Prenatal and postpartum tobacco use in adolescents and young adults: a qualitative study

Background: Younger obstetric patients are more likely to use combustible tobacco products and/or cannabis during pregnancy and, among those who quit, are more likely to relapse in the postpartum. Few studies have explored the context of prenatal tobacco use in this population from the narratives and perspectives of these patients. We performed a qualitative interview study of young pregnant people, their beliefs, attitudes, reasons for nicotine and tobacco use, and tobacco cessation experiences to address this gap. Methods: Pregnant patients under the age of 22 were recruited from prenatal clinics in Pittsburgh for a cohort study. A subsample of participants were invited to participate in semi-structured interviews about tobacco and cannabis use. Two coders independently coded all transcripts using an open, inductive approach. The research team then used a qualitative description approach to perform thematic analysis by reviewing high frequency codes, identifying patterns and categories, and identifying themes. Results: We conducted 57 interviews with 46 participants between the ages of 17-23 (M = 19.7 years). Most (n=33) identified as Black/African American, 9 as White, and 4 as Biracial. Thirty-eight were interviewed while pregnant (n=13 1st trimester, n=18 2nd trimester, n=12, 3rd trimester) and 14 were interviewed in the postpartum. We identified the following themes: 1) participants recognized tobacco to be harmful for both the pregnant individual and the fetus; 2) they perceived tobacco use to be more harmful than cannabis use, and co-use to be more harmful than cannabis use alone; 3) peer and social influences contributed to tobacco initiation but also provided support for tobacco cessation; 4) they preferred to reduce or stop tobacco use through their own strategies rather than relying on clinicians or cessation aids; and 5) postpartum relapse was attributed to difficulty of dual transition into adulthood and parenthood. Conclusion: While several themes - knowledge about the harms of tobacco use, greater perceived risk for tobacco compared to cannabis use, and the importance of peer and social support for tobacco cessation efforts - corroborate findings from studies with older pregnant patients, our study highlights some unique stressors contributing to postpartum relapse to combustible tobacco use in younger individuals and the need for better connection with clinical services supporting tobacco cessation.