Crosland BA, Garg B, Bandoli GE, et al. Risk of Adverse Neonatal Outcomes After Combined Prenatal Cannabis and Nicotine Exposure. JAMA Netw Open. 2024;7(5):e2410151. doi:10.1001/jamanetworkopen.2024.10151
Key Points
Question Is in utero exposure to cannabis and nicotine in combination associated with greater adverse outcomes than exposure to either substance alone during pregnancy?
Findings In this population-based cohort study of more than 3.1 million pregnant individuals, combined use of cannabis and nicotine products in pregnancy was associated with an increased risk of maternal and neonatal morbidity compared with use of either substance alone, including infant and neonatal death, infants small for gestational age, and preterm delivery.
Meaning These findings suggest that more effective public health measures and counseling prior to conception and during pregnancy are warranted to mitigate the potential for adverse offspring outcomes from combined prenatal cannabis and nicotine use.
Abstract
Importance The prevalence of cannabis use in pregnancy is rising and is associated with adverse perinatal outcomes. In parallel, combined prenatal use of cannabis and nicotine is also increasing, but little is known about the combined impact of both substances on pregnancy and offspring outcomes compared with each substance alone.
Objective To assess the perinatal outcomes associated with combined cannabis and nicotine exposure compared with each substance alone during pregnancy.
Design, Setting, and Participants This retrospective population-based cohort study included linked hospital discharge data (obtained from the California Department of Health Care Access and Information) and vital statistics (obtained from the California Department of Public Health) from January 1, 2012, through December 31, 2019. Pregnant individuals with singleton gestations and gestational ages of 23 to 42 weeks were included. Data were analyzed from October 14, 2023, to March 4, 2024.
Exposures Cannabis-related diagnosis and prenatal nicotine product use were captured using codes from International Classification of Diseases, Ninth Revision, Clinical Modification, and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification.
Main Outcome and Measures The main outcomes were infant and neonatal death, infants small for gestational age, and preterm delivery. Results were analyzed by multivariable Poisson regression models.
Results A total of 3 129 259 pregnant individuals were included (mean [SD] maternal age 29.3 [6.0] years), of whom 23 007 (0.7%) had a cannabis-related diagnosis, 56 811 (1.8%) had a nicotine-use diagnosis, and 10 312 (0.3%) had both in pregnancy. Compared with nonusers, those with cannabis or nicotine use diagnoses alone had increased rates of infant (0.7% for both) and neonatal (0.3% for both) death, small for gestational age (14.3% and 13.7%, respectively), and preterm delivery (<37 weeks) (12.2% and 12.0%, respectively). Moreover, risks in those with both cannabis and nicotine use were higher for infant death (1.2%; adjusted risk ratio [ARR], 2.18 [95% CI, 1.82-2.62]), neonatal death (0.6%; ARR, 1.76 [95% CI, 1.36-2.28]), small for gestational age (18.0%; ARR, 1.94 [95% CI, 1.86-2.02]), and preterm delivery (17.5%; ARR, 1.83 [95% CI, 1.75-1.91]).
Conclusions and Relevance These findings suggest that co-occurring maternal use of cannabis and nicotine products in pregnancy is associated with an increased risk of infant and neonatal death and maternal and neonatal morbidity compared with use of either substance alone. Given the increasing prevalence of combined cannabis and nicotine use in pregnancy, these findings can help guide health care practitioners with preconception and prenatal counseling, especially regarding the benefits of cessation.