Citation
Perceived Risk of Weekly Cannabis Use, past 30-Day Cannabis Use, and Frequency of Cannabis Use among Pregnant Women in the United States

Material Information

Title:
Perceived Risk of Weekly Cannabis Use, past 30-Day Cannabis Use, and Frequency of Cannabis Use among Pregnant Women in the United States
Creator:
Odom, Gage C
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (54 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Epidemiology
Committee Chair:
Lopez-Quintero,Catalina
Committee Co-Chair:
Striley,Catherine L
Committee Members:
Cottler,Linda B
Graduation Date:
12/13/2019

Subjects

Subjects / Keywords:
cannabis -- cannabis-use -- pregnancy -- risk
Epidemiology -- Dissertations, Academic -- UF
Genre:
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Epidemiology thesis, M.S.

Notes

Abstract:
Consistent evidence suggests the prevalence of cannabis use has increased among pregnant women in the US, however, less is known about subpopulations at higher risk of use. This study aims to estimate the prevalence and correlates of perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of past 30-day cannabis use. Data from 2,247 pregnant women 14 to 44 years of age surveyed in the 2015 to 2017 National Survey on Drug Use and Health (NSDUH) series was analyzed. Multivariable logistic and negative binomial regression models were conducted to assess the associations between the primary outcomes and multiple correlates. Estimates include adjusted Odds Ratios (aOR) and Incidence Rate Ratios (aIRR) with 95% confidence intervals (C.I.). Among US pregnant women, 21.6% (95% C.I.=19.4, 23.8) did not perceive any risk associated with weekly cannabis use, 5.3% (95% C.I.=4.2, 6.5) used cannabis in the past 30-days, and used cannabis on average 15.6 days a month (95% C.I.=13.5, 17.7) when past 30-day cannabis use was reported. These estimates significantly increased from 2015 to 2017. Younger age, Non-Hispanic Black race/ethnicity, early trimester of pregnancy, co-use of tobacco and/or alcohol, and living in poverty were also associated with these outcomes. As cannabis legalization spreads and cannabis use is increasingly perceived as safe, there is a growing need for research to determine the reasons why women in the identified at-risk subgroups are using cannabis during pregnancy and what motivates frequent use. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (M.S.)--University of Florida, 2019.
Local:
Adviser: Lopez-Quintero,Catalina.
Local:
Co-adviser: Striley,Catherine L.
Statement of Responsibility:
by Gage C Odom.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
LD1780 2019 ( lcc )

Downloads

This item has the following downloads:


Full Text

PAGE 1

1 PERCEIVED RISK OF WEEKLY CANNABIS USE, PAST 30 DAY CANNABIS USE, AND FREQUENCY OF CANNABIS USE AMONG PREGNANT WOMEN IN THE UNITED STATES By GAGE C . ODOM A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERS ITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2019

PAGE 2

2 © 2019 Gage C. Odom

PAGE 3

3 To my grandparents

PAGE 4

4 ACKNOWLEDGMENTS I have a number of people to thank for help and encouragement throughout my degree and the completion of this thesis. I would first like to thank my mentor, Dr. Catalina Lopez Quintero for continuous guidance throughout the thesis processes, with ideas, guidelines, advice , encouragement, and facilitating new ways to think about the problems I am looking at in my thesis and will be looking at in the future. She has spent much time reading through drafts, helping with editing, giving advice for coding, and has been absolutel y invaluable to the completion of this thesis. I also want to express sincere gratefulness for the other members of my committee, Dr. Catherine Striley and Dr. Linda Cottler, for their expertise, assistance, and guidance in the development of my thesis. I would also like to thank my grandparents, whose emotional and financial support has given me the opportunity to write a thesis in the first place. Their support has provided many great opportunities to me, and I plan to use knowledge gained from these oppo rtunities to help to eliminate challenges for those who have not been as fortunate as I have been.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 2 METHODS ................................ ................................ ................................ .............. 16 2.1 Data Source and Study Population ................................ ................................ ... 16 2.2 Measures ................................ ................................ ................................ .......... 17 2.2.1 Dependent Variables ................................ ................................ ............... 17 2.2.2 Independent Variables ................................ ................................ ............. 18 2.2.2.1 Socio demographic factors ................................ ............................ 18 2.2.2.2 Substance use rel ated factors ................................ ........................ 19 2.2.2.3 Health and pregnancy related factors ................................ ............ 20 2.2.2.4 Year of survey ................................ ................................ ................ 20 2.3 Statistical analysis ................................ ................................ ............................. 20 3 RESULTS ................................ ................................ ................................ ............... 22 3.1 Characteristics of the Study Population ................................ ............................ 22 3.2 Prevalence and Correlates of Perceiving No Risk of Weekly Cannabis Use .... 24 3.2.1 Prevalence of Perceiving No Risk of Weekly Cannabis Use ................... 24 3.2.2 Correlates of Perceiving No Risk of Weekly Cannabis Use ..................... 25 3.3 Prevalence and Correlates of Past 30 day Cannabis Use ................................ 29 3.3.1 Prevalence of Past 30 day Cannabis Use ................................ ............... 29 3.3.2 Correlates of Cannabis Use in the Past 30 days ................................ ..... 30 3.4 Frequency and Correlates of Use Frequency of Cannabis in the Past 30 Days ................................ ................................ ................................ .................... 34 3.4.1 Frequency of the Mean Number of Days of Cannabis Use in the Past 30 Days Among the Total Sample ................................ ................................ 34 3.4.2 Frequency of the Mean Number of Days of Cannabis Use in the Past 30 Days Among Pregnant Women Who Had Used Cannabis in the Past 30 Days ................................ ................................ ................................ ......... 35 3.4.3 Correlates of Cannabis Use Frequency in the Past 30 Days .................. 35 4 DISCUSSION ................................ ................................ ................................ ......... 41

PAGE 6

6 4.1 Study Strengths and Limitations ................................ ................................ ....... 46 4.2 Conclusions ................................ ................................ ................................ ...... 47 LIST OF REFERENCES ................................ ................................ ............................... 48 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 54

PAGE 7

7 LIST OF TABLES Table page 3 1 Characteristics of the overall study sample. ................................ ....................... 23 3 2 Characteristicsand cor relates of perceiving no risk of weekly cannabis use ...... 26 3 3 Characteristics and correlates of cannabis use in the past 30 days ................... 31 3 4 Characteristics and modeled number of days of cannabis use in the past 30 days. ................................ ................................ ................................ ................... 37

PAGE 8

8 LIST OF FIGURES Figure page 3 1 Changes in perceived risk of weekl y cannabis use ................................ ............ 29 3 2 Changes in past 30 day cannabis use ................................ ................................ 34 3 3 (a) Changes in the mean number of days of cannabis use among the tota l sample. (b) Changes in the mean number of days of cannabis among past 30 day users . ................................ ................................ ................................ ...... 40

PAGE 9

9 Abstract of Thesis Presente d to the Graduate School of the University of Florid a in Partial Fulfillment of the Requ irements for the Degree of Master of Science PERCEIVED RISK OF WEEKLY CANNABIS USE, PAST 30 DAY CANNABIS USE, AND FREQUENCY OF CANNABIS USE AMONG PREGNANT WOMEN IN THE UNITED STATES By Gage C. Odom December 2019 Chair: Catalina Lopez Quintero Major: E pidemiology Consistent evidence suggests the prevalence of cannabis use has increased among pregnant women in the US, however, less is known about subpopulations at higher risk of use. This study aims to estimate the prevalence and correlates of perceived risk of weekly cannabis use, past 30 day cannabis use, and frequency of past 30 day cannabis use. Data from 2,247 pregnant women 14 to 44 years of age surveyed in the 2015 to 2017 National Survey on Drug Use and Health (NSDUH) series was analyzed. Multiva riable logistic and negative binomial regression models were conducted to assess the associations between the primary outcomes and multiple correlates. Estimates include adjusted Odds Ratios (aOR) and Incidence Rate Ratios (aIRR) with 95% confidence interv als (C.I.). Among US pregnant women, 21.6% (95% C.I.=19.4, 23.8) did not perceive any risk associated with weekly cannabis use, 5.3% (95% C.I.=4.2, 6.5) used cannabis in the past 30 days, and used cannabis on average 15.6 days a month (95% C.I.=13.5, 17.7) when past 30 day cannabis use was reported. These estimates significantly increased from 2015 to 2017. Younger age, Non Hispanic

PAGE 10

10 Black race/ethnicity, early trimester of pregnancy, co use of tobacco and/or alcohol, and living in poverty were also associ ated with these outcomes. As cannabis legalization spreads and cannabis use is increasingly perceived as safe, there is a growing need for research to determine the reasons why women in the identified at risk subgroups are using cannabis during pregnancy a nd what motivates frequent use.

PAGE 11

11 CHAPTER 1 INTRODUCTION Cannabis is the most commonly used psychoactive substance in the United States other than alcohol and nicotine. 1 Analyses of the National Household Survey on Drug Use and Health (NSDUH) have consisten tly shown that unlike alcohol and tobacco use, prenatal cannabis use has significantly increased in recent years 2 7 , with recent estimates showing an increase in past 30 day use from 3.4% between 2002 to 2003 to 7.0% between 2016 to 2017 5 . Furthermore, thi s increase in cannabis use among pregnant women is coupled with significant increases in daily cannabis use, based on 2002 to 2017 NSDUH data 5 , and an increase in the prevalence of cannabis use disorder among all age and race/ethnic subgroups between 1993 and 2014, based on national data on hospitalized pregnant women. 8 Changes in attitudes may relate to changes in cannabis use as legality shifts with 33 states and the District of Columbia to date having chosen to legalize cannabis for medicinal or recreati onal use. 9 A 2018 Gallup poll reports 66% of Americans think cannabis should be made recreationally legal, the highest percentage of support they have reported historically. 10 The need to understand how attitudes towards cannabis and cannabis use change am ong pregnant women is a priority. Perceived risk is an important factor in personal decision making and thus it may effect whether or not specific populations will engage in certain behaviors. 11 As such, a significant relationship between higher rates of c annabis use and not perceiving risk of cannabis use has been widely documented. 1, 12 14 Rates of not perceiving any risk associated with cannabis use were almost four times higher among adult pregnant women who used cannabis in the past 30 days (65.4%) com pared with rates among pregnant non

