Residence in states with medically legal cannabis was associated with higher odds of cannabis use during the preconception period but not associated with use at any other time. The difference in odds of cannabis use between medically and recreationally legal states could be explained by several factors. Provider responses to women may vary based on legalization status and could impact a pregnant woman’s choice to discontinue use early in pregnancy. A recent study in Pennsylvania found healthcare providers were much more likely to focus on legal implications of use rather than health implications when women disclosed use in pregnancy . In medically legal states, cannabis use is often only allowed for a limited set of medical conditions . Therefore, if providers focus on the legality of use in states with more restrictions, pregnant women might be more convinced to quit using cannabis; whereas, in recreational states no “illegal use” exists and perhaps there is less pressure from providers for women to quit cannabis use. Similarly, another study found if providers did not discuss cannabis use during a visit most pregnant women assumed this meant cannabis use during pregnancy posed no health risk . Duration of legalization may also play a role in the differences observed between recreational and medical cannabis states. Medical cannabis legalization first took place in 1996 and in the subsequent two decades resulted in the development of cannabis prevention programs specific to pregnancy, whereas, context of more recent recreational legalization are in their infancy. Further research is warranted to examine how prevention practices differ between states with recreational and medical cannabis legalization and the resultant outcomes.As seen in other studies, the association with inadequate prenatal care and cannabis use in this study may be a result of selection bias insofar as women who use substances may not access prenatal care due to their substance use behaviors or fear of being reported. Alternatively, women using substances during pregnancy tend to be younger and with lower education attainment and may not access prenatal care due to some other external barriers irrespective of substance use and therefore continue use because they do not receive education about cessation of substances during pregnancy .

Inadequate prenatal care is associated with cannabis use across all time periods in this study suggesting a need for public health or clinical interventions prior to pregnancy. One possibility would be to consider delivering cannabis prevention education outside prenatal care through public service announcements and warning labels on legally sold cannabis products consistent with prevention strategies used for prenatal alcohol use . Furthermore, since the study found that parity was a protective factor against cannabis growing system use in all three time periods, offering prevention education for women of reproductive age at any medical appointment may be an effective strategy to reach women before future pregnancies and promote abstinence from any substance use prior to conception. Based on the review of the literature, this study is possibly the first to include e-cigarettes in the assessment of tobacco co-use with cannabis. E-cigarettes present an emerging public health crisis and are considered especially harmful during pregnancy given the increase in nicotine exposure to the pregnant woman and fetus . The odds of tobacco use in association with cannabis use were slightly higher than in other studies looking at traditional tobacco use alone . Possibly, as e-cigarette use increases during pregnancy, there is a concomitant increase in use of cannabis especially given new technology making it easy to “vape” nicotine and cannabis together .Whittington and et al., provided evidence that e-cigarette use is on the rise in pregnancy as is concurrently used with combustible tobacco which could account for the magnitude of the association found in this study. Notably, the indicator for tobacco use in this study was one or more cigarettes and did not differentiate between intensity of smoking possibly leading to an overestimation of use in our sample resulting in the higher reported odds. Interpretation of the study findings is subject to several limitations including the cross-sectional design which precludes causal inference. In addition, the stigma associated with substance use in pregnancy may have resulted in under reporting of use and underestimation of prevalence rates, although the PRAMS computer-assisted interviews could decrease this bias to some degree . The PRAMS also relies on women to recall their substance use from the past year, during the postpartum period, potentially leading to over- or under-reporting of past year use of cannabis.

