BACKGROUND:Perinatal cannabis use has become more common in the United States. However, the evidence that associates prenatal cannabis use with increased risk for adverse maternal and child health outcomes is also growing. Therefore, it is important to include perinatal cannabis risks in standard health warnings to perinatal patients. As health messaging that resonates with perinatal individuals who use cannabis regularly has not yet been identified, further testing is needed. Therefore, we sought to gain perspectives from postpartum individuals who used cannabis regularly in early pregnancy on perinatal cannabis use health messages. METHODS:This analysis used data from a larger qualitative study that recruited participants who were 4 to 12 months postpartum and self-reported daily or weekly cannabis use during early pregnancy (at ~8 weeks gestation) at prenatal care entry. We used a semi-structured interview guide to solicit participants' thoughts on 4 different messages containing perinatal cannabis use health information and warnings. We conducted interviews in April to May 2022. We used thematic analysis to identify key aspects of acceptable perinatal cannabis health messaging. RESULTS:Sixteen participants provided feedback on the health messages. Participants were 21 to 33 years old, 6 to 11 months postpartum, and self-identified as black (n = 4), Hispanic (n = 4), and white (n = 8). None of the messages were wholly accepted across participants, but we identified 3 key aspects of acceptable health messaging for perinatal cannabis use: (1) use of neutral language and images, (2) inclusion of evidence for health risks, (3) present options or alternatives for cannabis use. CONCLUSION:Findings provide evidence for perinatal cannabis use clinical health messaging that could resonate with perinatal patients who use cannabis and encourage open dialogue with their health care providers. Further research is needed to understand the actual impact of message exposure on perinatal cannabis use.

INTRODUCTION:Rates of prenatal e-cigarette use are increasing, but little is known about whether behavioral health characteristics are associated with use during early pregnancy, when intervention may have greatest impact. METHODS:This cross-sectional study examined pregnancies in a Northern California healthcare system (11/2020-12/2024) with universal screening for prenatal e-cigarette use, depression, intimate partner violence (IPV), and other substances (alcohol, cannabis, prescription opioids, stimulants, and other tobacco products). Adjusted prevalence ratios for e-cigarette use were estimated using modified Poisson regression. Analyses were conducted in 2025. RESULTS:Among 180,350 pregnancies, 1.1% reported prenatal e-cigarette use. In mutually adjusted models, e-cigarette use was more prevalent among individuals with depression (aPR=1.72;95%CI=1.45-2.04); IPV (aPR=1.39;95%CI=1.15-1.66); and other substance use (aPRs=1.97-4.59;p<.05). Increasing frequency of alcohol, cannabis, and opioids was associated with higher e-cigarette prevalence. CONCLUSIONS:Prenatal e-cigarette use was uncommon but concentrated among individuals with behavioral health conditions and other substance use, highlighting the need for integrated, prevention-focused care in prenatal settings.