PAGE 12

12 cannabis users (16.5%). 15 A 2015 study showed that approximately 70% of both pregnant and non pregnant women believed there was no risk or a slight risk of harm from using cannabis once or twice a week. 4 Besides changes in attitudes towards cannabis use, medicalization of cannabis may also explain increases in past 30 day cannabis use and daily use among pregnant women. 5 Potential use of cannabis for treating nausea and vomiting during pregnancy 15 and other conditions co mmon among pregnant and childbearing age women, such as IBS and headaches/migraines 16 17 , may explain the observed trends. Women in the early stages of pregnancy may also be using cannabis therapeutically to alleviate hyperemesis gravidarum 16 , i.e. severe, prolonged vomiting occurring during pregnancy. A 2006 study reported 68% of the survey participants used cannabis to treat hyperemesis gravidarum, and 92% of those respondents rated cannabis as either 16 In addition, a recent study among 4,735 pregnant women showed that those with nausea and vomiting during pregnancy had nearly 2 to 4 times greater odds of prenatal cannabis use during the first trimester of pregnancy than women without nausea and vomiting during pregnancy. 18 Correlates that have shown to influence past 30 day cannabis use among pregnant women include: income, marital status, and previous tobacco, alcohol, or illicit drug use. 4, 19 20 Pregnant women with low annual household levels of incom e (>$50,000) were twice as likely to be past year cannabis users compared to women with incomes over $75,000; pregnant divorced, separated, widowed, or never married women were 4 or more times as likely to be past year cannabis users as married women. Also , pregnant women who were past 30 day or past 2 12 month tobacco ,

PAGE 13

13 smokers or heavy, binge, and general users of alcohol in the past 30 days were more likely than nonsmokers/nondrinkers to be past year cannabis users. Additionally, pregnant women who used o ther illicit drugs (e.g., hallucinogens, heroin, cocaine, inhalants, and any psychotherapeutics) in the past 30 days or past 2 12 months were more likely to be past year marijuana users than pregnant women who did not. 4 Other correlates, such as depression and population density remain to be explored. Although cannabis is the most commonly used federally controlled drug in pregnant populations in the US 17 , and the most commonly used psychoactive substance in the United States other than alcohol and nicotine 1 , previous literature on use outcomes remains controversial 21 . Increasing evidence from animal and human studies suggests prenatal exposure to cannabis affects development throughout life. Animal models suggest that prenatal cannabis exposure can lead to low birth weight and a have shown that cannabis exposure during mice pregnancy results in reduced average birth weight, an increase in male pups per littler with a de creased fetal to placental weight ratio in male fetuses, which denotes a sex specific effect of the exposure. 22 In addition, prenatal exposure to tetrahydrocannabinol (THC), a cannabinoid identified in cannabis, has been linked to impaired cortical develop ment, particularly affecting skilled motor function and other neurological activities. 24 Dose response studies suggest that maternal exposure to low doses of THC result in atypical locomotor activity, alterations in the dopamine system, and altered neurotr ansmitter and neuronal circuit settings, with moderate and higher doses causing increased severity of these symptoms as well as

PAGE 14

14 offspring. 23 Moreover, prenatal exposure to cann abis has also been associated with altered breathing patterns and increased the length of apnoeas in newborn mice. 25 Human studies on the other hand have shown that prenatal use of cannabis alters folic acid uptake 26 , may lead to increases in the risk of m iscarriage 27 28 , delays embryo development 29 30 , and may lead to preterm birth before 37 weeks gestation. A 2015 systematic review of 24 studies found that women who used cannabis during pregnancy showed an increase in the odds of anemia, and that infants exposed to cannabis in utero have decreases in average birth weight and an increased likelihood of need for placement into the neonatal intensive care unit. 31 A 2019 cohort study seems to be consistent with this review, showing a decrease in average birth weight and an increase in incidence of low birth rate and preterm birth. 32 Secondary outcomes may include: stillbirth, spontaneous abortion, and prenatal death 27 28, 33 Potential later life outcomes include deficits in verbal and visual reasoning skills, s hort term memory recollection, hyperactivity, and reduced executive functioning in children, while adolescents and young adults may experience deficits in executive functioning, working memory, response inhibition, and may initiate substance use at an earl ier age. 34 35 A 2018 systematic review of neuropsychological outcomes in children 1 to 11 years of age supports these outcomes, as it found associations between prenatal cannabis exposure and decreased performance on memory, impulse control, problem solvin g, quantitative reasoning, verbal development, and visual analysis tests. 36 Furthermore, a 2018 treatment guideline describes cannabinoid hyperemesis syndrome (CHS), a condition defined in chronic cannabis users by symptoms including significant nausea, vo miting, and abdominal pain. 37 The prevalence of this condit ion lacks comprehensive studies but

PAGE 15

15 a 2016 study was able to show the prevalence of CHS in Colorado doubled after recreational cannabis was legalized. 38 This is especially concerning because the fi rst trimester of pregnancy presents the greatest risk of drug exposure to the fetus 29, 34 , and the presence cannabinoid hyperemesis syndrome may lead to other negative neonatal outcomes, such as malnutrition or vitamin deficiency. As cannabis use is consid ered less risky and becomes accepted in society and more widely available, studies regarding cannabis use and correlates of use among pregnant women are becoming more relevant. Increases in the prevalence and frequency of cannabis use among pregnant women are well documented, but less is known about specific sub populations at higher risk of use. Therefore, the main objectives of this study were to complement current epidemiological estimates by assessing changes in risk perception, past 30 day use, and fre quency of past 30 day use in more recent years, and identifying correlates of perceiving no risk associated with weekly cannabis use, past 30 day cannabis use, and frequency of cannabis use in the past 30 days among a nationally representative sample of pr egnant women aged 14 to 44 over a recent three year period. These findings can assist in identifying at risk sub populations who can be targeted for future studies on the etiology of cannabis use during pregnancy or the design and implementation of future intervention strategies.

PAGE 16

16 C HAPTER 2 METHODS 2.1 Data Source and Study Population The National Survey on Drug Use and Health (NSDUH) series (formerly titled National Household Survey on Drug Abuse) primarily measures the prevalence and correlates of drug u se in the United States quarterly and annually. Information is provided on the use of illicit drugs, alcohol, and tobacco among members of United States households aged 12 and older. Questions include age at first use, as well as lifetime, annual, and past month use for drugs such as: marijuana, cocaine (and crack), hallucinogens, heroin, inhalants, alcohol, tobacco, and nonmedical use of prescription drugs, including pain relievers, tranquilizers, stimulants, and sedatives. The survey covers substance abus e treatment history, and includes questions from the Diagnostic and Statistical Manual (DSM) of Mental Disorders to assess a history of a Major Depressive Episode in the past 12 months. Respondents were also asked about personal and family income, health care access and coverage, and perceptions of risks. Socio demographic and health related data includes factors such as: gender, age, race, ethnicity, population density, income level, state of residence, trimester of pregnancy, self reported overall health status, past 12 months major depressive episode, insurance coverage, educational level, job status, veteran status, and household composition. NSDUH Surveys are administered by computer assisted personal interviewing (CAPI) conducted by an interviewer and audio computer assisted self interviewing (ACASI). For this report, we analyzed data from the 2015, 2016, and 2017 National Survey on Drug Use and Health (NSDUH). Response rates for each year were:

PAGE 17

17 69.66%, 68.44% and 67.12% respectively. Informed consent was obtained from each participant or their representative before the start of each interview. Additional information on survey procedures is available elsewhere. 39 The 2015 to 2017 NSDUH series provided estimates of cannabis use patterns, as well as risk perception and other cannabis use related behaviors among a nationally representative sample of pregnant women. In this study, a sample of 2,247 women age 14 to 44 with complete data and who reported to be pregnant were identified by year interviewed and were included in the analyses. Pregnancy status was assessed by asking participants whether or not they were pregnant when completing the survey. 2.2 Measures 2.2.1 Dependent Variables Dependent variables included perceived risk of weekly cannabis use, can nabis use in the past 30 days, and frequency of past 30 day cannabis use. Perceived r isk: Perceived risk of weekly cannabis use was defined by recoding binomial var any risk (n=22) were coded as 1 (i.e. no risk), and respondents who perceived any level of risk [slight (n=541), moderate (n=487), or great risk (n=637)] were coded as 0 (i.e. any risk) . Past 30 d ay c annabis u se: Past 30 day cannabis use was assessed with a yes / no question.

PAGE 18

18 Frequency of p ast 30 day c annabis u se : Frequency of past 30 day cannabis use was assessed by asking participants who had used cannabis in the past 30 days the me an number of days of use. 2.2.2 Independent Variables Independent variables included socio demographic factors, substance use related factors, health and pregnancy related factors, and the year of the survey. 2.2.2.1 Socio demographic factors Socio demogr aphic factors for this study included age group, self identified race/ethnicity, population density, poverty level, any health insurance coverage, and residence in a state with medical marijuana legalized when the survey was applied . Age g roups : The origi nal variable AGE2 was recoded into three categories of Self identified r ace/ e thnicity : The original questionnaire variable NEWRACE2 is a 7 level categorical variable that was recoded into a variable with four categories; Non Hispanic White, Non Hispanic Black, Non Hispanic Other and Hispanic. Population d ensity: CBSA (Core Based Statistical Area cla ssification) with 1 million or more persons (Large Metropolitan), with fewer than 1 million persons (Small Metropolitan), or those not in a CBSA (non metropolitan). Poverty : The assessment of poverty was created for each individual based on their poverty threshold (determined by their age, family size, the number of

PAGE 19

19 children in the household and total family income). Since the NSDUH only collects categorical values of family income, for each level of income, the midpoint of each range was assigned as the e ffective family income. Family income was divided by the poverty threshold and multiplied by 100 to show family income as a percentage of the federal poverty threshold. Health i nsurance : A dichotomous variable was recoded from a categorical variable askin g if the subject was covered by any health insurance. 2.2.2.2 Substance use related factors Substance use related factors included past 30 day alcohol and/or tobacco use, and past 30 day use of drugs other than cannabis. Alcohol and t obacco u se in the p a st 30 d ays : A binomial variable for alcohol use in the past 30 days and a binomial variable for tobacco use in the past 30 days were combined into a variable with four categories: No past 30 day use of alcohol or tobacco, past 30 day use of alcohol only, p ast 30 day use of tobacco only, and past 30 day use of alcohol and tobacco. Use of d rugs o ther t han c annabis in the p ast 30 d ays : A dichotomous variable assessed whether the subject used an illicit drug other than cannabis in the past 30 days, with 0 bein variable included the use of cocaine, hallucinogens, heroin, inhalants, methamphetamines, or psychedelics , or nonmedical use of prescription drugs, including pain relievers, tranquilizers, stimulants, and sedatives.

