Nicola Marsden-Haug, MPH
Epidemiologist
Kitsap Public Health District

In 2015, the Kitsap Public Health District (KPHD) identified an unusual, statistically significant decline in smoking among pregnant civilian women. Declining from 12 percent in 2013 to 8 percent in 2014, the county rate fell below that of Washington state for the first time. This coincided with a decline in youth cigarette smoking and soaring rates of youth e-cigarette use (6 percent in 2012 to 19 percent in 2014). KPHD had also received anecdotal reports of increased e-cigarette and marijuana use by pregnant women.

Given our concern that the reduced smoking rate might be associated with other substance use during pregnancy and in the absence of local or statewide data, KPHD resolved to collect our own data to help us understand our community trends and guide any necessary public health interventions. Local general funds supported a staff epidemiologist to oversee the design, implementation and analysis. A public health graduate student carried out much of the work as a practicum project.

We engaged with all civilian prenatal care providers countywide to survey pregnant women. Clinic reception staff distributed surveys to patients as they appeared for their scheduled appointments. Written instructions directed women to complete the survey only if they were pregnant, 18 years or older, and had not already done so. After anonymously completing the surveys in the waiting rooms, patients deposited them in a box that was picked up regularly by KPHD staff.

Health care providers in these clinics were electronically surveyed to assess their perceptions about the prevalence of smoking, e-cigarette and recreational marijuana use among their patients; current regional practices for cessation counseling; and availability of educational resources.

Over five weeks in the summer of 2016, 468 surveys were completed by pregnant women, representing nearly a quarter of the county’s annual civilian births. Most respondents were Caucasian (78 percent); only 6 percent were Hispanic. Thirty-seven percent were 24- to 28years-old, and 41 percent were covered by Medicaid. These demographics closely mirror the typical annual county births profile.

Twenty percent of those surveyed reported smoking in the three months prior to their pregnancies, but their reported smoking declined to 10 percent when asked about the last 30 days of their current pregnancy. Younger women (18-23 years) reported smoking more often than older women (32 percent vs. 17 percent). E-cigarette use rates were slightly lower: 7 percent in the three months prior to pregnancy, and down to 3 percent during the last 30 days. Recreational marijuana use was 17 percent prior to and 10 percent during pregnancy.

Among the 6 percent of respondents who reported switching from cigarettes to exclusively e-cigarettes or a combination of cigarettes and e-cigarettes because of their pregnancy, 39 percent cited “It is better for my unborn baby,” as the reason, and 36 percent indicated “I am trying to quit.” Separately, 13 percent of respondents stopped using marijuana because of their pregnancy; 64 percent cited, “It is better for my unborn baby” as the reason. A significantly higher proportion of marijuana users as compared with cigarette smokers quit or switched due to concerns about their unborn baby (64 percent vs. 39 percent), whereas the mother’s own health was more frequently cited among cigarette users who quit than among marijuana users who quit (32 percent vs. 17 percent).

While most respondents (86 percent) didn’t want or need any information on these substances, the majority (61 percent) of the remainder would prefer to have a conversation with their provider, while 36 percent would opt for written materials.

The response rate for the electronic provider survey was 57 percent. Most providers (63 percent) do not ask nicotine users whether they smoke tobacco cigarettes or use e-cigarettes. Only 36 percent offer their pregnant patients educational materials about tobacco cigarettes and none provide materials regarding e-cigarettes. The majority of providers (87 percent and 75 percent, respectively) believe they would benefit from receiving more scientific resources and patient educational materials related to e-cigarette and marijuana use in pregnancy.

These findings are the first local estimates of e-cigarette and marijuana use during pregnancy, which  can be used to begin building a body of evidence for policy development. While e-cigarette use during pregnancy appeared to be less prevalent than cigarette use at the time of this evaluation, recreational marijuana use was comparable to cigarettes. Some women are indeed decreasing or stopping use of these substances because of pregnancy, yet between 3-10 percent of women continue use during pregnancy. Many patients desire discussion regarding these substances, yet most local providers want more educational information about e-cigarette or marijuana use for either their patients or themselves. We have shared the findings with our prenatal care providers and will be discussing them further with our Perinatal Task Force.