Importance:Understanding how cannabis legalization and large-scale societal disruptions influence adolescent cannabis use is important, as early use is associated with adverse health and educational outcomes. California has the largest regulated cannabis market in the US and provides a unique context to study how major policy and societal shifts are associated with adolescent cannabis use. Objective:To examine how rates of adolescent cannabis use in California changed after recreational cannabis legalization (RCL) and the COVID-19 pandemic. Design, Setting, and Participants:This population-based time-series cross-sectional study included adolescents aged 13 to 17 years in a large, integrated health care delivery system in California who were universally screened for cannabis use during standard pediatric care from January 2011 to December 2024. Data were analyzed from March to September 2025. Exposures:California state RCL passage (November 9, 2016), which reduced penalties for underage possession of cannabis; implementation of legal sales of cannabis for adults (January 1, 2018); and the COVID-19 pandemic (March 19, 2020). Main Outcomes and Measures:Any cannabis use in the past-year, self-reported based on universal screening at standard pediatric well-child visits. Interrupted time series analyses were fit using Poisson regression, standardized for sociodemographic characteristics of the adolescent Kaiser Permanente Northern California population. Results:The study included 1 308 655 screening questionnaires completed over the 14-year study period (mean [SD] 7789 [3673] adolescent screenings per month), with a mean (SD) age of 15.0 (1.4) years at screening and 666 881 (51.0%) questionnaires from female participants. Before RCL passage, the mean rate of adolescent cannabis use was decreasing, from 10.39% (95% CI, 9.96%-10.82%) in January 2011 to 6.83% (95% CI, 6.54%-7.14%) in October 2016 (annual trend rate ratio [RR], 0.93 [95% CI, 0.92-0.94] per year). Rates started increasing at the time of RCL passage (slope change RR, 1.19 [95% CI, 1.06-1.35]), and rates continued to increase after implementation of legal retail sales (annual trend RR, 1.06 [95% CI, 1.02-1.11] per year). After the COVID-19 pandemic began, rates of adolescent cannabis use decreased substantially (level change RR, 0.86 [95% CI, 0.76-0.97]; slope change RR, 0.80 [95% CI, 0.70-0.91]). Rates of adolescent cannabis use continued to decrease slightly in the years after COVID-19, reaching a mean of 6.45% (95% CI, 6.15%-6.77%) in December 2024 (annual trend RR, 0.98 [95% CI, 0.96-0.997] per year). Conclusions and Relevance:In this large, retrospective cross-sectional study, adolescent cannabis use increased following RCL and decreased following the COVID-19 pandemic, returning to prelegalization rates by 2024. These results have important implications for clinicians and policymakers and could help estimate future changes in adolescent cannabis use in response to broad policy changes and societal shifts and inform more effective prevention strategies.

PURPOSE:Studies have identified differences by patient characteristics in addiction treatment utilization in the early COVID-19 pandemic period, yet an understanding of longitudinal changes in utilization patterns remains unclear. We examined treatment utilization trends over three years post-pandemic, with a particular focus on differences by age and race and ethnicity. METHODS:Using electronic health record data, this retrospective cohort study examined overall and telehealth addiction treatment initiation and engagement 3 years pre- and 3 years post-pandemic (3/16/2020) following identification of 170,618 episodes involving problematic substance use among 124,413 adults in a large, integrated Northern California health system. Interrupted time series models were fit to examine annual utilization rates during pre- and post-pandemic periods (3/1/2017-1/15/2020 and 5/17/2020-2/28/2023, respectively), and level- and trend-changes in utilization from pre- to post-pandemic, overall and by age group and race and ethnicity. RESULTS:Overall treatment initiation decreased from 27.0% to 24.2% during the pre-pandemic period by approximately 2% annually (RR [95% CI] = 0.98 [0.96, 0.99]), increased by 6% after the onset of the pandemic (1.06 [1.03, 1.10]), and then decreased by 2% annually in the post-pandemic period to 23.0% (0.98 [0.79, 0.99]). Telehealth initiation increased from 1.9% to 2.6% during the pre-pandemic period by 12% annually (RR [95% CI] = 1.12 [1.06, 1.19]), increased five-fold immediately after pandemic onset (RR [95% CI] = 5.14 [4.62, 5.72]), and then decreased by 10% annually (RR [95% CI] = 0.90 [0.88, 0.92]). Overall and telehealth engagement followed similar patterns. Pre- to post-pandemic trends in utilization varied by age group and slightly by race and ethnicity, which may have been primarily driven by initial increases in utilization at the onset of the pandemic. CONCLUSIONS:Following immediate increases in treatment initiation and engagement during the pandemic, utilization via telehealth decreased slightly over time. Availability of telehealth was not associated with increased or sustained utilization over time. Despite some variation in trends over time by age group and race and ethnicity, we did not find strong evidence of differences across groups.