PAGE 20

20 2.2.2.3 H ealth and pregnancy related factors Health and pregnancy related factors included trimester of pregnancy, self reported health status, and past year DSM IV major depression episode. Pregnancy t rimester : A categorical variable was used to determine if women 14 to 44 years of age were in the first, second, or third trimester of pregnancy with 24 participants recorded as missing for this v ariable. Self reported h ealth s tatus: assessment of their overall health was recoded into a binomial variable of fair/poor health, or good/very good/excellent health. Past year d epression: To assess a history of a Major Depressive Episode in the past 12 months, we recoded the original variables showing DSM IV youth major depressive episode occurrence in the past 12 months, and DSM IV adult major depressive episode occurrence in the past 12 months. Any positive an swer was month depression. 2.2.2.4 Year of s urvey Year of s urvey : We also added a variable YEAR to control for potential survey variations overtime. 2.3 Statistical analysis NSDUH analysis weights with Taylor series lineariza tion were applied to accommodate for the sampling design. 40 Because we pooled data from 2015 to 2017, a new analytic weight variable was created upon aggregating the three datasets and dividing the analytic weight variable provided by three, the number of data sets combined. 41 We used SAS 9.4 to obtain proper standard error estimates for the cross tabulations and logistic regression models and STATA 14.0 for the negative binomial

PAGE 21

21 regression models. First, we described the overall sample by its socio demogra phic, substance abuse, and health and pregnancy related characteristics. We then described respondents by perceived risk of weekly cannabis use, past 30 day cannabis use, and the mean number of days of past 30 day cannabis use in the total sample and among pregnant women who used cannabis in the past 30 days. We then conducted logistic regression models for assessing associations between perceived risk of weekly cannabis use and past 30 day cannabis use, the outcome variables, and year, socio demographic, substance abuse, and health and pregnancy related factors. Perceived risk was included as a covariate in the past 30 day logistic models and frequency models. Univariate and multivariable logistic regression model associations were expressed as Odds Ratios (OR) and adjusted Odds Ratios (aOR) with corresponding 95% confidence Intervals (C.I.). We also conducted negative binomial regression models to assess the association between the number of days of past 30 day cannabis use and year, socio demographic, sub stance abuse, and health and pregnancy related factors. Univariate and multivariable negative binomial regression model associations were expressed as Incident Rate Ratios (IRR) and adjusted Incident Rate Rations (aIRR) with corresponding 95% confidence in tervals (C.I.). By checking parameters related to overdispersion, NBR pro vided a better fit for analysis.

PAGE 22

22 CHAPTER 3 RESULTS 3.1 Characteristics of the Study Population Our sample population consisted of women age 14 to 44 years of age. In our sample, 1.7% of women were ages 14 to 17, 32.4% were ages 18 to 29, and 65.9% were ages 30 to 44. Most respondents (55.4%) were Non Hispanic White, with 15% being Non Hispanic Black, 9.4% being Non Hispanic Other, and being 20.3% Hispanic (Table 3 1). Few respondents lived in a non metropolitan area (5.2%), with the majority living in small (39.6%) or large (55.2%) metropolitan areas. In the sample, 23% of the women lived in poverty, and 19.8% lived in the middle income bracket, with 57.3% living with incomes more than 2X the Federal Poverty Threshold (FPT) . In our sample, slightly more than half of women (51.8%) lived in a state where medical marijuana has been legalized. Most women (79.9%) in our sample had not used alcohol or tobacco in the past 30 days, with 6.7% us ing alcohol only in the past 30 days, 10.6% using tobacco only in the past 30 days, and 2.8% using both in the past 30 days. Only 1.9% of women in our sample used any drug other than cannabis in the past 30 days. Each trimester of pregnancy was represented by about one third of our sample. Most of our sample had an excellent to good self identified overall health status (94.8%) while only 5.2% self identified as fair to poor overall health status. Seven percent of the women met criteria for a history of a D SM IV Major Depressive Episode in the past 12 months.

PAGE 23

23 Table 3 1 . Characteristics of the overall study sample. (n=2,247), 2015 to 2017 National Survey of Drug Use and Health. Characteristics Total Sample Sample Size n = 2,247 a % b (95% C.I.) Socio demographic factors Age Group (years old) 14 to 17 (n=72) 1.7 (1.1, 2.3) 18 to 29 (n=1,080) 32.4 (30.2, 34.6) 30 to 44 (n=1,095) 65.9 (63.6, 68.1) Self identified race/ethnicity Non Hispanic White (n=1, 179) 55.4 (52.1. 58.7) Non Hispanic Black (n=365) 14.9 (13.3, 16.6) Non Hispanic Other (n=239) 9.4 (7.5, 11.2) Hispanic (n=464) 20.3 (17.7, 23.0) Population density Large metropolitan (n=916) 55.2 (52.4, 58.1) Small metrop olitan (n=1,145) 39.6 (36.7, 42.2) Non metropolitan (n=186) 5.2 (4.1, 6.3) Poverty level Living in poverty (n=629) 23.0 (20.7, 25.0) Income up to 2X FPT (n=542) 19.7 (17.4, 22.0) Income more than 2X FPT (n=1,094) 57.3 (54.6, 60.2) Residence in medical marijuana legalized state No (n=1,114) 48.2 (45.0, 51.4) Yes (n=1,133) 51.8 (48.6, 55.0) Substance use related factors Alcohol and/or tobacco use in the past 30 days Neither (n=1,742) 79.9 (78.3, 81.6) Alcohol use only (n=144) 6.7 (5.3, 8.0) Tobacco use only (n=289) 10.6 (9.2, 12.0) Alcohol and tobacco use (n=72) 2.8 (1.8, 3.7) Past 30 day use of drugs other than C annabis No (n=2,206) 98.1 (97.3, 99.0) Yes (n=41) 1.9 (1.0, 2.7)

PAGE 24

24 Table 3 1 Continued Characteristics Total Sample Sample Size n = 2,247 a % b (95% C.I.) Health and pregnancy related F actors Trimester of pregnancy First (n=710) 32.3 (29.0, 35.4) Second (n=798) 35.0 (32.4, 37.7) Third (n=715) 32.7 (29.9, 35.5) Self reported overall health status Excellent to good (n=2,105) 94.8 (93.6. 95.9) Fair to Poor (n=142) 5.2 (4.1, 6.4) Past 12 months MDE c No (n=2,073) 93.0 (91.7, 94.3) Y es (n=174) 7.0 (5.7, 8.3) Risk perception of weekly cannabis use Any risk (n=1,665) 78.4 (76.1, 80.5) No risk (n=582) 21.6 (19.4, 23.8) Yea r of the survey 2015 (n=786) 33.0 (30.6, 35.6) 2016 (n=729) 33.0 (31.2, 35.7) 2017 (n=732) 34.0 (30.7, 36.2) Notes: a = unweighted number; b = Estimates from weighted analyses; c = Major Depressive Episode as defined by DSM IV 3. 2 Prevalence and Correlates of P erceiv ing No Risk of Weekly Cannabis U se 3.2.1 Prevalence of Perceiving No Risk of Weekly Cannabis U se Overall, one fifth of women (21.6%, 95% C.I.=19.4, 23.8) said there was no risk, abis use. The figure (Figure 3 1 ) shows estimated changes by year in perceived risk of weekly cannabis use over time.

PAGE 25

25 Significant differences in the socio demographic, substance use related, and health/pregnancy related characteristics were seen across strata of risk perception (Table 3 2). As shown in Table 3 2, those who perceived any risk of weekly cannabis use differed from those who did not perceive any risk in multiple characteristics. For example , higher rates of not perceiving any risk were seen among those who were younger, in another racial/ethnic group than Hispanics, residents in metropolitan areas, living in poverty , had used alcohol, tobacco or other drugs than cannabis, and had a history of a DSM IV Major Depressive Episode in the past 12 months. 3.2.2 Corre lates of Perceiving No Risk of Weekly Cannabis U se Our multivariable models (Table 3 2) in dicated young pregnant women (ages 18 to 29) were more likely than older pregnant women (ages 30 to 44) (aOR=1.7; 95% C.I.=1.3, 2.2) to perceive no risk or have no knowledge of any risk of weekly cannabis use. Non Hispanic Whites (aOR=2.6; 95% C.I.=1.7, 3. 8), Non Hispanic Blacks (aOR=2.4; 95% C.I.=1.4, 4.0), and Non Hispanic Others (aOR=2.5; 95% C.I.=1.3, 5.0) were all more likely than Hispanics to perceive no risk or have no knowledge of risk of weekly cannabis use. Pregnant women living in poverty (aOR=1. 8; 95% C.I.=1.3, 2.5) were more likely to perceive no risk or have no knowledge of any risk of weekly cannabis use than respondents with income higher than 2X FPT. Pregnant women who used tobacco only (aOR=1.7; 95% C.I.=1.1, 2.6) in the past 30 days were m ore likely than those who did not to perceive any risk or have no knowledge of risk of weekly cannabis use. Pregnant women showed an increase in likelihood to perceive no risk or have no knowledge of risk of weekly cannabis use in 2017 (aOR=1.6; 95% C.I.=1 .2, 2.3) when compared to pregnant women in 2015 .

