Women’s Cigarette and Marijuana Use in Pregnancy: Identifying the Role of Past Versus Recent Violence Exposure

Abstract

Both cigarette smoking and marijuana use during pregnancy pose serious risks to healthy fetal development, yet little is known about the comparative contribution of recent versus past traumatic experiences to women’s smoking behavior. The current study aimed to examine the relative contributions of childhood adversity and past year intimate partner violence (IPV) to women’s cigarette and marijuana use during pregnancy in a high-risk, low-income sample. Participants (n = 101) were interviewed to evaluate past year IPV, childhood adversity, and cigarette and marijuana use. Results indicated that approximately one in four pregnant women in the sample reported that they were currently smoking cigarettes. Only a minority of those who reported prepregnancy smoking (22.5%) were able to quit smoking once pregnant. Regarding marijuana use, 6.9% of women reported use during pregnancy, with 68.1% of women using prior to pregnancy ceasing use once pregnant. Results of multinomial regressions controlling for income and education indicated that past year physical abuse by a partner was associated with light cigarette use during pregnancy whereas high rates of childhood adversity were associated with moderate cigarette use during pregnancy. Sexual IPV was associated with marijuana use during pregnancy. Comprehensive assessment of women’s history of exposure to violence, including both past and recent exposure, provides insight into which women may have the most difficulty with unassisted cessation in the prenatal period. Providing better intervention and support around cigarette and marijuana cessation for women exposed to violence is a critical need, especially among groups that are at sociodemographic risk for substance use in pregnancy.

Keywords

smoking pregnancy domestic violence child maltreatment depression cannabis

Smoking rates among pregnant women have declined over time in the United States, as illustrated by comprehensive national surveys showing a national prevalence of 12.3% in 2010 and 8.4% in 2014 (Curtin & Mathews, 2016; Tong, Dietz, Morrow, D’Angelo, Farr, Rockhill, & England, 2013). Several sociodemographic risk factors for smoking in pregnancy have been identified, including younger maternal age, low maternal education, and delayed prenatal care (Ventura, Hamilton, Mathews, & Chandra, 2003). Consistent with services linked to disadvantages in education and income, women who access Women, Infant, and Children (WIC) Food and Nutrition Services report higher rates of smoking during pregnancy, with an estimated prevalence of 12.6% in 2014 (Curtin & Mathews, 2016). In contrast, the prevalence of marijuana use has been rising in the United States, especially following its legalization in many states for medical purposes (Cerdá, Wall, Keyes, Galea, & Hasin, 2012). One recent, nationally representative study found that the prevalence of past month marijuana use was 3.9% among pregnant women (Ko, Farr, Tong, Creanga, & Callaghan, 2015). Although little research exists on sociodemographic predictors of marijuana use in pregnancy, unemployment has been found to be a significant risk factor while college education and parenthood are significant protective factors (Merline, O’Malley, Schulenberg, Bachman, & Johnston, 2004). The present study aims to extend previous work by examining how women’s past and recent exposure to violence and adversity might explain risk for cigarette and marijuana use during pregnancy.

Cigarette Use During Pregnancy

Developing a clear and comprehensive understanding for who is most at risk for cigarette use during pregnancy is a critical public health issue because smoking during pregnancy is associated with a host of negative effects on the mother and her baby, including fetal growth restriction, preterm birth, still birth, and neonatal mortality (Cnattingius, 2004; Mund, Louwen, Klingelhoefer, & Gerber, 2013). The consequences of prenatal smoking are observed in children well after birth. Children exposed to prenatal smoking are at a higher risk of asthma (Hollams, de Klerk, Holt, & Sly, 2014), obesity (Harris, Willett, & Michels, 2013), bipolar disorder (Talati et al., 2013), and conduct problems (Gaysina et al., 2013). Compared with women who have never smoked, smokers suffer increased mortality from lung cancer, chronic lung disease, heart disease, and stroke, among other medical concerns (Pirie, Peto, Reeves, Green, & Beral, 2013). Given the risks associated with prenatal smoking, it is recommended that health care providers advise all pregnant women to quit (Siu, 2015). Although smoking cessation prior to pregnancy is ideal, even cessation as late as the second trimester may significantly remediate the negative effects of smoking on some infant outcomes (Cnattingius, 2004; Reeves & Bernstein, 2008).

