Beyond Opioids: Tobacco and Other Substance Use Among Pregnant Women

January 14, 2020 | Natalie Foster

Perinatal substance use is not only a serious public health issue resulting in detrimental and even life-threatening fetal outcomes, but it’s one that continues to grow. The 2017 National Survey on Drug Use and Health found an increase in both tobacco and alcohol use among pregnant women from 2016 to 2017, with 22.6 percent of pregnant women reportedly using alcohol or tobacco.

Tobacco use during pregnancy can result in poor fetal development and birth outcomes, including preterm delivery, growth restriction, and infant mortality. Women are at the highest risk of developing substance use disorder (SUD) during their reproductive years—and also have the highest prevalence of smoking compared to other age groups—leading to an increased risk of poor birth outcomes for women who are or may become pregnant. Studies also report that the vast majority of individuals in treatment for substance use problems use tobacco—between 77-88 percent. Despite these figures, tobacco cessation is not consistently integrated into treatment programs, nor is it considered a standard of care. Compared to other substances, there is seemingly a less urgent programmatic and political response.

This can be chalked up to “stigma, social norms, and money… because tobacco and alcohol are legal, people assume they can’t be that bad,” said Stephen Patrick, MD, Associate Professor of Pediatrics and Health Policy at Vanderbilt University School of Medicine.

When used in conjunction with other substances though, tobacco can lead to detrimental health outcomes for mothers and infants. Heavier smoking has been shown to be associated with peak neonatal abstinence syndrome scores in conjunction with opioid use.

There is also a disparity that exists in the rate of smoking by socioeconomic status and race. For example, 16.7 percent of American Indian or Alaska Native women smoked at some point during pregnancy, compared to 10.5 percent of white women and six percent of Black women. To chip away at these disparities, there needs to be a more holistic approach beyond education and treatment programs, says Frances Limtiaco, chair of the Tobacco Control Network and Tobacco and Vapor Product Prevention and Control Program Manager at the Washington State Department of Health.

In particular, there needs to be efforts to “implement policies that address the socio-economic determinants of health and disproportionate marketing practices that target low-income communities and those with behavioral health conditions,” Limtiaco said.

Though they don’t specifically target women of reproductive age, research shows tobacco taxes help. A 2014 study from the American Journal of Public Health found that for every $1 increase in a tobacco tax implemented between 2000-2010, low-educated white and black mothers smoked between 14-22 cigarettes per month, a decrease of nearly two percent.

Washington State lawmakers have led the way to address tobacco cessation, particularly among pregnant women. There’s currently a quit line program for women who are planning pregnancy, currently pregnant, or breastfeeding, and ‘Quitting While Pregnant,’ a mobile app module launching early 2020. State officials are also working to integrate nicotine cessation into education materials and treatment programs for other substances. Through a collaboration with the Marijuana Prevention and Education Program, the Department of Health is integrating information on marijuana and tobacco use for pregnant and breastfeeding mothers. Additionally, the state is building capacity for co-treatment of nicotine addiction in State Opioid Response (SOR) grant-funded agencies, which will incorporate nicotine addiction treatment and education in programs for opioids.

Last year Massachusetts introduced legislation that would create a special commission to identify barriers to substance use treatment in the perinatal period. The proposed commission would bring together key stakeholders from across the state to, “identify barriers to care, including insurance coverage access to medication assisted treatment; access to mental health treatment; access to treatment postpartum that facilitates parenting; screening for substance use disorder; and the integration of perinatal care and substance use treatment,” said State Sen. Joan Lovely, who introduced the bill. The legislation is currently pending.

When building programs that address tobacco and substance use in perinatal women, it’s important to be as comprehensive as possible. “Women dealing with postpartum depression or other perinatal mood disorders may struggle to quit smoking or address other substance use. It is imperative that we continue to destigmatize perinatal mood disorders and ensure treatment to help address the underlying causes of SUD,” said Massachusetts State Sen. Lovely.

Overall, programs and policies need to expand to cover and care for women affected by use of all legal and illegal substances. “Over time focus will shift and a new substance will create national concern,” said Vanderbilt’s Patrick. “When we do this, we often forget about legal substances like tobacco and alcohol.” The focus should be on providing best screening, education, and treatment practices for all substances to promote healthy women and infants.