PAGE 26

26 Table 3 2 . Characteristics of the overall study sample by perceived risk of weekly cannabis use and correlates of perceiving no risk of weekly cannabis use among pregnant women in the United States. Resul ts of univariate and multivariable regression models (n=2,247) from the 2015 2017 National Survey of Drug Use and Health. Perceived risk of weekly cannabis use Perceiving no risk of weekly cannabis use Characteristics Any risk No risk p value Sample Size n=1665 a n=582 a % b (95% C.I.) % b (95% C.I.) 78.4 (76.2, 80.6) 21.6 (19.4, 23.8) OR 95% C.I. aOR 95% C.I. Socio demographic factors Age Group (years old) <0.01 14 to 17 (n=72) 1.5 (1.0, 2.1) 2. 3 (0.6, 4.1) 2.0 (0.8, 4.9) 1.4 (0.5, 4.8) 18 to 29 (n=1,080) 29.2 (26.8, 31.6) 44.1 (38.9, 49.4) 2.0 (1.6, 2.6) 1.7 (1.3, 2.2) 30 to 44 (n=1,095) 69.3 (66.8, 71.8) 53.6 (48.4, 58.7) 1 1 Self identified race/ethnicity <0.01 Non Hispanic Wh ite (n=1,179) 54.0 (50.4, 57.6) 60.2 (54.6, 65.9) 2.3 (1.6, 3.2) 2.6 (1.7, 3.8) Non Hispanic Black (n=365) 13.8 (11.8, 15.7) 19.3 (14.7, 23.9) 2.9 (1.9, 4.5) 2.4 (1.4, 4.0) Non Hispanic Other (n=239) 9.4 (7.3, 11.5) 9.2 (5.4, 13.0) 1.9 (1.0, 3.7) 2.5 (1.3, 5.0) Hispanic (n=464) 22.8 (19.9, 25.7) 11.2 (7.7, 14.8) 1 1 Population density <0.05 Large metropolitan (n=916) 57.1 (53.9, 60.2) 48.3 (43.0, 53.7) 0.6 (0.4, 1.0) 1.1 (0.9, 1.5) Small metropolitan (n=1,145) 38.1 (34.8, 41.3) 45.0 (39 .8, 50.2) 0.8 (0.5, 1.4) 1.1 (0.7, 1.7) Non metropolitan (n=186) 4.8 (3.5, 6.1) 6.6 (4.4, 8.8) 1 1 Poverty level <0.01 Living in poverty (n=629) 20.4 (18.1, 22.8) 32.1 (28.0, 36.3) 2.2 (1.7, 2.9) 1.8 (1.3, 2.5) Income up to 2X FPT (n=542) 18.7 (16.0, 21.4) 23.5 (18.2, 28.8) 1.7 (1.2, 2.5) 1.4 (0.9, 2.2) Income more than 2X FPT (n=1,094) 60.8 (57.7, 64.0) 44.4 (39.1, 49.7) 1 1

PAGE 27

27 Table 3 2 . Continued Perceived risk of weekly cannabis use Perceiving no risk of weekly cannabis use Char acteristics Any risk No risk p value Sample Size n=1665 a n=582 a % b (95% C.I.) % b (95% C.I.) 78.4 (76.2, 80.6) 21.6 (19.4, 23.8) OR 95% C.I. aOR 95% C.I. Residence in medical marijuana legalized 0.79 state No (n=1,114) 48.4 (44.7, 52.1) 47.6 (42.7, 52.6) 1 1 Yes (n=1,133) 51.6 (47.9, 55.3) 52.4 (47.4, 57.3) 1 (0.8, 1.2) 1.1 (0.9, 1.4) Substance use related factors Alcohol and/or tobacco use in the past <0.01 30 days Neither (n=1,742) 83.7 (81.8, 85.6) 66.3 (61.2, 71.4) 1 1 Alcohol use only (n=144) 6.4 (5.0, 7.8) 7.6 (4.7, 10.5) 1.5 (1.0, 2.3) 1.1 (0.7, 1.8) Tobacco use only (n=289) 7.9 (6.4, 9.5) 20.4 (16.8, 24.0) 3.2 (2.3, 4.6) 1.7 (1.1, 2.6) Alcohol and tobacco use (n=72) 2.0 (1.2, 2.8) 5.7 (2.9, 8.4) 3.5 (2.0, 6.5) 1.6 (0.7, 3.3) Past 30 day use of drugs other than <0.01 cannabis No (n=2,206) 99.1 (98.6, 99.6) 94.7 (91.6. 97.9) 1 1 Yes (n=41) 0.9 (0.4, 1.4) 5.3 (2.1, 8.4) 5.8 (2.6, 13.0) 3.1 (1.2, 8.1)

PAGE 28

28 Table 3 2 . Continued Perceived risk of weekly cannabis use Perceiving no risk of weekly cannabis use Characteristics Any risk No risk p value Sample Size n=1665 a n=582 a % b (95% C.I.) % b (95% C.I.) 78.4 (76.2, 80.6) 21.6 (19.4, 23.8) OR 95% C.I. aOR 95% C.I. Health and pregnancy related factors Trimester of pregnancy 0.21 First (n=710) 31.7 (28.0, 35.4) 34.2 (29.0, 39.5) 1.0 (0.7, 1.3) 0. 8 (0.6, 1.1) Second (n=798) 36.3 (32.9, 39.8) 30.4 (24.7, 36.1) 0.7 (0.5, 1.1) 0.7 (0.5, 1.1) Third (n=715) 31.9 (28.7, 35.1) 35.4 (29.9, 40.9) 1 1 Self reported overall health status 0.44 Excellent to good (n=2,105) 95.0 (93.7, 96.2) 94.0 (91.6, 96.4) 1 1 Fair to Poor (n=142) 5.0 (3.8, 6.3) 6.0 (3.6, 8.4) 1.2 (0.7, 2.0) 0.7 (0.4, 1.1) Past 12 months MDE c <0.01 No (n=2,073) 94.2 (92.7, 95.7) 88.6 (84.8, 92.5) 1 1 Yes (n=174) 5.8 (4.3, 7.3) 11.4 (7.5, 15.2) 2.1 (1.3, 3.6 ) 1.6 (0.9, 2.8) Risk perception of weekly cannabis use Any risk (n=1,665) N/A N/A N/A N/A N/A N/A N/A N/A No risk (n=582) N/A N/A N/A N/A N/A N/A N/A N/A Year of the survey <0.01 2015 (n=786) 34.9 (31.9, 37.8) 26.8 (22.4, 31.3) 1 1 2016 (n=729) 33.9 (31.5, 36.3) 31.8 (26.5, 37.0) 1.2 (0.9, 1.6) 1.3 (0.9, 1.7) 2017 (n=732) 31.2 (28.0, 34.5) 41.4 (36.1, 46.7) 1.7 (1.3, 2.4) 1.6 (1.2, 2.3) Notes: a = unweighted number; b = Estimates from weighted analyses; c = Major Depressiv e Episode as defined by DSM IV

PAGE 29

29 Figure 3 1. Changes in perceived risk of weekly cannabis use. (n=2,247), 2015 to 2017 National Survey of Drug Use and Health. 3. 3 Prevalence and Correlates of Past 30 day Cannabis U se 3.3.1 Prevalence of Past 30 day Cannabi s U se Overall, 5.3% (95% C.I.=4.2, 6.5) of pregnant women in our sample (n=2,247) used cannabis in the past 30 days from 2015 to 2017. The figure (Figure 3 2 ) shows changes in the trends of past 30 day cannabis use over time. Significant differences in th e socio demographic, substance use related, and health/pregnancy related characteristics were seen across strata of past 30 day cannabis use (Table 3 3). As shown in Table 3 3, those who had used cannabis in the past 30 days differed from those who did not use cannabis in the past 30 days in multiple characteristics. For example , higher rates of past 30 day cannabis use were seen among those who were significantly more likely to be younger, Non Hispanic Black, live in poverty , use alcohol, tobacco or other drugs than cannabis, be in the first trimester of pregnancy, have a self reported health status of fair to poor, have a history of a DSM IV Major Depressive Episode in the past 12 months, have no risk perception

PAGE 30

30 of weekly cannabis use, or have been surveye d in a more recent NSDUH survey wave. 3.3.2 Cor relates of Cannabis Use in the P ast 30 days Our multivariable models (Table 3 3) indicated that pregnant young women (ages 18 to 29) were nearly twice as likely as pregnant women in the oldest age group (ages 30 44) (aOR=1.8; 95% C.I.=1.1, 2.8) to report past 30 day cannabis use. Non Hispanic Blacks were much more likely than Hispanics to endorse past 30 day cannabis use (aOR=3.5; 95% C.I.=1.5, 8.1). Pregnant women who reside in a state where medical cannabis i s legalized (aOR=2.1; 95% C.I.=1.3, 3.4) were more likely than those not living in medical cannabis legalized states to have used cannabis in the past 30 days. Past 30 day alcohol use (aOR=8.1; 95% C.I.=3.6, 18.3), past 30 day tobacco use (aOR=6.0; 95% C.I .=3.4, 10.6), and past 30 day alcohol and tobacco use (aOR=16.9; 95% C.I.=7.4, 38.4) significantly increased the likelihood of past 30 day cannabis use. Being in the first trimester of pregnancy (aOR=1.7; 95% C.I.=1.1, 2.9) increased the likelihood of past 30 day cannabis use. Having no risk perception of weekly cannabis use (aOR=6.0; 95% C. I. =3.4, 10.7) significantly increased the likelihood of past 30 day cannabis use. Pregnant women showed an increased likelihood of endorsing past 30 day cannabis use in 2017 when compared to 2015 (aOR=2.1; 95% C.I.=1.2, 3.6).

PAGE 31

31 Table 3 3 . Characteristics of the overall study sample by cannabis use in the past 30 days and correlates of cannabis use in the past 30 days among pregnant women in the United States. Results of u nivariate and multivariable regression models (n=2,247) from the 2015 to 2017 National Survey of Drug Use and Health. Cannabis use in the past 30 days Cannabis use in the past 30 days Characteristics Yes No p value OR 95% C.I. aOR 95% C.I. Sample Size n = 152 a n = 2,095 a % b (95% C.I.) % b (95% C.I.) 5.3 (4.2, 6.5) 94.7 (93.5, 95.8) Socio demographic factors Age Group (years old) <0.01 14 to 17 (n=72) 3.8 (0.1, 7.4) 1.6 (1.0, 2.2) 3.5 (1.2, 10.4) 2.9 (0.9, 9.5) 18 to 29 (n=1,080) 48.7 (38.6, 58.9) 31.5 (29.3, 33.7) 2.3 (1.5, 3.5) 1.8 (1.1, 2.8) 30 to 44 (n=1,095) 47.5 (37.7, 57.3) 66.9 (64.6, 69.2) 1 1 Self identified race/ethnicity <0.01 Non Hispanic White (n=1, 179) 55.4 (43.0, 67.9) 55.4 (52.0, 58.7) 2.4 (1.4, 4.1) 1.7 (0.9, 3.4) Non Hispanic Black (n=365) 27.8 (17.0, 38.7) 14.2 (12.5, 15.9) 4.8 (2.4, 9.7) 3.5 (1.5, 8.1) Non Hispanic Other (n=239) 8.0 (0.8, 15.2) 9.4 (7.6, 11.3) 2.0 (0.7, 5.2) 1.5 (0.4, 4 .9) Hispanic (n=464) 8.8 (5.0, 12.6) 21.0 (18.1, 23.8) 1 1 Population density 0.23 Large metropolitan (n=916) 47.3 (36.3, 58.2) 55.6 (53.0, 58.5) 0.6 (0.3, 1.1) 1.2 (0.6, 2.2) Small metropolitan (n=1,145) 45.3 (34.0, 56.6) 39.3 (36.5, 4 2.0) 0.8 (0.4, 1.6) 1.3 (0.6, 3.1) Non metropolitan (n=186) 7.4 (2.8, 12.1) 5.1 (4.0, 6.3) 1 1 Poverty level <0.01 Living in poverty (n=629) 31.3 (22.7, 40.0) 22.5 (20.4, 24.6) 2.0 (1.3, 3.2) 0.9 (0.5, 1.7) Income up to 2X FPT (n=542) 28.5 (18.0, 39.1) 19.3 (16.8, 21.7) 2.2 (1.2, 3.9) 1.3 (0.8, 2.3) Income more than 2X FPT (n=1,094) 40.2 (30.0, 50.3) 58.3 (55.4, 61.1) 1 1