Once pregnant, a significant portion of smokers quit (35.1%-42.6%; Tong, Dietz, Farr, D’Angelo, & England, 2013), and by the third trimester, 53% of women report quitting smoking (Gilbert, Nelson, & Greaves, 2015). In a study of smokers’ behaviors after finding out about their pregnancy, 22% became abstainers in the weeks leading up to their first prenatal care visit, while 62% reduced their smoking, and 16% maintained or increased their smoking (Heil et al., 2014). Despite the importance of quitting for the health and well-being of the mother and her child, research on what may contribute to continued or increased smoking versus smoking termination in pregnant women has focused overwhelmingly on sociodemographic risks, resulting in relatively less literature on the role that past and recent adversity might play in women’s smoking during pregnancy.

Previous work on demographic and psychosocial predictors of smoking maintenance during pregnancy indicates that economic disadvantage is a strong risk factor for smoking (Hiscock, Bauld, Amos, Fidler, & Munafò, 2012). Pregnant smokers also tend to be younger, have lower educational attainment, and are more likely to be without a spouse/partner than are pregnant nonsmokers (Cui, Shooshtari, Forget, Clara, & Cheung, 2014; Smedberg, Lupattelli, Mårdby, & Nordeng, 2014). They also report experiencing more stress, a lack of social support, and attend prenatal classes at lower rates (Gilbert et al., 2015). Smoking during pregnancy is further influenced by mental health difficulties. For example, in a comparison of women who were smokers prior to pregnancy, those who were currently experiencing depression were twice as likely as their nondepressed counterparts to continue to smoke during pregnancy (Smedberg, Lupattelli, Mårdby, Øverland, & Nordeng, 2015). For this reason, it is critical that studies examining smoking during this period regularly examine and control for the effects of depression.

Marijuana Use During Pregnancy

Although the effects of marijuana use on fetal development are somewhat mixed, recent reviews indicate that it has negative effects on neurological development (Metz & Strickrath, 2015). Furthermore, the increased potency of marijuana as compared with that used several decades ago suggests that old research should be reevaluated (Metz & Strickrath, 2015). One recent meta-analysis found that marijuana use by women during pregnancy was associated with fetal difficulties including: anemia, low birth weight, and time spent in the neonatal intensive care unit after birth (Gunn et al., 2016). Furthermore, marijuana is also found in breastmilk, suggesting caution in use across both pregnancy and postpartum (Metz & Strickrath, 2015). With the rapid legalization of medical and recreational marijuana across states, medical and public health professionals have expressed some concern that pregnant women may use marijuana to alleviate nausea in the first trimester of pregnancy (Volkow, Compton, & Wargo, 2017).

Indeed, marijuana use in pregnancy appears to be relatively common, with one study finding that 29.6% of women screened positive for marijuana use at their first prenatal visit (Mark, Desai, & Terplan, 2016). In this study, marijuana use in pregnancy was associated with unemployment, low educational attainment, and use of tobacco and alcohol (Mark et al., 2016). Further, marijuana use demonstrated bivariate associations with both depression and past history of abuse, suggesting that psychosocial factors also play an important role in marijuana use during pregnancy (Mark et al., 2016). Fortunately, the prevalence of marijuana use declines across pregnancy (Volkow, Han, Compton, & Blanco, 2017), suggesting that many women do try to reduce or cease use.

The Association of Adversity With Cigarette and Marijuana Use During Pregnancy

Childhood adversity and trauma have been associated with a number of health risk behaviors, including cigarette use in pregnancy and especially pernicious smoking behaviors, such as smoking within 5 min of waking and smoking to relieve negative affect (Blalock et al., 2011; Chung et al., 2010). There is evidence to suggest, however, that childhood adversity might not be the only type of adversity to influence smoking behavior in pregnancy. Intimate partner violence (IPV), which includes acts or threats of physical, sexual, or psychological aggression against a current or former partner, has a small to medium effect on women’s smoking risk (d = .41; Crane, Hawes, & Weinberger, 2013). Further, the association between IPV and smoking has been found to be stronger for pregnant than for nonpregnant women (d = .49 vs. d = .37, Crane et al., 2013). IPV has also been associated with decreased rates of quitting or reducing smoking during pregnancy (Bailey & Daugherty, 2007). In a study of high-risk African-American pregnant women, experiencing any form of IPV was associated with increased odds of smoking (Shneyderman & Kiely, 2013).