Importance:As cannabis becomes more accessible and socially accepted, concerns have grown about its potential implications for adolescent mental health. While prior research has linked adolescent cannabis use to psychiatric symptoms, few large, population-based, longitudinal studies have examined associations with clinically diagnosed psychiatric disorders. Objective:To evaluate whether adolescent cannabis use is associated with an increased risk of incident psychotic, bipolar, depressive, and anxiety disorders during adolescence and young adulthood. Design, Setting, and Participants:This cohort study included adolescents aged 13 to 17 years who were screened for past-year cannabis use at Kaiser Permanente Northern California from 2016 to 2023. Adolescents were followed up through age 25 years or until December 31, 2023. Data were analyzed from February 21, 2024, to August 27, 2025. Exposure:Time-varying self-reported past-year cannabis use based on universal, confidential screening during standard pediatric care. Main Outcomes and Measures:Incident clinician-diagnosed psychotic, bipolar, depressive, and anxiety disorders, which were identified through electronic health records using International Classification of Disease codes. Cox proportional hazards regression models were used to measure the strength of associations between adolescent cannabis use and incident psychiatric diagnoses, with adjustments for sex, race and ethnicity, neighborhood deprivation index, insurance type, and time-varying alcohol and other substance use. Results:Of 463 396 adolescents (234 114 males [50.5%]; mean [SD] age, 14.5 [1.3] years) included in the sample, 136 708 were Hispanic individuals (29.5%), 93 737 were non-Hispanic Asian individuals (20.2%), 35 346 were non-Hispanic Black individuals (7.6%), 153 102 were non-Hispanic White individuals (33.0%), and 18 795 individuals were multiracial or of other races or ethnicities (4.1%). At baseline, 26 345 adolescents (5.7%) self-reported past-year cannabis use. Past-year cannabis use was associated with an increased risk of incident psychotic (adjusted hazard ratio [AHR], 2.19; 95% CI, 1.97-2.42), bipolar (AHR, 2.01; 95% CI, 1.82-2.22), depressive (AHR, 1.34; 95% CI, 1.30-1.39), and anxiety disorders (AHR, 1.24; 95% CI, 1.21-1.28). The strength of the associations between cannabis use and incident depressive and anxiety disorders decreased as adolescents aged. This pattern was similar but slightly attenuated after additional adjustment for past psychiatric conditions (psychotic disorder: AHR, 1.92; 95% CI, 1.73-2.13; bipolar disorder: AHR, 1.73; 95% CI, 1.57-1.90; depressive disorder: AHR, 1.33; 95% CI, 1.29-1.38; anxiety disorder: AHR, 1.19; 95% CI, 1.16-1.23). Conclusions and Relevance:This cohort study found that adolescent cannabis use was associated with increased risk of incident psychiatric disorders, particularly psychotic and bipolar disorders. These results could inform the development of clinical and educational interventions for parents, adolescents, and clinicians, as well as protective policies to prevent or delay adolescent cannabis use in the context of expanding cannabis legalization.

Objective:This cross-sectional study examined associations between modes of cannabis use (smoke, vape, edibles, and/or dabs) during the year before pregnancy and cannabis use disorder (CUD). Method:Patients were universally screened for substance use at entrance to prenatal care in an integrated healthcare delivery system (January 2020-July 2024). CUD diagnoses were ascertained from ICD-10 codes in electronic health records during the year before pregnancy. At entrance to prenatal care, patients self-reported frequency of cannabis used during the year before pregnancy (monthly or less, weekly, daily, none) and modes of use during the year before pregnancy (smoke, vape, edibles, dabs). Mode was categorized as no cannabis use, only smoking, only vaping, only dabbing, only edibles, or multiple modes. Results:Of 159,270 pregnancies among 130,712 women (mean age of 31.8 [SD = 5.2]), 16.6% used cannabis during the year before pregnancy (4.4% only smoked, 1.0% only vaped, 0.1% only dabbed, 3.8% only used edibles, and 7.2% used multiple modes); 908 (0.6%) had a CUD diagnosis in the year before pregnancy. Compared to no cannabis use, use of multiple modes was associated with the greatest CUD prevalence (adjusted prevalence ratio, aPR:11.11, 95% CI: 9.09-13.58), followed by only smoking (aPR:10.10, 95% CI: 8.11-12.58), only dabbing (aPR: 8.99, 95% CI: 3.98-20.30), only vaping (aPR: 5.03, 95% CI:3.04-8.33), and only using edibles (aPR:3.21, 95% CI: 2.15-4.79). Comparing modes, only smoking was associated with greater CUD than only vaping (aPR 2.01, 95% CI: 1.22-3.30) and only using edibles (aPR 3.15, 95% CI: 2.11-4.70); and only dabbing was associated with greater CUD prevalence than only using edibles (aPR 2.80, 95% CI: 1.15-6.82). Conclusions:Use of multiple cannabis modes and use of smoked or dabbed modes, compared with edibles or vaping, were associated with a higher prevalence of preconception CUD.