PAGE 32

32 Table 3 3 . Continued Cannabis use in the past 30 days Cannabis use in the past 30 days Char acteristics Yes No p value OR 95% C.I. aOR 95% C.I. Sample Size n = 152 a n = 2,095 a % b (95% C.I.) % b (95% C.I.) 5.3 (4.2, 6.5) 94.7 (93.5, 95.8) Substance use related factors Alcohol and/or tobacco use i n the past 30 days <0.01 Neither (n=1,742) 28.1 (18.2, 37.9) 82.9 (81.2, 84.6) 1 1 Alcohol use (n=144) 20.1 (9.8, 30.4) 5.9 (4.6, 7.2) 9.9 (4.6, 21.7) 8.1 (3.6, 18.3) Tobacco use (n=289) 32.2 (22.6, 41.8) 9.4 (8.0, 10.8) 10.2 (5. 9, 17.5) 6.0 (3.4, 10.6) Alcohol and tobacco use (n=72) 19.6 (11.4, 27.9) 1.8 (1.0, 2.6) 33.0 (16.8, 65.0) 16.9 (7.4, 38.4) Past 30 day use of drugs other than cannabis <0.01 No (n=2,206) 87.6 (78.4, 96.7) 98.7 (98.1, 99.4) 1 1 Yes (n=41) 1 2.4 (3.3, 21.6) 1.3 (0.6, 1.9) 10.7 (4.0, 28.2) 2.6 (0.7, 9.3) Health and pregnancy related factors Trimester of pregnancy <0.01 First (n=710) 54.4 (45.6, 63.3) 31.0 (27.7, 34.4) 2.5 (1.6, 4.1) 1.7 (1.1, 2.9) Second (n=798 ) 22.6 (14.3, 31.0) 35.8 (33.0, 39.0) 0.9 (0.5, 1.6) 1.0 (0.5, 1.9) Third (n=715) 23.0 (14.7, 31.2) 33.2 (30.4, 36.1) 1 1 Self reported overall health status <0.01 Excellent to good (n=2,105) 88.0 (80.9, 95.1) 95.2 (94.0, 96.3) 1 1 Fair to Poor (n=142) 12.0 (4.9, 19.1) 4.8 (3.7, 6.0) 2.7 (1.3, 5.5) 1.3 (0.5, 3.3)

PAGE 33

33 Table 3 3 . Continued Cannabis use in the past 30 days Cannabis use in the past 30 days Characteristics Yes No p value OR 95% C.I. aOR 95% C.I. Sample Size n = 152 a n = 2,095 a % b (95% C.I.) % b (95% C.I.) 5.3 (4.2, 6.5) 94.7 (93.5, 95.8) Past 12 months MDE c <0.01 No (n=2,073) 83.5 (75.8, 91.2) 93.5 (92.3, 94.8) 1 1 Yes (n=174) 16.5 (8.8, 24.2) 6.5 (5.2, 7.7) 2.9 (1.6, 5.4) 1.6 (0.8, 3.5) Risk perception of weekly cannabis <0.01 use Any risk (n=1,665) 31.1 (21.4, 40.7) 81.1 (78.7, 83.4) 1 1 No risk (n=582) 68.9 (59.3, 78.6) 18.9 (16.6, 21.3) 9.0 (5.3, 15.3) 6.0 (3.4, 10.7) Year of the survey <0.01 2015 (n=786) 19.8 (12.7, 27.0) 33.9 (31.4, 36.4) 1 1 2016 (n=729) 31.4 (19.3, 43.4) 33.5 (31.3, 35.8) 1.6 (0.9, 3.0) 1.8 (0.9, 3.9) 2017 (n=732) 48.8 (37.3, 60.4) 32.6 (29.9, 35.2) 2.6 (1.6, 4.0) 2.1 (1.2, 3.6) Notes: a = unweighted number; b = Estimates from weighted analyses; c = Major Depressive Episode as defined by DSM IV

PAGE 34

34 Figure 3 2. Changes in past 30 day cannabis use. (n=2,247), 2015 to 2017 National Survey of Drug Use and Health. 3.4 Frequency and Correlates of Use Frequency of Cannabis in the P ast 30 D ays 3.4.1 Frequency of the Mean Number of Days of Cannabis Use in the Past 30 D ays A mong the Total S ample In the total population, the mean number of days of cannabis use was 0.8 (95% C.I.= 0 .6, 11). T he figure (Figure 3 3 [a] ) shows changes in the frequency of cannabis use in the past 30 days over time among the total sample. The mean number of days of cannabis use in the past 30 days in the total sample was significantly higher among those in a younge r age group, Non Hispanic Blacks, those residing in a small or non metropolitan area, those residing in a medical marijuana legalized state, those who have used alcohol, tobacco, or both alcohol and tobacco, those who have used drugs other than cannabis in the past 30 days, those in the first trimester of pregnancy, those with fair to poor self reported overall health status, those with a past 12 month major depressive disorder, those who did not perceive any risk of weekly cannabis use, and those in the 20 17 survey wave.

PAGE 35

35 3.4.2 Frequency of the Mean N umber o f Days of Cannabis Use in the Past 30 Days Among Pregnant Women W ho Had Used Cannabis in the Past 30 D ays The mean number of days of cannabis use among past 30 day cannabis users was 15.6 (95% C.I.=13.5, 17 .7) days. The figure (Figure 3 3 [b] ) shows changes in the frequency of cannabis use in the past 30 days among pregnant women who had used cannabis in the past 30 days by year of the survey. The mean number of days of cannabis use in the past 30 days a mong those who had used cannabis in the past 30 days was significantly higher among those in the oldest age group, those who were Non Hispa n ic Black or Non Hispanic Other, those residing in a small metropolitan area, those with an income up to or more than 2X FPT, those who used both alcohol and tobacco in the past 30 days, those who used drugs other than cannabis in the past 30 days, those in the first or second trimester of pregnancy, those with a fair to poor self reported overall health status, those wi th no risk perception of weekly cannabis use, and those in the 2016 or 2017 survey wave. 3.4.3 Correlates of Cannabis Use Frequency in the Past 30 Days Our negative binomial regression models (Table 3 4) identified correlates of frequent past 30 day canna bis use among pregnant women. Among respondents, those who were between the ages of 18 to 29 were nearly three times more likely (aIRR, 2.7; 95% C.I.=1.3, 5.4) to use cannabis more often in the past 30 days than those who were between the ages of 30 to 44. Non Hispanic Blacks were nearly three times more likely (aIRR, 2.8; 95% C.I.=1.2, 6.8) to use cannabis in the past 30 days more often than Hispanics. Pregnant women living in large metropolitan areas were twice as likely (aIRR, 2.2; 95% C.I.=1.0, 4.9) to use cannabis in the past 30 days more often than pregnant women living in a non metropolitan area.

PAGE 36

36 Pregnant women living in poverty were nearly three times (aIRR, 2.9; 95% C.I.=1.5, 5.7) as likely to use cannabis in the past 30 days more often than pregna nt women with in the hi ghest income category. Pregnant women who also used alcohol only (aIRR, 8.8; 95% C.I.=3.1, 18.1), tobacco only (aIRR, 11.7; 95% C.I.=4.7, 29.5), or both tobacco and alcohol in the past 30 days (aIRR, 39.4; 95% C.I.=16.1, 96.7) were m uch more likely to use cannabis use in the past 30 days more often than women who did not use tobacco or alcohol in the past 30 days. Pregnant women who used any illicit drug other than cannabis in the past 30 days were also more likely to use cannabis mor e often than non users (aIRR, 4.9; 95% C.I.=1.3, 18.2). Women in the first (aIRR, 2.8; 95% C.I.=1.1, 6.9) or second (aIRR, 3.2; 95% C.I.=1.3, 7.9) trimester of pregnancy used cannabis in the past 30 days more often than women in their third trimester of pr egnancy. Pregnant women who did not know of any risk or did not think there was any risk of weekly cannabis use were 23 times more likely to use cannabis more often than pregnant women who perceived any risk associated with weekly cannabis use (aIRR, 23.4; 95% C.I.=10.8, 50.7). Pregnant women from the 2016 (aIRR, 9.7; 95% C.I.=3.3, 28.3) and 2017 (aIRR, 4.4; 95% C.I.=2.6, 7.5) surveys compared to the sample in 2015, were more likely to report an increase in the number of d ays of past 30 day cannabis use.