Far less research has examined the effects of abuse and adversity on marijuana use in pregnancy. One recent study by Mark and colleagues (2016) identified a bivariate association between abuse history and marijuana use in pregnancy, but the significance of this relationship disappeared after controlling for other factors. Of note, the measure of abuse in this study was a single item assessing the presence of any physical or sexual abuse and therefore does not provide clear information on childhood versus recent violence. Another recent study of pregnant women in a substance detoxification program in rural Appalachia found that past year IPV was significantly associated with past year marijuana use (Shannon, Nash, & Jackson, 2016). The robustness of this association was not examined in a multivariate analysis; further, the sample was unique insomuch as it was a treatment-seeking sample, and it is therefore not clear whether such an association would hold in a broader sample of pregnant women. Retrospective studies of IPV and marijuana use in pregnancy in other samples, however, have found similar associations (Alhusen et al., 2014).

The Current Study

In sum, the influence of demographic factors, mental health, and adversity have each been independently evaluated in relation to cigarette—and to a lesser extent marijuana—use during pregnancy. To our knowledge, no studies have examined these factors simultaneously. This is critically important as childhood adversity, adulthood IPV, and consequent mental health distress are strongly and consistently related in numerous studies. Further, no research has assessed the predictive influence of these factors on varying smoking levels (i.e., light vs. moderate usage). Because there is evidence that the negative effects of cigarette use on infants may be predicted not just by use but also by frequency or chronicity of use over the perinatal period (e.g., Cnattingius, 2004; Reeves & Bernstein, 2008), distinguishing what factors place women at risk for different types of cigarette smoking behavior during pregnancy is an important next step in identifying those who may require more intervention.

The current study aims to address these gaps in the literature by examining cigarette and marijuana use in a high-risk, low-income sample of pregnant women. First, we seek to identify the factors associated with various levels of cigarette use during pregnancy (i.e., never smokers, ceased smoking, light smokers, moderate smokers). In regard to cigarette smoking, no women in the sample reported a smoking frequency sufficiently high to be considered heavy smokers (see Table 1). Second, we seek to identify factors associated with any marijuana use in pregnancy (i.e., no use vs. self-reported use). Of specific interest is the relative contribution of childhood adversity versus recent exposure to IPV to the frequency of smoking in pregnancy, controlling for women’s income, educational attainment, and depressed mood.

Table 1.

Women’s Smoking Behavior During Pregnancy.

Cigarette Smoking (n = 100)	Past 3 Months or Since Pregnancy if < 3 Mos Gestation
Never smoked	64.0%
Not currently smoking (but did smoke prior to pregnancy)	8.0%
<1 cigarette/day	3.0%
1-5 cigarettes/day	14.0%
6-10 cigarettes/day	7.0%
11-20 cigarettes/day	4.0%
21-40 cigarettes/day	0.0%
41+ cigarettes/day	0.0%
Marijuana use (n = 101)
Never smoked prior to pregnancy	78.22%
Prior to pregnancy	21.78%
During pregnancy	6.93%

Method

Participants

Participants included currently pregnant women (n = 101) who were recruited from a WIC Food and Nutrition Service program in the South Bend and Mishawaka, Indiana. Women were, on average, 17 weeks pregnant (Range = 3-39 weeks, SD = 10.16). Women ranged in age from 18 to 40, with an average age of 26 (SD = 5.67) and were a racially/ethnically diverse group (37.6% Black, 36.6% White, 17.8% Hispanic/Latina, and 7.9% biracial or multiracial). Consistent with the target demographic of the service agency, average monthly household income was low (US$1002.07; SD = US$879.03). Regarding educational attainment, 21% of participants had not completed high school, 37% had completed either high school or a GED, 32% had attended some college, and 10% had a college or graduate degree. One woman did not report data on her smoking behavior, resulting in an analyzed sample of n = 100 for cigarette use and n = 101 for marijuana use.