OBJECTIVES:To examine joint associations between race/ethnicity and urbanicity in any cannabis use and modes of cannabis use during preconception. METHODS:In this cross-sectional study, insured pregnant patients (N = 146,166) were screened for cannabis use at prenatal care entry between February, 2020 and September, 2023 at a large integrated healthcare system in Northern California and answered questions about preconception cannabis use (any cannabis use and modes of use [smoking, blunts, edibles, vaping, dabs and topicals]). Multivariable Poisson regression models examined associations between race/ethnicity and urbanicity in preconception cannabis use. RESULTS:The prevalence of any cannabis use was 17%, smoking was the most common mode (67%). Preconception cannabis use was often highest in cities and lowest in town/rural areas. The magnitude of place-based differences was often greatest among non-Hispanic (NH) Black patients and patients from NH multi-racial/other/unknown racial/ethnic groups. For example, while the prevalence of any cannabis use and smoking was highest in cities and lowest in town/rural areas among each racial/ethnic group, the adjusted prevalence ratio (aPR) (1.55; 95% confidence interval [CI]=1.27-1.90) for any cannabis use comparing cities to town/rural areas was higher among NH Black patients; and the aPR for smoking (1.55; 95% CI=1.07-2.24) was highest for patients from NH multi-racial/other/unknown racial/ethnic groups. CONCLUSIONS:Living in cities is often associated with increased preconception cannabis use. The greater magnitude of place-based differences in use among NH Black patients and patients from NH multi-racial/other/unknown racial/ethnic groups indicates that where these patients live potentially matters more in preconception cannabis use.

BACKGROUND:Prenatal cannabis use is increasing, and pregnant individuals often seek guidance from cannabis retailers. It is unknown whether budtender messaging varies by community social vulnerability. METHODS:This cross-sectional mystery shopper study included 505 randomly selected California licensed cannabis retailers (2/26/2024-1/28/2025). Social vulnerability within a 15-minute drive-time buffer around retailers was measured by the CDC Social Vulnerability Index (SVI; range 0-1; four domains: socioeconomic status, household characteristics, racial/ethnic minority status, housing/transportation). The primary outcome was a 4-category prenatal cannabis risk communication measure: clear risk messaging [reference], mode-specific lower-risk messaging, no clear safety/risk messaging, and safety-affirming messaging. Secondary outcomes included product recommendations, fetal or infant health risks, information sources, and guidance to consult a clinician. Logistic and multinomial logistic regression models assessed associations between SVI and outcomes; SVI was multiplied by 10, so estimates reflect odds associated with a 0.1 increase in SVI. RESULTS:Greater household vulnerability was associated with safety-affirming messaging (OR=1.26;95%CI:1.01-1.56) and no clear safety/risk messaging (OR=1.25; 95%CI:1.05-1.50) versus clear risk messaging. Greater racial/ethnic minority vulnerability was associated with safety-affirming versus clear risk messaging (OR=1.21; 95%CI:1.00-1.47). Greater housing/transportation vulnerability was associated with mode-specific lower-risk messaging versus clear risk messaging (OR=1.42; 95%CI:1.06-1.91). Citing warnings was more common in areas with greater socioeconomic vulnerability (OR=1.23; 95%CI:1.01-1.51). Other outcomes did not differ by SVI. CONCLUSIONS:Budtenders in more vulnerable areas were more likely to provide safety-affirming, mode-specific lower-risk, or no clear safety/risk messaging rather than clear prenatal cannabis risk messaging. Findings highlight the need for consistent, evidence-based communication in retail settings.