PAGE 37

37 Ta ble 3 4 . Characteristics of the overall study sample by mean number of days of canna bis use in the past 30 days and modeled number of days of cannabis use in the past 30 days among pregnant women in the Uni ted States. Results of negative binomial regressio n models (n=2,247) from the 2015 2017 National Survey of Drug Use and Health. Characteristics Mean number of days of cannabis use in the past 30 days c IRR 95% C.I. aIRR 95% C.I. Total sample p value Past 30 day users p value Sample Size n = 2,247 a n = 152 a Mean (95% C.I.) Mean (95% C.I.) 0.8 (0.6, 1.1) 15.6 (13.5, 17.7) Socio demographic factors Age Group (years old) <0.01 <0.01 14 to 17 (n=72) 1.1 ( 0.2, 2.3) 9.2 (1.6, 16.7) 4.2 (1.2,14.7) 0.8 (0.3, 2.2) 18 to 29 (n=1,080) 1.2 (0.8, 1.7) 15.5 (12.7, 18.3) 3.8 (2.2, 6.7) 2.7 (1.3, 5.4) 30 to 44 (n=1,095) 0.6 (0.4, 0.9) 16.3 (13.5, 19.0) 1 1 Self identified race/ethnicity <0.01 <0.01 Non Hispanic White (n=1,179) 0. 8 (0.4, 1.1) 14.2 (11.3, 17.2) 2.2 (1.0, 4.6) 2.1 (0.7, 6.3) Non Hispanic Black (n=365) 1.8 (0.8, 2.9) 18.3 (14.0, 22.6) 5.8 (1.9, 17.9) 2.8 (1.2, 6.8) Non Hispanic Other (n=239) 0.7 ( 0.0, 1.5) 16.1 (5.1, 27.2) 1.6 (0.5, 4.7) 1.7 (0.5, 6.3) Hispa nic (n=464) 0.4 (0.2, 0.5) 15.4 (10.6, 20.2) 1 1 Population density <0.01 <0.01 Large metropolitan (n=916) 0.7 (0.3, 1.0) 14.6 (10.8, 18.3) 1.9 (1.0, 3.4) 2.2 (1.0, 4.9) Small metropolitan (n=1,145) 1.1 (0.7, 1.4) 17.3 (14.2, 20.4) 2.2 ( 0.8, 6.0) 0.6 (0.2, 1.8) Non metropolitan (n=186) 0.9 (0.2, 1.7) 12.2 (4.9, 19.5) 1 1 Poverty level <0.01 <0.01 Living in poverty (n=629) 0.2 (0.7, 1.4) 14.2 (10.9, 17.4) 2.0 (1.2, 3.5) 2.9 (1.5, 5.7) Income up to 2X FPT (n=542) 0.4 (0.5, 2.1) 16.6 (12.5, 20.8) 2.3 (1.0, 5.1) 0.7 (0.3, 1.6) Income more than 2X FPT (n=1,094) 0.1 (0.4, 0.8) 16.1 (13.0, 19.2) 1 1

PAGE 38

38 Table 3 4. Continu ed Characteristics Mean number of days of cannabis use in the past 30 days c IRR 95% C.I. aIRR 95% C.I . Total sample p value Past 30 day users p value Sample Size n = 2,247 a n = 152 a Mean (95% C.I.) Mean (95% C.I.) 0.8 (0.6, 1.1) 15.6 (13.5, 17.7) Substance use related factors Alcohol and/or to bacco use in the past 30 days <0.01 <0.01 Neither 0.3 (0.1, 0.4) 15.7 (11.5, 19.9) 1 1 Alcohol use 1.7 (0.4, 3.0) 10.6 (5.4, 15.9) 8.8 (3.1, 25.2) 7.4 (3.1, 18.1) Tobacco use 2.4 (1.5, 3.3) 14.8 (12.0, 17.7) 12.7 (5.6, 28.6) 11.7 (4.7 , 29.5) Alcohol and tobacco use 8.3 (4.2, 12.5) 22 (18.0, 26.1) 36.1 (14.3, 91.4) 39.4 (16.1, 96.7) Past 30 day use of drugs other than cannabis <0.01 <0.01 No 0.7 (0.5. 0.9) 15.3 (13.3, 17.3) 1 1 Yes 6.5 (1.8, 11.3) 18.2 (12.7, 23.7) 8.2 (3.8, 17.7) 4.9 (1.3, 18.2) Health and pregnancy related factors Trimester of pregnancy <0.01 <0.01 First 1.4 (1.0, 1.9) 16 (13.7, 18.4) 3.1 (1.6, 6.1) 2.8 (1.1, 6.9) Second 0.6 (0.3, 0.8) 16.3 (12.4, 20.3) 1.6 (0.8, 3.3) 3.2 (1.3, 7.9) Third 0.5 (0.2, 0.9) 14.5 (9.8, 19.1) 1 1

PAGE 39

39 Table 3 4 . Continued Notes: a = unweighted number; b = Estimates from weighted analyses; c = Weighted mean d = Major Depressive Episode as defined by DSM IV Characteristics Mean number of days of cannabis use in the past 30 days c IRR 95% C.I. aIRR 95% C.I. Total sample p value Past 30 day users p value Sample Size n = 2,247 a n = 152 a Mean (95% C.I.) Mean (95% C.I.) 0.8 (0.6, 1.1) 15.6 (13.5, 17.7) Self reported overall health status <0.01 <0.01 Excellent to good (n=2,105) 0.8 (0.6, 1.0) 15.4 (13.4, 17.5) 1 1 Fair to Poor (n=142) 2.1 (0.4, 3.7) 17.0 (11.7, 22.3) 2.4 (1.1, 5.2) 1.3 (0.4, 4.3) Past 12 months MDE d <0.01 <0.01 No (n=2,073) 0.8 (0.6, 1.0) 16.0 (14.1, 17.9) 1 1 Yes (n=174) 1.8 (0.7, 2.8) 13.9 ( 9.7, 18.2) 2.0 (1.1, 3.6) 2.1 (0.8, 5.9) Risk perception of weekly <0.01 <0.01 cannabis use Any risk (n=1,665) 0.3 (0.1, 0.4) 12.4 (8.7, 16.1) 1 1 No risk (n=582) 2.9 (2.1, 3.7) 17.1 (15.2, 19.0) 10 (6.0, 17.7) 23.4 (10.8, 50.7 ) Year of the survey <0.01 <0.01 2015 (n=786) 0.3 (0.2, 0.4) 9.7 (6.0, 13.4) 1 1 2016 (n=729) 0.9 (0.5, 1.4) 18.2 (14.3, 22.0) 2.9 (1.6, 5.4) 9.7 (3.3, 28.3) 2017 (n=732) 1.3 (0.8, 1.8) 16.4 (13.3, 19.5) 4.1 (2.5, 6.8) 4.4 (2.6, 7.5)

PAGE 40

40 (a) (b) Figure 3 3 . (a) Changes in the mean number of days of cannabis use in the past 30 days among the total samp le. (n=2247), 2015 to 2017 National Survey of Drug Use and Health (b) Changes in the mean number of days of cannabis use in the past 30 days among those who had used cannabis in the past 30 days. (n=152), 2015 to 2017 National Survey of Drug Use and Health

PAGE 41

41 CHAPTER 4 DISCUSSION The main findings of our study can be summarized as follows: 1) Risk perception of weekly cannabis use has changed overtime among pregnant women, with more women perceiving no risk in 2017 compared to 2015; 2) The prevalence of past 30 day cannabis use and the mean number of days of cannabis use significantly increased from 2015 to 2017 among US pregnant women; 3) Younger maternal age, Non Hispanic Black race/ethnicity, early trimester of pregnancy, and co use of tobacco and/or alcoh ol were all associated with risk perception of weekly cannabis use, past 30 day cannabis use, and the mean number of days of cannabis use in the past 30 days. Lower income was positively associated with perceiving no risk of weekly cannabis use and the num ber of days of cannabis use in the past 30 days. Early pregnancy and no risk perception were positively associated with past 30 day cannabis use and the number of days of cannabis use. Finally, residence in a state with legal medicinal cannabis was positiv ely associated only with past 30 day cannabis use. Attitudes regarding the risk of cannabis use among all population groups have been changing as legalization grows. Our results are consistent with prior studies showing reductions in risk perception of reg ular cannabis use, including among pregnant women. 1, 11, 13 15, 18 We also found a positive relationship between not perceiving any risk associated with weekly cannabis use and both past 30 day cannabis use and frequency of past 30 day cannabis use, which provides additional support for the well documented 12 relationship between risk perception and use and may explain the observed trends of cannabis use among pregnant women. Since our study is a cross sectional study, it was not possible to assess causality or study the reciprocal

PAGE 42

42 relation between risk perception and use, for example, how use affects risk perception overtime and across multiple pregnancies. Future studies in this area are needed . Pregnant women show changes in use over time, with recent NSDU H analyses showing increases in past 30 day cannabis use prevalence by 62% from 2002 to 2014 and doubling (3.4% to 7.0%) from 2002 to 2017. 3, 5 Our findings are consistent with prior reports, showing increases in prevalence rates of 30 day cannabis use ove r a three year time span. 2 3 In addition to changes in attitudes, increases in the numbers of days of use suggest that medicalization of cannabis may play an important role in explaining the observed trends. Female medical cannabis users were more likely t han males to report using cannabis to treat symptoms of nausea, anxiety, IBS, and headaches/migraines, many of which are present during pregnancy. 13 Evidence shows cannabis is often used during pregnancy to treat nausea and vomiting, with prenatal cannabi s use increasing each year from 2009 to 2016 among pregnant women with a nausea and vomiting diagnosis. 18 The small subsample of pregnant women using cannabis exclusively for medical reasons (n=15) in the past year precluded us from conducting additional a nalyses to identified at risk groups. More studies on the reason and patterns of use of cannabis for medical and recreational reasons among pregnant women are needed. Notably, our subsample of Hispanics showed lower past 30 day cannabis use than Non Hispan ic blacks, and a higher risk perception of cannabis use than pregnant women in any other racial ethnic group. Given the protective effect that Hispanic ethnicity confers, we selected this group as a reference, which may in part explain why previous NSDUH a nalyses did not find differences among minority past 30 day

PAGE 43

43 cannabis users. 3 Recent studies showed a similar protective effect among Hispanic pregnant women 42 , and Hispanic women with lower acculturation levels 42 43 , and emphasize the role of cultural fact ors on preventing women from using cannabis while pregnant. In this national sample approximately one out of every five women used alcohol and/or tobacco while pregnant, and as many as one third of pregnant women who used cannabis in the past 30 days had a lso co used tobacco. Use of tobacco and/or alcohol was strongly associated with the use and frequency of use of cannabis in the past 30 days, even after controlling for trimester of pregnancy and use of other drugs than cannabis. Previous analysis of NSDUH data from adults age 18 or older who met criteria for past year cannabis use disorder in 2005 to 2013 showed concomitant nicotine dependence (40.9%) and alcohol dependence (44.1%) 44 , with other studies showing increases in past year (74.5%) and past month (43.6%) cannabis use among pregnant women who were also opioid poly drug users. 45 Data from the US National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2001 to 2002 series has also shown strong associations between DSM IV cannabis use disorders and other substance and psychiatric disorders, including alcohol and nicotine use disorders. 46 The pervasive effects of tobacco and alcohol use during pregnancy have been widely studied 2, 47 48 , however less is known regarding the effects of pren atal exposure to cannabis. Current evidence suggests that cannabis also increases the risk of negative outcomes such as preterm birth, low birth weight, cognitive defects, and behavioral problems. 27, 34 36

PAGE 44

44 A 2017 study showed that of 306 surveys returned, 34% of pregnant women surveyed continued to use cannabis after learning of their pregnancy status, with results also showing those who continued to use cannabis during pregnancy were less likely than those who quit after learning of their pregnancy status to believe t hat cannabis use could be harmfu l during pregnancy (26% vs. 75%, P <0.001). 49 Based on our findings, as well as other previous literature 45, 47, 50 , co use of cannabis with other substances, occurs among pregnant women; therefore, additional s creening and intervention development and implementation efforts are a priority. Typically, substance use screening and intervention are not integrated into routine prenatal care 51 54 , and pregnant women, who are more likely to be in need for these service s, are less likely to receive them compared to non pregnant women. 54 55 In addition, drug screening and effective interventions for cannabis use prevention during pregnancy are underdeveloped. Current recommendations include early screening of cannabis use 56 and cognitive behavioral therapy 29, 56 ; however, availability of screening tests with both a high sensitivity and specificity for pregnant women remains an issue. 57 As expected and previously reported 4 , early pregnancy was associated with use and freque ncy of use in the past 30 days. This finding is of concern as use in the first months of pregnancy may compromise embryonic development, specifically neuronal development 23, 29 30 . Another concern is that past 30 day cannabis use during the second and thir d trimester also occurred among 3% to 4% of pregnant women, with those who had used cannabis in the past 30 days using a mean number of 15.6 days per month. These findings re iterate the importance of screening and intervention even in advanced pregnancy s tages.