Procedures

Data presented in the current study were collected as part of a university–community partnership, and the protocol was approved by the institutional review boards of both the participating university and the hospital overseeing the local WIC Food and Nutrition Service program. To recruit participants, trained project personnel provided a brief description of the study and a flyer during all WIC prenatal care appointments scheduled on days when an interviewer was available on site. Interviewers were onsite approximately 1 full day each week; the day of week was selected to coincide with the day on which most prenatal appointments were scheduled. Only women 18 or older were eligible to participate, and recruitment continued over the span of approximately 5 months. If women were interested in participating, they went into a private room where they completed an informed consent. As a part of this process women were introduced to the overall purpose of the study, which was to examine the effects of adversity on perinatal health and breastfeeding. Data for the current study were drawn from the prenatal interview. All questionnaires were administered via interview (in either Spanish or English). On average, the interview took 30 to 40 minutes; women were compensated US$10 in the form of a gift certificate to a local grocery store.

Measures

Demographics

Participants completed a brief demographics survey that asked them to provide basic background information, including age, racial/ethnic background, educational attainment, and monthly household income.

Childhood adversity

Childhood adversity was assessed using the Adverse Childhood Experiences (ACEs) Questionnaire. The ACEs questionnaire was developed as part of a large epidemiological study that examined the longitudinal physical and mental health consequences of child maltreatment (Dube et al., 2003; Felitti et al., 1998). The ACEs questionnaire is a 10-item survey that retrospectively assesses childhood physical, psychological, and sexual abuse, neglect, and household disruption or dysfunction. Participants were asked to respond “Yes” or “No” to indicate exposure to each event prior to their eighteenth birthday. Scores across items were summed for a total ACEs score that ranged from 0 to 10.

IPV

IPV was assessed using the Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). In the current study, women’s reports of physical assault (12 items; for example, partner pushed or grabbed participant), psychological aggression (eight items; for example, partner insulted or shouted at participant) and sexual coercion (seven items; for example, partner used threats to obtain sex) were included. Participants responded to each item on a scale of 0 to 7, with response choices 0 (This has never happened to me) through 6 (More than 20 times in the past year) assessing violence exposure in the past year, and 7 capturing events that had occurred, but not in the past year. In the current study, the CTS2 was scored using the midpoint method, which provides an estimate of IPV frequency in the past year and was then log transformed to correct for positive skew (Straus, Hamby, & Warren, 2003). Internal reliabilities for the current study were good: Physical Assault (α = .93), Psychological Aggression (α = .89) and Sexual Coercion (α = .57).

Cigarette use

Women’s cigarette use was assessed using the Tobacco Use section of the Pregnancy Risk and Monitoring Survey—Phase 7 Core Questions (Centers for Disease Control and Prevention (CDC), 2012). One item assessed whether or not women had smoked any cigarettes in the past 2 years (yes/no); women who responded that they had not smoked in the past 2 years were considered “nonsmokers.” Two items assessed women’s frequency of smoking in the 3 months before pregnancy, and in the past 3 months of pregnancy (or since becoming pregnant for women <3 months gestation). Women could report on their use on an ordinal scale: 41+ cigarettes/day, 21 to 41 cigarettes/day, 11 to 20 cigarettes/day, 6 to 10 cigarettes/day, 1 to 5 cigarettes/day, <1 cigarette/day, or did not smoke at all. Those women who reported any use prior to pregnancy, but no use during pregnancy were coded as “ceased smoking once pregnant.” Consistent with previous work (e.g., da Veiga & Wilder, 2008), the remaining women were coded as light smokers (<1-5 cigarettes/day) or moderate smokers (6-20 cigarettes/day) based on their reported smoking behavior during pregnancy.

