Cannabis surpasses tobacco among pregnant women: national trends and predictors of use in the U.S., 2015–2023

Background Rapid cannabis legalization in the United States has heightened concern about prenatal exposure as social acceptance increases. While tobacco use during pregnancy has steadily declined, emerging evidence suggests cannabis use may be rising. We examined national trends in tobacco-only use, cannabis-only use, and co-use among pregnant individuals from 2015 to 2023 and identified associated sociodemographic factors. Methods We analyzed nationally representative 2015–2023 National Survey on Drug Use and Health data restricted to pregnant women ages 15–44 (N = 6,099). Outcomes were self-reported past-30-day tobacco-only use, cannabis-only use, and co-use. Weighted prevalence was estimated for 2015–2019, 2020, and 2021–2023. Multivariable logistic regressions for 2015–2019 and 2021–2023 assessed predictors relative to non-use, reporting adjusted odds ratios and average marginal effects. Regressions were not estimated for 2020 due to limited sample size. Results Tobacco-only use declined from 12.0% in 2015 to 3.9% in 2023. Cannabis-only use more than doubled pre-pandemic and peaked at 6.3% in 2022, surpassing tobacco before converging in 2023. Co-use declined to 0.8% by 2023. Pre-pandemic, lower education, unmarried status, lower income, and public insurance were associated with higher tobacco-only use and co-use. Hispanic individuals had lower likelihoods of all use patterns relative to non-Hispanic White individuals. Post-pandemic, educational gradients in cannabis-only use emerged, while Medicaid and Medicare coverage remained associated with higher tobacco-only use and uninsured status became associated with higher cannabis-only use. Conclusion Prenatal substance use patterns are shifting, with cannabis surpassing tobacco in recent years. Updated screening, counseling, and policy responses are needed to address evolving prenatal exposure risks.