Cigar and Marijuana Blunt Use Among Pregnant and Nonpregnant Women of Reproductive Age in the United States, 2006–2016

Abstract

Objectives. To assess trends in prevalence of cigar and blunt use in relation to cigarette use among pregnant and nonpregnant women of reproductive age.

Methods. We used 2006 to 2016 data from the US National Survey on Drug Use and Health to assess past-month use of cigarettes, cigars, and blunts among a total of 8695 pregnant women and 162 451 nonpregnant women aged 18 to 44 years.

Results. Cigarette use was more prevalent than cigar or blunt use in pregnant and nonpregnant women, with higher prevalence in nonpregnant women for each product. Among all women, cigarette use decreased and blunt use increased over time, whereas cigar use remained stable. Smoking prevalence was highest in the first trimester.

Conclusions. The health implications of the increase in blunt use are not well known in the scientific literature or by the general public. Given the rapid changes in state marijuana laws, this issue should be a public health priority.

Tobacco smoking during pregnancy is the leading preventable cause of poor pregnancy outcomes in the United States and a major public health issue.¹ Research on smoking during pregnancy focuses primarily on cigarette smoking, with little emphasis on cigars or blunts (partially or entirely hollowed out cigar wrappers containing marijuana). The examination of cigar smoking during pregnancy is increasingly important, because cigar sales have increased by 51% between 2008 and 2015,² prompting some to regard it as an ignored public health threat.³ Similarly, the use of marijuana is increasing, especially among reproductive-aged women.⁴ Increases in cigar smoking and in smoking of blunts (i.e., smoking both tobacco and marijuana) could potentially affect maternal and child health.

METHODS

We acquired 2006 to 2016 data from the annual US National Survey on Drug Use and Health (NSDUH) for 171 146 women aged 18 to 44 years. Details about the NSDUH are reported elsewhere.⁵ Approximately 59% of these records corresponded to non-Hispanic White women, 18% to Hispanic women, and 14% to non-Hispanic African American women. Approximately 29% of these records corresponded to women aged 18 to 21 years, and 42% were for women aged 25 to 44 years.

We used statistical analyses to compare prevalence of self-reported use of cigarettes, cigars, and blunts between 8695 pregnant and 162 451 nonpregnant women and between trimesters of pregnancy. We used procedures in SAS version 9.4 (SAS/STAT 14.3) that accounted for the complex survey design and NSDUH-provided survey weights at the person level.⁶ The SURVEYFREQ procedure in SAS was used to estimate nationally representative use prevalence percentages. Logistic regression analyses were appropriate for testing whether use prevalence was statistically associated with pregnancy status (or trimester) and survey year. When significant differences in use rates were present among trimesters at a .05 significance level, we performed additional tests to compare individual pairs of the 3 trimesters for significant differences, with a Bonferroni adjustment made to the P values of these tests to ensure that the overall likelihood of incorrectly declaring at least 1 pair of trimesters significantly different was no higher than .05.

RESULTS

Figure 1 shows the average percentage of cigarette, cigar, and blunt users over the past 30 days, by product and year. For each product, statistical differences in use prevalence between pregnant and nonpregnant women were consistent across years. Thus, we assessed these differences on average across the 11 years. Significant differences (P ≤ .001) were noted for each product and for co-use of tobacco (cigarettes or cigars) and blunts, with a higher prevalence seen among nonpregnant women. Across all years, the likelihood of pregnant women having smoked cigarettes in the past 30 days (14.5%; SE = 0.5%) was lower than in nonpregnant women (26.4%; SE = 0.2%). Similarly, the likelihood of pregnant women having smoked cigars (1.2%; SE = 0.1%) was lower than in nonpregnant women (3.4%; SE = 0.1%); the likelihood of pregnant women having smoked blunts (1.8%; SE = 0.2%) was lower than in nonpregnant women (4.0%; SE = 0.1%). When assessing co-use of tobacco (cigarettes or cigars) and blunts (data not shown), the prevalence of use also was lower for pregnant women (1.3%; SE = 0.2%) than for nonpregnant women (2.8%; SE = 0.1%).