Marijuana use

Women’s marijuana use was assessed using the PRAMS—Phase 7 Core Questions (CDC, 2012). One item assessed whether or not women had used marijuana before pregnancy (yes/no) and one item assessed whether or not women had used marijuana during pregnancy (yes/no). Endorsed marijuana use in pregnancy was coded as “1” and denied marijuana use in pregnancy was coded as “0.”

Results

Childhood Adversity and Past Year IPV

Rates of ACEs in this sample were high, with 71% of participants indicating they had experienced at least one type of childhood adversity (e.g., physical abuse, parental imprisonment); the median number of reported events was two (M = 2.71, SD = 2.83, Range = 0-10). Regarding past year exposure to IPV, 72% of women reported at least one incident of psychological aggression (M = 18.58; SD = 34.23), 22% reported at least one incident of physical assault (M = 6.74, SD = 26.40), and 21% reported at least one incident of sexual coercion (M = 3.79, SD = 10.76). Only 8.0% of women reported no exposure to either IPV or childhood adversity.

Incidence of Cigarette Use During Pregnancy

In the past 3 months of pregnancy (or since becoming pregnant for those at <3 months gestation), 64% of women never smoked, 8.0% did not smoke during pregnancy (but did before), 17.0% smoked less than one to five cigarettes/day, and 11.0% smoked six or more cigarettes/day. A breakdown of women’s reported smoking behaviors can be found in Table 1. The prevalence of IPV within each group is as follows: never smokers (43% IPV-exposed), ceased smoking (25% IPV-exposed), light smokers (53% IPV-exposed), and moderate smokers (55% IPV-exposed).

Predictors of Cigarette Use During Pregnancy

Descriptive statistics and a correlation matrix of all predictors examined in the regression model can be found in Table 2. Multinomial logistic regression was used to evaluate the role of IPV and childhood adversity in women’s smoking behavior during pregnancy, controlling for depression, income, and educational attainment (see Table 3). The overall model was significant (χ² = 38.54, p<.05, Pseudo R² = 18.7%). There were no significant differences in childhood adversity or past year IPV between recently ceased and never smokers. Light smokers were significantly more likely than were never smokers to have experienced past year physical IPV (RRR = 2.25; CI[1.04, 4.88]), but there were no differences between light smokers and never smokers in exposure to childhood adversity or other forms of IPV. Moderate smokers reported significantly more ACEs that did never smokers (RRR = 1.48; CI[1.12, 1.96]). Moderate smokers were no more likely to report past year IPV than were never smokers.

Table 2.

Descriptive Statistics and Correlations Between Predictors of Women’s Smoking Behavior.

Variable	M (SD)^a	1.	2.^b	3.	4.	5.	6.	7.
1. Income	1002.07 (879.02)	1
2. Some college^b	41.58%	.13	1
3. Total ACEs	2.71 (2.82)	−.13	.09	1
4. Physical IPV	6.70 (26.27)	−.06	.00	.36***	1
5. Sexual IPV	3.75 (10.72)	−.11	.08	.12	.26**	1
6. Psych. IPV	18.47 (34.27)	−.05	.03	.26**	.68***	.37***	1
7. Depressed Mood	14.96(10.31)	−.10	.07	.30**	.18†	.19	.37***	1

Note. ACEs = adverse childhood experiences; IPV = intimate partner violence.

Descriptive statistics are presented on raw data for maximal interpretability. Correlations reflect relationships among transformed variables. Income was z scored prior to analysis and all IPV scales were log transformed due to positive skew on these variables.

Coded as “high school or less” (0) versus “some college or more” (1). Correlations in this row/column are point biserial correlations.

p < .05. **p < .01. ***p < .001.

Table 3.

Multinomial Regressions Examining Predictors of Women’s Cigarette Smoking Behavior During Pregnancy.

