S. Overview of Cotinine cutoff values for smoking status classification. Int J Environ Res Public Health 2016; 13 (12) E1236
- 35 Klebanoff MA, Levine RJ, Morris CD. et al. Accuracy of self-reported cigarette smoking among pregnant women in the 1990s. Paediatr Perinat Epidemiol 2001; 15 (02) 140-143
- 36 Aris IM, Kleinman KP, Belfort MB, Kaimal A, Oken EA. A 2017 US reference for singleton birth weight percentiles using obstetric estimates of gestation. Pediatrics 2019; 144 (01) e20190076
- 37 Coleman-Cowger VH, Schauer GL, Peters EN. 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. Drug Alcohol Depend 2017; 177: 130-135
- 38 Massey SH, Allen NB, Pool LR. et al. Impact of prenatal exposure characterization on early risk detection: methodologic insights for the HEALthy Brain and Child Development (HBCD) study. Neurotoxicol Teratol 2021; 88: 107035
- 39 Gunn JK, Rosales CB, Center KE. et al. Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis. BMJ Open 2016; 6 (04) e009986
- 40 National Academies of Sciences Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington (DC): National Academies Press (US); 2017
- 41 El Marroun H, Tiemeier H, Steegers EA. et al. Intrauterine cannabis exposure affects fetal growth trajectories: the Generation R Study. J Am Acad Child Adolesc Psychiatry 2009; 48 (12) 1173-1181
- 42 Hutchings DE, Martin BR, Gamagaris Z, Miller N, Fico T. Plasma concentrations of delta-9-tetrahydrocannabinol in dams and fetuses following acute or multiple prenatal dosing in rats. Life Sci 1989; 44 (11) 697-701
- 43 Khare M, Taylor AH, Konje JC, Bell SC. Delta9-tetrahydrocannabinol inhibits cytotrophoblast cell proliferation and modulates gene transcription. Mol Hum Reprod 2006; 12 (05) 321-333
- 44 Galve-Roperh I, Chiurchiù V, Díaz-Alonso J, Bari M, Guzmán M, Maccarrone M. Cannabinoid receptor signaling in progenitor/stem cell proliferation and differentiation. Prog Lipid Res 2013; 52 (04) 633-650
- 45 Paul SE, Hatoum AS, Fine JD. et al. Associations between prenatal cannabis exposure and childhood outcomes: results from the ABCD study. JAMA Psychiatry 2021; 78 (01) 64-76
- 46 Klebanoff MA, Levine RJ, Clemens JD, DerSimonian R, Wilkins DG. Serum cotinine concentration and self-reported smoking during pregnancy. Am J Epidemiol 1998; 148 (03) 259-262