PAGE 45

45 There are other potential social covariates consistent with prior studies, suggesting a negative relationship between cannabis use among pregnant women and annual household levels of income. 5 Our results show that pregnant women who are living below the poverty line were both more likely to perceive no risk of weekly cannabis use, were nearly three times as likely to use cannabis more often in the past 30 days than pregnant women within an income bracket of more than 2X FPT , which is consistent with previous NSDUH studies. 3, 5 Recent studies 58 have revealed links between childhood neighborhood quality and cannabis use in adulthood, showing that pregnant women living in poverty may be at risk of using cannabis or other substance. We were also able to f ind in our own analysis that living in poverty is associated with an increased risk of perceiving no risk associated with weekly cannabis use while pregnant, a finding that needs to be further explored. We were able to show in our models that cannabis use in the past 30 days among pregnant women doubles when those women reside in a state where medical cannabis has been legalized, however, no association was observed between residence in a state with legalized medical cannabis and no risk perception of weekl y cannabis use, or an increase in the mean number of days of cannabis use in the past 30 days. Since the frequency of use did not increase in states where medical marijuana is legalized, medical reasons may not be the driver of increased use. Contrasting o ur findings, recent studies using data from 2002 to 2014 of substance treatment admissions to substance use treatment facilities show that among pregnant women, the rate of marijuana treatment admission between th ose years increased by more than four times in states where medical cannabis is legalized, compared to those states

PAGE 46

46 where medical cannabis is not legalized. 59 These results show there may be an increased need for pregnancy cannabis and drug use consultation from distributors and medical professiona ls in states where medical cannabis is legalized. 4.1 Study Strengths and Limitations reliance on self reported substance use, which may be subject to bias due to the historically illicit status of the drug and the government sponsored nature of the survey. 47, 55, 60 NSDUH uses ACASI technology to encourage respondents to report their behaviors directly to a computer rather than via an in person interviewer which reduces social des irability bias and other potential biases. This technology may be especially effective for our population in question, pregnant women, who may face more social pressures than normal to underreport drug use behaviors given potential legal implications. Howe ver, a recent study showed that self report bias may have become less pronounced over time as general attitudes towards cannabis use across the US are shifting. 4, 14 15 This decrease in negative attitudes over time has been found to be consistent with othe r studies showing increase in cannabis related outcomes that did not rely on any self reported substance use 66, 70 , which helps to support the validity of our findings. Despite these limitations, our study, which is based on a nationally representative sam ple of pregnant women, complements prior studies and serves as a baseline for assessing the impact of changes in recreational and medical cannabis legalization, as well as assists to identify women at risk of using cannabis during pregnancy. The use of ACA SI technology for the NSDUH also counterbalances a main limitation of the study, being the self reported nature of a government sponsored survey may cause bias for

PAGE 47

47 the participant, and the ability to respond via computer directly reduces these biases. This is also the first study that examines the associations between three separate outcomes and medical/legal cannabis legalization in state or residence among pregnant women. 4.2 Conclusions Overall, this study helps to confirm reductions in perception of ris k of weekly cannabis use over time, increases in past 30 day cannabis use and increases in days used as well as identifying specific population subgroups more at risk for increases in past 30 day cannabis use, such as Non Hispanic Black pregnant women betw een the ages of 18 to 29, those who have used alcohol and/or tobacco in the past 30 days, and those with no perception of risk of weekly cannabis use. As more states legalize some form of cannabis use, and its use is increasingly perceived as safe, there i s a growing need for additional research on the etiology and outcomes of cannabis use during pregnancy, particularly among the at risk subpopulations identified in this study. The American Congress of Obstetrics and Gynecology recommends that all women be screened for marijuana use in pregnancy 56 but currently, substance use screening and intervention are not typically integrated into routine prenatal care 51 54 . Regardless, women should still be discouraged by medical professionals from using cannabis durin g pregnancy until more information on the effects of prenatal exposure to cannabis becomes available.

PAGE 48

48 LIST OF REFERENCES 1. Carliner, H., Brown, Q. L., Sarvet, A. L., & Hasin, D. S. (2017). Cannabis use, attitudes, and legal status in the US: a review. P reventive medicine , 104 , 13 23. 2. Agrawal, A., Rogers, C. E., Lessov Schlaggar, C. N., Carter, E. B., Lenze, S. N., & Grucza, R. A. (2019). Alcohol, cigarette, and cannabis use between 2002 and 2016 in pregnant women from a nationally representative sample. JAMA pediatrics , 173 (1), 95 96. 3. Brown, Q. L., Sarvet, A. L., Shmulewitz, D., Martins, S. S., Wall, M. M., & Hasin, D. S. (2017). Trends in marijuana use among pregnant and nonpregnant reproductive aged women, 2002 2014. Jama , 317 (2), 207 209. 4. Ko, J. Y., Farr, S. L., Tong, V. T., Creanga, A. A., & Callaghan, W. M. (2015). Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. American journal of obstetrics and gynecology , 213 (2), 201 e1. 5. Volkow, N. D., Han, B., Compton, W. M., & McCance Katz, E. F. (2019). Self reported medical and nonmedical cannabis use among pregnant women in the United States. JAMA . 6. Alshaarawy, O., & Anthony, J. C. (2019). Cannabis use among women of reproductive age in the United States: 2 002 2017. Addictive Behaviors, 99, 106082. doi: 10.1016/j.addbeh.2019.106082 7. Singh, S., Filion, K. B., Abenhaim, H. A., & Eisenberg, M. J. (2019). Prevalence and Outcomes of Prenatal Recreational Cannabis Use in High Income Countries: A Scoping Review. BJ OG: An International Journal of Obstetrics & Gynaecology. doi: 10.1111/1471 0528.15946 8. Shi, Y., & Zhong, S. (2018). Trends in cannabis use disorder among pregnant women in the US, 1993 2014. Journal of general internal medicine , 33 (3), 245 246. 9. Ncsl.org. (2019). State Medical Marijuana Laws. [online] Available at: http://www.ncsl.org/research/health/state medical marijuana laws.aspx 10. 2018 [News Article] in Gallup Poll. Ret rieved from https:// https://news.gallup.com/poll/243908/two three americans support legalizing marijuana.aspx 11. Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health education quarterly, 11(1), 1 47.

PAGE 49

49 12. Piontek, D., Kraus, L. , Bjarnason, T., Demetrovics, Z., & Ramstedt, M. (2013). Individual and country level effects of cannabis related perceptions on cannabis use. A multilevel study among adolescents in 32 European countries. Journal of Adolescent Health , 52 (4), 473 479. 13. Cut tler, C., Mischley, L. K., & Sexton, M. (2016). Sex differences in cannabis use and effects: a cross sectional survey of cannabis users. Cannabis and cannabinoid research , 1 (1), 166 175. 14. Young Wolff, K. C., Sarovar, V., Tucker, L. Y., Conway, A., Alexeeff , S., Weisner, C., Armstrong M., & Goler, N. (2019). Self reported Daily, Weekly, and Monthly Cannabis Use Among Women Before and During Pregnancy. JAMA network open , 2 (7), e196471 e196471. 15. Jarlenski, M., Koma, J. W., Zank, J., Bodnar, L. M., Bogen, D. L. , & Chang, J. C. (2017). Trends in perception of risk of regular marijuana use among US pregnant and nonpregnant reproductive aged women. American Journal of Obstetrics & Gynecology , 217 (6), 705 707. 16. Westfall, R. E., Janssen, P. A., Lucas, P., & Capler, R . (2006). Survey of medicinal cannabis use among childbearing women: patterns of its use in pregnancy and retroactive self Complementary Therapies in Clinical Practice , 12 (1), 27 33. 17. Martin, C. E., Lo nginaker, N., Mark, K., Chisolm, M. S., & Terplan, M. (2015). Recent trends in treatment admissions for marijuana use during pregnancy. Journal of addiction medicine , 9 (2), 99 104. 18. Young Wolff, K. C., Sarovar, V., Tucker, L. Y., Avalos, L. A., Conway, A., Armstrong, M. A., & Goler, N. (2018). Association of nausea and vomiting in pregnancy with prenatal marijuana use. JAMA internal medicine , 178 (10), 1423 1424. 19. el Marroun, H., Tiemeier, H., Jaddoe, V. W., Hofman, A., Mackenbach, J. P., Steegers, E. A., Ve rhulst, F. C., van den Brink, W., & Huizink, A. C. (2008). Demographic, emotional and social determinants of cannabis use in early pregnancy: the Generation R study. Drug and alcohol dependence , 98 (3), 218 226. 20. Oh, S., Salas Wright, C. P., Vaughn, M. G., & DiNitto, D. M. (2017). Marijuana use during pregnancy: A comparison of trends and correlates among married and unmarried pregnant women. Drug and alcohol dependence , 181 , 229 233