	Smoking in Past 3 Months or Since Pregnancy if < 3 Mos Gestation
	RRR [95% CI]
Never smoked (Referent Category; n = 64)
Ceased smoking once pregnant (n = 8)
Income	0.67 [0.23, 1.92]
Some college	0.46 [0.07, 2.71]
Total ACEs	1.19 [0.84, 1.71]
Physical IPV	0.98 [0.35, 2.78]
Sexual IPV	0.00 [0.00, 0.00]
Psych. IPV	2.07 [0.96, 4.47]
Depressed mood	0.92 [0.23, 1.92]
Light smoking (<1-5 cigarettes/day, n = 17)
Income	0.53 [0.24, 1.17]
Some college	0.29 [0.07, 1.08]
Total ACEs	0.96 [0.84, 1.71]
Physical IPV	2.26 [1.04, 4.88]*
Sexual IPV	0.77 [0.43, 1.41]
Psych. IPV	0.97 [0.55, 1.17]
Depressed mood	0.98 [0.07, 1.08]
Moderate smoking (6+ cigarettes/day; n = 11)
Income	0.76 [0.27, 2.13]
Some college	0.21 [0.04, 1.16]
Total ACEs	1.48 [1.11, 1.96]**
Physical IPV	1.35 [0.55, 3.31]
Sexual IPV	0.85 [0.44 1.66]
Psych. IPV	1.14 [0.54, 2.13]
Depressed mood	1.00 [0.92, 1.08]
Overall model fit	χ² = 38.54*, Pseudo R² = .186

Note. RRR = Relative Risk Ration; CI = Confidence Interval; ACEs = adverse childhood experiences; IPV = intimate partner violence.

p < .05. **p < .01. ***p < .001.

Incidence of Marijuana Use in Pregnancy

Approximately one in five women (21.78%) reported marijuana use prior to pregnancy, and 6.93% of women reported use during their current pregnancy (See Table 1).

Predictors of Marijuana Use in Pregnancy

The model predicting marijuana use in pregnancy was significant (χ² = 16.12, p<.05; Pseudo R²=.32). There were no significant main effects, with the exception of past year sexual IPV, which was significantly associated with marijuana use in pregnancy, odds ratio (OR) = 2.16, 95% CI [1.14, 4.10]; See Table 4.

Table 4.

Logistic Regression Examining Predictors of Women’s Marijuana Use During Pregnancy.

	OR [95% CI]
Income	1.00 [1.00, 1.00]
Some college	4.76 [0.60, 37.60]
Total ACEs	0.88 [0.59, 1.30]
Physical IPV	1.04 [0.36, 3.00]
Sexual IPV	2.16 [1.14, 4.10]*
Psych. IPV	1.23 [0.46, 3.29]
Depressed mood	0.99 [0.89, 1.10]
Overall model fit	χ² = 26.13*, Pseudo R² = .317

Note. OR = odds ratio; CI = confidence interval; ACEs = adverse childhood experiences; IPV = intimate partner violence.

p < .05. **p < .01. ***p < .001.

Discussion

Results from the current study indicate that approximately one in four pregnant women were currently smoking cigarettes, but far fewer were using marijuana (6.93%). Compared with national rates, this incidence of cigarette smoking in this sample was high, confirming the high-risk nature of women interviewed. Less comparative data are available against which to gauge marijuana use, but rates of use for this sample are far lower in this sample than some other studies examining participants with similar sociodemographic characteristics (e.g., Mark et al., 2016). The objective of this study was to examine the relative contributions of childhood adversity and recent IPV to women’s cigarette and marijuana use in pregnancy, accounting for the known role of socioeconomic factors.

In regard to cigarette use, women who were light smokers were more likely than never smokers to report past year physical IPV. Women who were moderate smokers were also significantly more likely to report higher rates of childhood adversity than were never smokers. Unlike past research, which has focused on the contribution of either childhood adversity or IPV in isolation (Bailey & Daugherty, 2007; Blalock et al., 2011; Chung et al., 2010), the current study reveals that while both are risk factors for smoking, their contribution may be distinctive across different levels of smoking use. That childhood adversity is linked to more problematic smoking behavior than is recent exposure to violence is consistent with other literature suggesting that childhood exposure to trauma has particularly pernicious effects on health and well-being over the lifespan (e.g., Cloitre et al., 2009).