Introduction Neighborhood context is an important social determinant of health behaviors, including substance use, but less is known about whether neighborhood deprivation is similarly or differentially related to prenatal use of alcohol, cannabis, and nicotine. Methods Using electronic health record data from Kaiser Permanente Northern California, this retrospective observational study examined geographic variation in prenatal alcohol, cannabis, and nicotine use and evaluated whether neighborhood deprivation was associated with use of these substances during pregnancy. The sample included 173,578 pregnancies (November 2020-December 2024) among members with prenatal screening for substance use during early pregnancy as part of standard care. Neighborhood deprivation index (NDI) from geocoded census data was categorized into quartiles. Choropleth maps visualized tract-level prevalence of prenatal substance use, and modified Poisson regression models estimated associations between NDI quartiles and prenatal substance use using individual-level data. Data were analyzed July 2025-Feburary 2026. Results Prevalence of prenatal alcohol, cannabis, and nicotine was 9.6%, 8.9% and 2.0%, respectively. Compared with pregnancies in the least deprived neighborhoods, those in the most deprived neighborhoods had a lower prevalence of prenatal alcohol use (aPR [95% CI] = 0.87 [0.84, 0.92]), but higher prevalence of prenatal cannabis (aPR [95% CI] =1.80 [1.70, 1.90]) and nicotine use (aPR [95% CI] = 1.96 [1.74, 2.20]). Conclusions Neighborhood deprivation showed opposing associations across substances, with lower alcohol use but substantially higher cannabis and nicotine use in more deprived neighborhoods. Findings underscore the importance of considering neighborhood context and type of substance when developing preventive interventions.

INTRODUCTION:Breastfeeding is recommended. It is unknown whether preconception or prenatal cannabis use is related to breastfeeding behaviors. METHODS:This population-based retrospective cohort study included 200,207 pregnancies in Northern California (2016-2022) with live births screened in early pregnancy for cannabis use. Exposures included prenatal cannabis use, preconception cannabis use only, or no cannabis use. Additional analyses considered the frequency of prenatal cannabis use. Longitudinal breastfeeding outcomes assessed at each well-child visit during the first year included any breastfeeding and full breastfeeding (breastmilk without formula). Adjusted prevalence ratios were calculated using modified Poisson regression for longitudinal binary outcomes. Analyses were conducted in 2024 and 2025. The risk of stopping breastfeeding among those who started was modeled using Cox proportional hazard regression. RESULTS:Overall, 7.6% of pregnancies had preconception cannabis use only, and 7.2% had prenatal use. Most people (94.6% overall) initiated breastfeeding, with only modest differences by cannabis use (94.9% no cannabis use, 95.7% preconception cannabis use only, and 90.5% prenatal cannabis use). However, over time, prenatal cannabis use was associated with earlier discontinuation of breastfeeding (adjusted hazard ratio=1.12; 95% CI=1.09, 1.15) and lower prevalence of breastfeeding (adjusted prevalence ratio=0.84; 95% CI=0.82, 0.85 at 6 months and adjusted prevalence ratio=0.81; 95% CI=0.78, 0.83 at 12 months). Associations were stronger for higher-frequency use. There were small differences in breastfeeding between those with preconception cannabis use only and those with no use. Full breastfeeding results were similar. CONCLUSIONS:Despite high prevalence of breastfeeding initiation, prenatal cannabis use was associated with earlier breastfeeding discontinuation and lower prevalence at 6 and 12 months.

BACKGROUND:Despite effective treatments for opioid use disorder (OUD), relapse and treatment drop-out diminish their efficacy, increasing the risks of adverse outcomes, including death. Predicting important outcomes, including non-prescribed opioid use (NPOU) and treatment discontinuation among persons receiving medications for OUD (MOUD) can provide a proactive approach to these challenges. Our study uses ecological momentary assessment (EMA) and deep learning to predict momentary NPOU, medication nonadherence, and treatment retention in MOUD patients. METHODS:Study participants included adults receiving MOUD at a large outpatient treatment program. We predicted NPOU (EMA-based), medication nonadherence (Electronic Health Record [EHR]- and EMA-based), and treatment retention (EHR-based) using context-sensitive EMAs (e.g., stress, pain, social setting). We used recurrent deep learning models with 7-day sliding windows to predict the next-day outcomes, using Area Under the ROC Curve (AUC) for assessment. We employed SHapley additive ExPlanations (SHAP) to understand feature latency and importance. RESULTS:Participants comprised 62 adults with 14,322 observations. Model performance varied across EMA subtypes and outcomes with AUCs spanning 0.58-0.97. Recent substance use was the best performing predictor for EMA-based NPOU (AUC = 0.97). Life-contextual factors were best performers for EMA-based medication nonadherence (AUC = 0.68) and retention (AUC = 0.89), and substance use risk factors (e.g., nicotine and alcohol use) and self-reported MOUD adherence performed best for predicting EHR-based medication nonadherence (AUC = 0.79). SHAP revealed varying latencies between predictors and outcomes. CONCLUSIONS:Findings support the effectiveness of EMA and deep learning for forecasting actionable outcomes in persons receiving MOUD. These insights will enable the development of personalized dynamic risk profiles and just-in-time adaptive interventions (JITAIs) to mitigate high-risk OUD outcomes.