FIGURE 1—

Average Percentage of Cigarette, Cigar, and Blunt Users in the Last 30 Days, by Product and Year, in Pregnant and Nonpregnant Women Aged 18–44 Years: US National Survey on Drug Use and Health, 2006–2016

We found significant differences among years in use prevalence among women aged 18 to 44 years for cigarettes (P ≤ .001) and blunts (P = .030), with a downward trend seen for cigarettes and an upward trend for blunts (Figure 1). No significant differences among years were observed for smoking cigars (P = .43). For pregnant women, the likelihood of smoking cigarettes decreased from 2006 (17.6%; SE = 2.0%) to 2016 (10.1%; SE = 1.4%). The observed increase in the likelihood of nonpregnant women smoking blunts from 2006 (3.1%; SE = 0.2%) to 2016 (5.2%; SE = 0.2%) was less pronounced in pregnant women, for whom the likelihood varied irregularly from 0.8% to 2.5% across years.

For each product type, the likelihood of smoking was highest in the first trimester and then decreased in the last 2 trimesters (data not shown). For cigarettes, the likelihood differed significantly among trimesters (P ≤ .001), with differences between the first trimester and the other 2 trimesters being significant at an overall .05 level. For both cigars and blunts, the interaction of trimester and year effects was statistically significant (P < .001); thus, differences among trimesters were assessed by year. However, no trend over time could be accurately assessed, because no more than 20 surveyed pregnant women reported smoking cigars in a given year, and no more than 30 reported smoking blunts. Furthermore, for second or third trimesters, the number of surveyed pregnant women who reported smoking cigars or blunts was usually fewer than 10 per year. Over all study years, the number of pregnant women reporting cigar smoking decreased from 82 in the first trimester to 51 in the second to 21 in the third. These numbers yielded population prevalence estimates that declined from 2.2% in the first trimester to 0.3% by the third trimester. Similarly, the number of pregnant women reporting blunt smoking declined from 125 in the first trimester to 64 in the second to 35 in the third, yielding population prevalence estimates that declined from 3.9% in the first trimester to 0.6% by the third trimester.

DISCUSSION

From 2006 to 2016, pregnant women were less likely to smoke cigarettes, cigars, and blunts than were nonpregnant women, with declines in use occurring from first to third trimesters. Thus, pregnancy is an opportunity for mothers to reduce or discontinue tobacco use, through harm reduction (e.g., nicotine replacement therapy) or cessation interventions.^7,8 The likelihood of blunt smoking is increasing among reproductive-aged women, with use in the second and third trimesters increasing since 2013. Although co-use of marijuana and tobacco has increased over the past decade,⁹ no conclusive summary is available on the health consequences of using both together.

Pregnant women may smoke cigars or blunts for several reasons, including perception of lowered risk compared with cigarettes,¹⁰ social norms surrounding their use, and avoidance of the expense of highly taxed cigarettes. Flavor options also may appeal to pregnant women¹¹ who have sensitivities to tobacco smell and flavor. The adverse effects of cigar and blunt smoking during pregnancy are concerning because cigar smoke contains large amounts of toxicants, including carbon monoxide and nicotine, known to affect maternal and infant health.¹ Although cigar and blunt smoking is less prevalent than cigarette smoking, pregnant women may be regularly and increasingly using these products. As marijuana use rates rise among pregnant women,⁴ the need to address cigar and blunt use during pregnancy, and differences in cigar and blunt use by socioeconomic status or race/ethnicity, becomes more important.

Limitations to the use of NSDUH data to address these objectives include (1) self-reported data (not biochemically verified), (2) small numbers of pregnant women endorsing cigar and blunt use, (3) cross-sectional survey design rather than a longitudinal design, and (4) past-month smoking possibly not fully capturing smoking in the first trimester before knowing about pregnancy. Despite these limitations, this analysis provides new information on cigar and blunt use during pregnancy.

Clinicians typically focus on cigarette use rather than tobacco and marijuana use, possibly missing an opportunity to intervene among pregnant women who use alternative tobacco products. Future research should examine patterns of cigar and blunt use during pregnancy, recognizing the complexity of cigar products¹²; access tobacco use surveillance tools with biochemical verification to obtain more accurate use data; assess and improve the effectiveness of smoking cessation interventions; and explore the rapid changes in tobacco and marijuana policy, so that the public health implications can be better understood.