(30) Coping with Crisis: Housing Instability, Food Insecurity, and Cannabis Use in Pregnancy

Background & Introduction: The stress-coping model of substance use proposed by Thomas A. Wills and Shiffman in 1985 explains that substance use can be a coping mechanism used to deal with life stress (1). Multiple studies reinforce the conceptual framework established by Wills and Shiffman regarding the interplay between coping and substance use (2,3). As cortisol levels are known to increase during pregnancy, this makes pregnant individuals a particularly interesting population to explore this type of coping. While the prevalence varies in different populations, studies have shown that between one-third and two-thirds of people who use cannabis prior to conception continue at some level during pregnancy (4). The majority of people who continue cannabis use during pregnancy report doing so for symptom control (5). While multiple studies have explored cannabis use for managing specific symptoms during pregnancy, there is limited research examining the phenomenon of using cannabis to cope with stress encountered during this period. This study explores the association between cannabis use during pregnancy and both housing instability and food insecurity. The hypothesis is that pregnant people may be using cannabis to cope with the stress housing and food insecurity cause among pregnant individuals.

Methods: This study involves a subset of participants from the Trajectories of Cannabis Use in Pregnancy Study, a prospective longitudinal study examining cannabis use among pregnant individuals in Maryland, California, and Oklahoma. Participants who reported cannabis use within 30 days of conception were selected. At baseline, 173 participants completed a survey assessing food security, housing stability, and reasons for cannabis use four weeks before conception. Of those, 100 continued cannabis use during pregnancy and answered an additional question about reasons for use in the past four weeks. Food insecurity was defined as responding "often" or "always" to the statement "The food that I/we bought didn’t last, and I/we didn’t have money to get more," with options ranging from "never" to "always.". Housing instability was assessed by asking participants to choose from: “I have a steady place to live,” “I have a place today, but worry about losing it,” or “I don’t have a steady place to live.” Difficulty paying household bills was assessed by asking whether participants were unable to pay rent, mortgage, or utility bills (yes/no). Participants selected their primary reason for cannabis use from 22 options. Responses of "to relax," "stress," and "anxiety" were grouped into a "stress" category.

Results: Of the 173 participants reporting their experiences for the four weeks before conception, 53% reported using cannabis primarily for stress. Regarding race, 22% identified as White, 63% as Black, and 15% as belonging to other racial groups, preferred not to answer, or did not answer. When assessing food insecurity and difficulty paying household bills, 171 responses remained after excluding two participants who did not answer—one who primarily used cannabis for stress and one who used it for other reasons. Similarly, after assessing housing instability, 169 responses were retained following the exclusion of four participants—three who primarily used cannabis for stress and one who used it for other reasons. 

Among the 100 participants who reported continued cannabis use, 29% used cannabis primarily for stress, while 71% used it for other reasons. In the continued use group, 19% identified as White, 71% as Black, and 10% as belonging to other racial groups, preferred not to answer or did not answer. All of these participants responded to the questions assessing food insecurity, difficulty paying household bills, and housing instability. 

There was no statistically significant association between race and the primary reason for the use of cannabis in the four weeks before conception or continued use during pregnancy (p=0.16 and p=0.5, respectively). However, there was a marginally significant relationship between using cannabis for stress in the four weeks before conception and identifying as Black versus identifying as other races (p = 0.07).

Significantly more participants who used cannabis primarily for stress versus other reasons in the four weeks before conception reported food insecurity as compared to those who used cannabis for other reasons (12% vs 4%, p=0.05). However, these associations with food insecurity were no longer significant when comparing individuals who continued to use cannabis for stress versus continuing to use cannabis for other reasons during pregnancy (p = 0.287).

There were no statistically significant differences in difficulty paying household bills or in housing insecurity between the participants who primarily used cannabis for stress and participants who used it for other reasons in the four weeks before conception (33% v 26%, p=0.57 and 10% v 11% p = 1.0) or during pregnancy (38% v 39% p=0.89 and 10% v 14%, p = 0.75).

Conclusion & Discussion: While it did not meet the traditional p<.05 statistical significance level in our sample, we observed an association between food insecurity and cannabis use for stress before pregnancy; this relationship no longer existed when considering reasons for use among those who continued to use cannabis during pregnancy. This suggests that broader socioeconomic challenges may drive individuals toward cannabis use to manage their stress, but some people who were using cannabis as part of this coping strategy may discontinue once they become pregnant. This finding could imply that the drivers of cannabis use shift during pregnancy (5).

Using cannabis to cope with stress before pregnancy was marginally more common for Black participants than participants who identified as other races. This suggests that understanding more about the use of cannabis for coping with stress may be particularly important for people in marginalized racial groups. Further research is needed to explore this potential racial disparity and its connection to social determinants of health. Moreover, future research with larger sample sizes should examine whether these patterns persist throughout pregnancy and compare outcomes among those using cannabis versus other approaches to cope with the stresses of food insecurity and housing instability.

References: 1. Wills, T. A., & Shiffman, S. (1985). Coping and substance use: A conceptual framework. In S. Shiffman & T. A. Wills (Eds.), Coping and substance use. Academic Press. 

2. Wills, T. A. (1987). The role of coping in the development of substance use. In H. B. Kaplan (Ed.), Psychosocial stress: Trends in theory and research. Academic Press. 

3. Crutchfield, R. D., & Gove, W. R. (1984). Determinants of drug use: A test of the coping hypothesis. Social Science & Medicine, 18(6), 503–509. https://doi.org/10.1016/0277-9536(84)90008-x 

4. Pike, C. K., Sofis, M. J., & Budney, A. J. (2021). Correlates of continued cannabis use during pregnancy. Drug and alcohol dependence, 227, 108939. https://doi.org/10.1016/j.drugalcdep.2021.108939

5. Vanstone, M., Taneja, S., Popoola, A., Panday, J., Greyson, D., Lennox, R., & McDonald, S. D. (2021). Reasons for cannabis use during pregnancy and lactation: a qualitative study. CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne, 193(50), E1906–E1914. https://doi.org/10.1503/cmaj.211236