Background:Vaping in adolescents and young adults is increasingly common and has been shown to cause deleterious effects. Little is known about the effects of vaping on risk of coronavirus disease 2019 (COVID-19) among women of reproductive age. This study evaluated whether vaping nicotine and/or cannabis during the year before pregnancy was associated with medically-attended COVID-19 episodes. Methods:This large multicenter cross-sectional retrospective study evaluated women universally screened for vaping during the year before pregnancy as part of standard prenatal care from 9/1/2021 to 3/31/2023. Data came from the electronic health record and included nicotine and/or cannabis vaping during the year before pregnancy (exposure), medically-attended COVID-19 episode during the year before pregnancy (outcome), current and 5-year-history of tobacco smoking status, age, race/ethnicity, neighborhood deprivation index, body mass index, parity and Elixhauser Comorbidity Score. Associations between vaping and medically-attended COVID-19 episodes were estimated using Targeted Maximum Likelihood Estimation (TMLE) adjusting for covariates. Sensitivity analyses were performed after excluding women who had a history of current/former tobacco smoking. Results:The sample of 71,508 reproductive-aged women had a mean (standard deviation) age of 31.7 (5.2) years and 67.6% were non-White. Overall, 2,347 (3.3%) reported vaping nicotine and 3,505 (4.9%) reported vaping cannabis during the year before pregnancy (2.47% vaped nicotine only, 4.10% vaped cannabis only, and 0.81% vaped both). The prevalence of having a medically-attended COVID-19 episode was higher among those who vaped vs. did not vape nicotine (16.9% vs. 14.1%) and among those who vaped nicotine only (17.0%) or nicotine and cannabis (16.8%) vs. neither (14.1%). In the adjusted analyses, the prevalence of a medically-attended COVID-19 episode was greater among those who vaped nicotine (vs. no nicotine vaping) [adjusted prevalence ratio (aPR) =1.33, 95% confidence interval (CI): 1.16-1.53] and among those who vaped nicotine only (aPR =1.32 (05% CI: 1.14-1.52) or both nicotine and cannabis (aPR =1.40, 95% CI: 1.28-1.54) vs. those who did not vape. Vaping cannabis was not associated with medically-attended COVID-19 episode risk. Conclusions:Vaping nicotine only or in combination with cannabis was positively associated with medically-attended COVID-19 episodes among women during the year prior to pregnancy. Future research is needed to understand the mechanisms underlying this association.

Objective: Adverse childhood experiences (ACEs) are common risk factors for unhealthy behaviors and poor health outcomes throughout the life course, but their relationship with prenatal substance use is understudied. This retrospective cohort study included 44,284 patients with pregnancies between January 1, 2022, and June 28, 2024, in a large healthcare system in Northern California, United States of America with universal screening for ACEs, resilience, and substance use during early pregnancy. Methods: Multivariable regression models examined the relationship between ACEs and prenatal substance use and tested whether resilience moderated these associations. Results: Pregnant individuals with a greater number of ACEs had lower resilience, were younger, more likely to be Black, Non-Hispanic White, or Hispanic, and live in an area with greater neighborhood deprivation. In adjusted models, compared to those without ACEs, those with ACEs had a higher adjusted prevalence of prenatal alcohol use, cannabis use, nicotine use, pharmaceutical opioid use, stimulant use, and multiple substance use. Low resilience was independently associated with an increased prevalence of prenatal substance use. Conclusions: Results indicate that routine screening for ACEs may help identify pregnant individuals at risk for prenatal substance use, allowing for earlier linkage to resources and potentially improved maternal and child outcomes.