PAGE 50

50 21. El Marroun, H., Brown, Q. L., Lund, I. O., Coleman Cowger, V. H., Loree, A . M., Chawla, D., & Washio, Y. (2018). An epidemiological, developmental and clinical overview of cannabis use during pregnancy. Preventive medicine , 116 , 1 5. 22. Benevenuto, S. G., Domenico, M. D., Martins, M. A. G., Costa, N. S., de Souza, A. R. L., Costa, J. L., Tavares, M. F., Dolhnikoff, M., & Veras, M. M. (2017). Recreational use of marijuana during pregnancy and negative gestational and fetal outcomes: an experimental study in mice. Toxicology , 376 , 94 101. 23. de Salas Quiroga, A., Díaz Alonso, J., Garcí a Rincón, D., Remmers, F., Vega, D., Gómez Cañas, M., Lutz, B., Guzmán, M., & Galve Roperh, I. (2015). Prenatal exposure to cannabinoids evokes long lasting functional alterations by targeting CB1 receptors on developing cortical neurons. Proceedings of th e National Academy of Sciences , 112 (44), 13693 13698. 24. Campolongo, P., Trezza, V., Ratano, P., Palmery, M., & Cuomo, V. (2011). Developmental consequences of perinatal cannabis exposure: behavioral and neuroendocrine effects in adult rodents. Psychopharmac ology , 214 (1), 5 15. 25. Tree, K. C., Scotto di Perretolo, M., Peyronnet, J., & Cayetanot, F. (2014). In utero cannabinoid exposure alters breathing and the response to hypoxia in newborn mice. European Journal of Neuroscience , 40 (1), 2196 2204. 26. Sebastiani G , Borrás Novell C, Casanova MA, et al. The Effects of Alcohol and Drugs of Abuse on Maternal Nutritional Profile during Pregnancy. Nutrients. 2018;10(8):1008. doi:10.3390/nu10081008. 27. Correa, F., Wolfson, M. L., Valchi, P., Aisemberg, J., & Franchi, A. M. (2016). Endocannabinoid system and pregnancy. Reproduction , 152 (6), R191 R200. 28. Yonekura, M.D., FACOG Executive Director, LA Best Babies Network Dignity Health California Hospital Medical Center, M. L. (n.d.). Impact of Marijuana on Pregnancy, the Fetus an d Neonate. Presentation. Retrieved from http://paclac.org/wp content/uploads/2017/06/Margaret Yonekura_Impact of Marijuana on Pregnancy the Fetus_6_5_17.pdf 29. Alpár, A., Di Marzo, V., & Harkany, T. (2016). At the tip of an iceberg: prenatal marijuana and it s possible relation to neuropsychiatric outcome in the offspring. Biological Psychiatry , 79 (7), e33 e45. 30. Vitalis, T., Lainé, J., Simon, A., Roland, A., Leterrier, C., & Lenkei, Z. (2008). The type 1 cannabinoid receptor is highly expressed in embryonic co rtical projection neurons and negatively regulates neurite growth in vitro. European Journal of Neuroscience , 28 (9), 1705 1718.

PAGE 51

51 31. Gunn, J. K. L., Rosales, C. B., Center, K. E., Nuñez, A., Gibson, S. J., Christ, C., & Ehiri, J. E. (2016). Prenatal exposure to cannabis and maternal and child health outcomes: a systematic review and meta analysis. BMJ open , 6 (4), e009986. 32. Petrangelo, A., Czuzoj Shulman, N., Balayla, J., & Abenhaim, H. A. (2019). Cannabis Abuse or Dependence During Pregnancy: A Population Based Cohort Study on 12 Million Births. Journal of Obstetrics and Gynaecology Canada , 41 (5), 623 630. 33. Metz, T. D., Allshouse, A. A., Hogue, C. J., Goldenberg, R. L., Dudley, D. J., Varner, M. W., Conway, L., Saade, G., & Silver, R. M. (2017). Maternal marijua na use, adverse pregnancy outcomes, and neonatal morbidity. American journal of obstetrics and gynecology , 217 (4), 478 e1. 34. Huizink, A. C. (2014). Prenatal cannabis exposure and infant outcomes: overview of studies. Progress in Neuro Psychopharmacology and Biological Psychiatry , 52 , 45 52. 35. Grant, K. S., Petroff, R., Isoherranen, N., Stella, N., & Burbacher, T. M. (2018). Cannabis use during pregnancy: pharmacokinetics and effects on child development. Pharmacology & therapeutics , 182 , 133 151. 36. Sharapova, S. R., Phillips, E., Sirocco, K., Kaminski, J. W., Leeb, R. T., & Rolle, I. (2018). Effects of prenatal marijuana exposure on neuropsychological outcomes in children aged 1 11 years: A systematic review. Paediatric and Perinatal Epidemiology, 32(6), 512 53 2. doi: 10.1111/ppe.12505 37. Lapoint, J., Meyer, S., Charles, K. Y., Koenig, K. L., Lev, R., Thihalolipavan, S., Staats, K., & Kahn, C. A. (2018). Cannabinoid hyperemesis syndrome: public health implications and a novel model treatment guideline. Western Jou rnal of Emergency Medicine , 19 (2), 380. 38. Kim, H. S., & Monte, A. A. (2016). Colorado cannabis legalization and its effect on emergency care. Annals of emergency medicine , 68 (1), 71. 39. Center for Behavioral Health Statistics and Quality. (2018). 2017 Nationa l Survey on Drug Use and Health: Methodological summary and definitions. Rockville, MD: Substance Abuse and Mental Health Services Administration. 40. A Comparison of Variance Estimation Methods For Regression Analyses with the Mental Health Surveillance Stud y Clinical Sample. (n.d.). Retrieved from https://www.samhsa.gov/data/node/58791

PAGE 52

52 41. Centers for Disease Control and Prevention. (2018). Guidelines for Using NSDUH Restricted use Data [PDF file.] Retrieved from https://www.cdc.gov/rdc/b1datatype/datafiles /Guidelines for Using NSDUH Restricted use Data.pdf 42. Hernandez, M., von Sternberg, K. L., Castro, Y., & Velasquez, M. M. (2019). The Role of Acculturation and Alcohol Problems on Frequency of Cannabis Use Among Latinas at Risk of an Alcohol Exposed Pregnan cy. Substance Use & Misuse , 1 11 43. da Silva, I. A. N., Lima, D. A. S., de Menezes Benevenuto, S. G., & Veras, M. M. (2019). Cannabis sativa e gravidez: uma revisão. Biotemas , 32 (2), 1 11. 44. Wu, L. T., Zhu, H., Mannelli, P., & Swartz, M. S. (2017). Prevalence and correlates of treatment utilization among adults with cannabis use disorder in the United States. Drug and alcohol dependence , 177 , 153 162. 45. Metz, V. E., Brown, Q. L., Martins, S. S., & Palamar, J. J. (2018). Characteristics of drug use among pregnan t women in the United States: Opioid and non opioid illegal drug use. Drug and alcohol dependence , 183 , 261 266. 46. Grucza, R. A., Agrawal, A., Krauss, M. J., Cavazos Rehg, P. A., & Bierut, L. J. (2016). Recent trends in the prevalence of marijuana use and a ssociated disorders in the United States. JAMA Psychiatry, 73(3), 300 301. 47. Forray, A., & Foster, D. (2015). Substance use in the perinatal period. Current psychiatry reports , 17 (11), 91. 48. Louw, K. A. (2018). Substance use in pregnancy: the medical challen ge. Obstetric medicine , 11 (2), 54 66. 49. Mark, K., Gryczynski, J., Axenfeld, E., Schwartz, R. P., & Terplan, M. (2017). Pregnant women's current and intended cannabis use in relation to their views toward legalization and knowledge of potential harm. Journal of addiction medicine , 11 (3), 211 216. 50. Stinson, F. S., Ruan, W. J., Pickering, R., & Grant, B. F. (2006). Cannabis use disorders in the USA: prevalence, correlates and co morbidity. Psychological medicine , 36 (10), 1447 1460. 51. Petersen Williams, P., Peter sen, Z., Sorsdahl, K., Mathews, C., Everett Murphy, K., & Parry, C. D. (2015). Screening and brief interventions for alcohol and other drug use among pregnant women attending midwife obstetric units in Cape Town, South Africa: a qualitative study of the vi ews of health care professionals. Journal of midwifery & women's health , 60 (4), 401 409.

PAGE 53

53 52. Gotham, H. J., Wilson, K., Carlson, K., Rodriguez, G., Kuofie, A., & Witt, J. (2019). Implementing Substance Use Screening in Family Planning. The Journal for Nurs e Practitioners , 15 (4), 306 310. 53. Bayrampour, H., Zahradnik, M., Lisonkova, S., & Janssen, P. (2018). Women's perspectives about cannabis use during pregnancy and the postpartum period: An integrative review. Preventive medicine . 54. Terplan, M., McNamara, E. J., & Chisolm, M. S. (2012). Pregnant and non pregnant women with substance use disorders: the gap between treatment need and receipt. Journal of addictive diseases , 31 (4), 342 349. 55. Jaques, S. C., Kingsbury, A., Henshcke, P., Chomchai, C., Clews, S., Fal coner, J., Abdel Latif, M. E., Feller, J. M., & Oei, J. L. (2014). Cannabis, the pregnant woman and her child: weeding out the myths. Journal of Perinatology , 34 (6), 417. 56. Stickrath, E. (2019). Marijuana Use in Pregnancy: An Updated Look at Marijuana Use a nd Its Impact on Pregnancy. Clinical obstetrics and gynecology , 62 (1), 185 190. 57. Ondersma, S. J., Chang, G., Blake Lamb, T., Gilstad Hayden, K., Orav, J., Beatty, J. R., Goyert, G., & Yonkers, K. A. (2019). Accuracy of five self report screening instrument s for substance use in pregnancy. Addiction . 58. Lee, J. O., Jones, T. M., Kosterman, R., Cambron, C., Rhew, I. C., Herrenkohl, T. I., & Hill, K. G. (2018). Childhood neighborhood context and adult substance use problems: the role of socio economic status at the age of 30 years. Public health , 165 , 58 66. 59. Meinhofer, A., Witman, A., Murphy, S., & Bao, Y. (2019). Medical marijuana laws are associated with increases in substance use treatment admissions by pregnant women. Addiction . 60. Johnson, T., & Fendrich, M. (2005). Modeling sources of self report bias in a survey of drug use epidemiology. Annals of epidemiology , 15 (5), 381 389 61. Roberson, E. K., Patrick, W. K., & Hurwitz, E. L. (2014). Marijuana Use and Maternal Experiences of Sever Hawai'i Journal of Medicine & Public Health , 73 (9), 283

PAGE 54

54 BIOGRAPHICAL SKETCH Gage Odom is from Palatka, Florida. He received an Associate of Science in a Bachelor of Science in community health from University of North Flor ida. In F all 2019, he received his Master of Science in epidemiolo gy at the University of Florida.