Findings also suggest that past year sexual IPV is a unique predictor of marijuana use in this sample (see Table 4). This finding is consistent with some previous research (e.g., Mark et al., 2016), but importantly expands this body of work in several ways. First, the assessment of sexual IPV in this study was separated from the assessment of physical IPV, allowing for the examination of the unique and relative effects of each form of violence. Further, the current study included childhood adversity. Given childhood adversity’s known association with later violence, and its association with IPV in this study (see Table 2), its inclusion in the model serves to inform that the effect of sexual IPV on marijuana use is significant, even after accounting for the effect of childhood adversity.

Limitations

Although the current study offers unique information about the relative contributions of different forms of violence to cigarette and marijuana use in pregnancy, there are important limitations to recognize. First, some of the cell sizes in the multinomial logistic regression were quite small, making it unlikely that these analyses were sufficiently powered to detect all possible effects. The results from this study should therefore be considered preliminary in nature, and require replication in larger samples. The sample is also from a single geographic region of the United States, and as such, the findings should be regarded as requiring further replication in other geographic areas. Despite the sample’s constriction in terms of income and geography, the sample was racially and ethnically diverse, providing an important contribution to understanding cigarette and marijuana use across women of diverse backgrounds, including both English and Spanish speakers.

Implications for Practice and Policy

From a clinical perspective, this study suggests that a comprehensive assessment of women’s history of exposure to violence provides insight into which women may have the most difficulty with unassisted substance cessation in the prenatal period—above and beyond already known risk factors, including sociodemographic characteristics and prepregnancy smoking behaviors. It could be that women who have experienced recent IPV and past childhood adversity may experience a higher general stress burden, making cessation more difficult. Providing better intervention and support around smoking and marijuana cessation for women exposed to violence is therefore a critical need, even among groups that are at generally high sociodemographic risk. What is not evident from the current study, however, is the best mechanism for positive change. That is, it is not clear whether additional support for unassisted or assisted cessation would provide sufficient benefit for these women, or if psychoeducation regarding smoking cessation would be better if embedded in the context of other psychosocial and clinical supports related to the effects of violence. This is an important direction for future research. In sum, the current study points to the serious and long-lasting effects of violence on the lives of women and their developing children. The prevention of violence, in all its forms, is therefore a serious public health concern, as is providing additional supports for survivors of adversity.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Rodney F. Ganey, PhD Collaborative Community-Based Research Seed Grant.

ORCID iD

Kathryn Keough

Author Biographies

Laura E. Miller-Graff, PhD, is a assistant professor of psychology and peace studies and a core faculty member of the Kroc International Institute for Peace Studies. She earned her PhD in clinical science from the University of Michigan. Her research seeks to understand how various systems interact to promote or inhibit healthful development following violence exposure. She also seeks to identify effective intervention practices for children and families affected by violence. This line of work considers the status of psychosocial interventions currently available in international conflict settings and seeks to identify evidence-based intervention practices that facilitate resilience in families and communities.

Kathryn H. Howell, PhD, is an assistant professor in the Department of Psychology at the University of Memphis. She received her PhD from the University of Michigan Clinical Psychology program. She has extensively studied interventions for women and children who have experienced violence and other adversities, including the examination of risk and resilience pathways. Her research on resilience focuses on individual, relational, and community factors contributing to adaptive functioning. She currently serves as associate editor for the APA journal, Psychology of Violence and she is a licensed clinical psychologist with health service provider designation in the state of Tennessee.

Katherine Grein, MA, is a doctoral student in the joint Clinical Psychology and International Peace Studies program at the University of Notre Dame. She received her BA in psychology from St. Mary’s College of Maryland. Her research interests center on factors and processes contributing to resilience among populations exposed to violence (including intimate partner violence [IPV] and political violence). She is currently involved in research among first- and second-generation refugee populations, as well as research on interventions to bolster psychosocial resilience for IPV-exposed pregnant women in the United States, and political-violence exposed families in Palestine.

Kathryn Keough, BA, graduated from the University of Notre Dame undergraduate program in psychology and is currently a graduate student in clinical psychology at Farleigh Dickson University. She is interested in the effects of trauma throughout the lifespan and enhancing resilience among trauma-exposed populations. Her current research focuses on identifying social and emotional factors related to school refusal behavior in children and adolescents.

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