OBJECTIVE:We evaluated associations between prenatal cannabis use and major structural birth defects of the child. METHODS:This population-based retrospective cohort study comprised singleton births (January 2011-July 2020) universally screened for substance use at entrance to prenatal care. Prenatal cannabis use was defined as self-reported use or a positive toxicology test during pregnancy. Electronic health record and birth certificate data were used to identify 38 specific major structural birth defects within 8 organ systems (i.e., central nervous, eye, ear, cardiac, orofacial/respiratory, gastrointestinal, genitourinary/renal, and musculoskeletal). Modified Poisson regression models were conducted adjusting for propensity scores. RESULTS:Of 363,952 infants, 22,494(6.2%) were exposed to maternal prenatal cannabis use, and 6094 infants (2.17%) had a major structural birth defect. Maternal prenatal cannabis use was associated with gastroschisis in the unadjusted (RR = 2.00, 95% CI: 1.25-3.19) and other non-cannabis prenatal substance use (aRR = 1.68; 95% CI: 1.04-2.71) adjusted models, but not in the models adjusted for maternal age or the propensity score. Maternal prenatal cannabis use was associated with omphalocele in the unadjusted model (RR = 3.04; 95% CI: 1.42-6.48), maternal age-adjusted model (aRR = 3.54; 95% CI: 1.68-7.48), other prenatal substance use-adjusted model (aRR = 3.31; 95% CI: 1.50-7.31), and propensity score adjusted model (aRR: 2.92, 95% CI: 1.26-6.77). Cases of gastroschisis and omphalocele were rare: n = 172 (0.05%) and n = 48 (0.01%), respectively. No associations emerged between maternal prenatal cannabis use and any other birth defects. Findings were replicated when cannabis was defined by toxicology testing only. CONCLUSIONS:Maternal prenatal cannabis use was associated with an increased risk for gastroschisis and omphalocele. Clinicians should provide counseling in a supportive manner to pregnant individuals about the potential harms associated with prenatal cannabis use.

Background:Mental health clinicians are uniquely suited to support and provide important insights about substance use among pregnant patients. This mixed-methods study explored how mental health clinicians perceive and address prenatal cannabis use. Methods:Participants were licensed mental health clinicians from Kaiser Permanente Northern California's Early Start perinatal substance use screening and counseling program. Participants aimed to support patients' goals for a healthy pregnancy. ESS completed a survey (N = 26; 100 % Female; 73.1 % White; M age=48.1) and semi-structured interview (n = 14) on their perceptions about patients' prenatal cannabis use and engagement in the ES program. Interviews were recorded, transcribed coded, and thematically analyzed. Results:Survey results indicated clinicians perceive that nausea/morning sickness was the most common motive for prenatal cannabis use, and pregnant individuals were most likely to get information about prenatal cannabis use from their peers. Survey and interview results indicated clinicians most often used motivational interviewing, harm reduction, and psychoeducation to address cannabis use. Clinicians reported on psychotherapeutic factors (patient readiness, therapeutic rapport, and mental health support) that facilitate engagement and willingness to quit and/or reduce cannabis use during pregnancy. Other themes included ESS utilization of expertise in complementary mental health topics to support their work. Conclusions:In this mixed-methods study, clinicians described several approaches to increase pregnant patients' willingness to engage in perinatal substance use interventions, including eliciting motives for cannabis use and using patient-centered interventions focused on establishing rapport and addressing readiness to quit. Future interventions for patients might incorporate harm reduction and psychoeducation, address motivations for use and readiness to engage in care, emphasize peer support, and support the implementation of complementary interventions.

Importance Pregnant individuals seeking information about the safety of prenatal cannabis use may view budtenders (individuals who work at cannabis retailers) as a trusted source of information. However, the recommendations that budtenders provide to pregnant individuals considering cannabis use are unknown. Objective To characterize how budtenders respond to questions about the safety of blunt, tobacco, and cannabis use during pregnancy, and to evaluate whether advice varied by indication for use or by whether the retailer provided delivery. Design, Setting, and Participants In this cross-sectional study of California cannabis retailers, mystery shoppers posed as pregnant individuals looking for advice about the safety of prenatal substance use. Telephone calls with randomly selected licensed storefront retailers were conducted from February 26, 2024, to January 28, 2025. Exposures Mystery shoppers followed 2 versions of a script (mental health vs no mental health indications for use) with questions about the safety of prenatal blunt, tobacco, and cannabis use. Main Outcomes and Measures The primary outcome was retailers’ responses about the safety of prenatal blunt, tobacco, and cannabis use. Secondary outcomes included product recommendations, opinions on safer vs more harmful modes of prenatal cannabis use, and whether to speak with a physician. Results Of the 505 employees at selected retailers (ie, budtenders), 79.6% (95% CI, 74.8%-83.7%) said prenatal blunt use was unsafe, 79.2% (95% CI, 74.4%-86.4%) said prenatal tobacco use was unsafe, and 40.4% (95% CI, 35.1%-45.9%) said prenatal cannabis use was unsafe. More advised that prenatal cannabis use was safe (20.6%; 95% CI, 16.0%-26.1%) vs blunts (0.8%; 95% CI, 0.2%-2.9%) or tobacco (0.8%; 95% CI, 0.2%-2.9%) or stated that they could not give advice about the safety of prenatal cannabis (19.8%; 95% CI, 15.3%-25.2%) vs tobacco (14.3%; 95% CI, 10.5%-19.2%). Only 5.7% (95% CI, 4.0%-8.1%) mentioned store or product warnings. Budtender recommendations included low- or no-tetrahydrocannabinol cannabis products, harm reduction (eg, use less frequently), and noncannabis strategies (eg, mindfulness). Edibles were most endorsed as safe, while smoking was most endorsed as harmful. Overall, 44.0% (95% CI, 37.3%-50.8%) recommended speaking to a physician before prompting and 46.1% (95% CI, 39.4%-53.0%) after prompting. Responses were generally similar regardless of stated indication for use or delivery service availability. Conclusions and Relevance In this cross-sectional study, most budtenders advised against prenatal blunt and tobacco use. Fewer advised against prenatal cannabis use, highlighting the need for more visible, effective warnings and mandatory budtender education covering risks of prenatal cannabis use.

BACKGROUND:Local policies prohibiting cannabis sales and lower cannabis retail availability are associated with a lower prevalence of adolescent cannabis use. In this study, we examined whether local prohibitions on cannabis retail and cannabis retailer proximity and density are associated with adverse cannabis-related mental health outcomes among adolescents. METHODS:Cross-sectional study of 95,645 Northern California adolescents aged 13-17 who completed a well-check questionnaire in 2021 during standard pediatric care. Exposures included local bans on cannabis storefront and delivery retailers, and retail proximity and density in relation to adolescents' geocoded residences. Past-year psychotic, depressive, and anxiety disorders were identified using ICD codes; self-reported depression symptoms came from the questionnaire. RESULTS:Relative to adolescents in jurisdictions allowing storefront and delivery retail, those in jurisdictions prohibiting storefront retail only (aPR = 0.52; 95%CI: 0.32-0.85), or prohibiting both (aPR = 0.67; 95%CI: 0.48-0.92) had a lower prevalence of psychotic disorders. Greater retailer density (≥6 vs. 0 retailers within a 15-min drive) was associated with a greater prevalence of anxiety disorders (aPR = 1.11; 95%CI: 1.04-1.19), depressive disorders (aPR = 1.10; 95%CI: 1.02-1.19) and depression symptoms (aPR = 1.08; 95%CI: 1.01-1.15). Having a ≥20-min (vs. <5-min) drive to the nearest retailer was associated with a lower prevalence of psychotic (aPR = 0.53; 95%CI: 0.33-0.86), anxiety (aPR = 0.89; 95%CI: 0.82-0.97), and depressive disorders (aPR = 0.89; 95%CI: 0.81-0.98) and depression symptoms (aPR = 0.91; 95%CI: 0.84-0.99). CONCLUSIONS:Local policies prohibiting storefront retail were associated with a lower prevalence of psychotic disorders. Greater retail availability of cannabis near adolescents' residences was associated with a greater prevalence of psychotic, anxiety, and depressive disorders, and depression symptoms. Policies limiting retail density and availability may help reduce cannabis-related harms and merit further assessment.

(Abstracted from JAMA Health Forum 2024;5(11):e243656) In the United States, the rates of self-reported prenatal cannabis use rose from 3% in 2002 to 7% in 2017. Pregnant individuals say that they use cannabis for mental health and physical symptoms and because they believe it is safer than medications for those ailments.