Limitations due to the use of secondary data include the inability to measure cannabis use throughout the pregnancy and only at designated times as specified in the survey questions. Finally, due to the difficulty of analyzing policies in motion given that recreational cannabis legalization is a new policy, a possibility exists that not enough time has passed to estimate the full impact of the changing policy on use rates . Also, cannabis use rates may be higher in recreational or medical states prior to the passage of cannabis laws and therefore the higher rates of use were not associated with the policy change. Future studies should take advantage of additional years of post recreational legalization data as they become available and analyze the direct impact on policies on prenatal use.With the passage of Proposition 64 , state voters elected to integrate cannabis into civil regulation. The California Department of Food and Agriculture oversees state-licensed cannabis cultivation and defined it as agriculture.Prior to the possibility of state licensure for cultivators, however, counties can decide on other designations and implement strict limitations. In effect, local governments have become gatekeepers to whether and how cultivation of personal, medical or recreational cannabis can occur and the repercussions of noncompliance. When cannabis is denied a consistent status as agriculture, despite being a legal agricultural commodity according to the state, localities can determine who counts as a farmer and who is considered compliant, non-compliant and even criminal. In Siskiyou County’s unincorporated areas, the Sheriff’s Office now arbitrates between the effectively criminal and agricultural. Paradoxically for this libertarian county, the furor around cannabis has seen calls for government intervention, and has led to officials passing highly stringent cannabis cultivation regulations that have been enforced largely by law enforcement, muddying the line between noncompliance and criminality. These strict regulations produced a situation where “not one person” has been able to come into compliance, according to a knowledgeable government official. Nonetheless, at the sheriff’s urging, Siskiyou declared a “state of emergency” due to “nearly universal non-compliance” , branding cannabis cultivation an “out-of-control problem.” Such a strong reaction against cannabis can be understood in terms of cannabis’s potential to reorganize Siskiyou’s agricultural and economic landscape.

According to some estimates, there are now approximately twice as many cannabis cultivators as non-cannabis farmers and ranchers in Siskiyou , a significant change from just a few years ago. Although cannabis has been cultivated in this mostly white county for decades, since 2015 it has become associated with an in-migration of Hmong-American cultivators. Made highly visible through enforcement practices, policy forums and media discourses, Hmong-Americans have become symbolically representative of the “problem.” This high visibility, however, obscures a deeper issue, what Doremus et al. see as a nostalgic, static conception of rural culture that requires defensive action as a bulwark against change. Such locally-defined conceptions need to be understood , especially in how they are defined and defended and what effects they have on parity among farmers growing different types of crops. Our goals in this study were to consider the consequences of an enforcement-first regulatory approach — a common regulatory strategy across California — and its differential effects across local populations. Using Siskiyou County as a case study, we paid attention to the public agencies, actors and discourses that guided the formation and enforcement of restrictive cannabis cultivation regulations as well as attempts to ameliorate perceptions of racialized enforcement. This study attends to novel post legalization apparatuses, their grounding in traditional definitions of culture and the ways these dynamics reactivate prohibition. We used qualitative ethnographic methods of research, including participant observation and interviews. In situations of criminalization, which we define not only as the leveling of criminal sanctions but being discursively labeled or responded to as criminal-like , quantitative data can be unreliable and opaque, which necessitates the use of qualitative ethnographic methods . In 2018–2019, we talked to a wide range of people — including cannabis growers from a diversity of ethnic backgrounds, government officials, business people, subdivision residents, farm service providers, medical cannabis advocates, realtors, lawyers, farmers and ranchers, and,hydroponics rack system with the assistance of a Hmong-American interpreter, members of the Hmong-American community. We also analyzed public records and county ordinances, Board of Supervisors meeting minutes and audio , Sheriff’s Office press releases and documents, related media articles and videos, and websites of owners’ associations in the subdivisions where cannabis law enforcement efforts have focused. Some cannabis cultivators regarded us suspiciously and were hesitant to speak openly, an unsurprising phenomenon when researching hidden, illegal and stigmatized activities, like “drug” commerce . This circumspection was most intense among Hmong-American growers on subdivisions, who had been particularly highlighted through enforcement efforts and local, regional and national media accounts linking their relatively recent presence in Siskiyou to cannabis growing. Human subjects in this research are protected under the Committee for Protection of Human Subjects, protocol number 2018-04-1136 , of the Office for Protection of Human Subjects at UC Berkeley.Siskiyou is a large rural county located in the mid-Klamath River basin in Northern California . Since the mid-19th century, inmigrants have historically engaged in agriculture, predominantly livestock grazing and hay production, and natural resource extraction, primarily timber and mining.

Public records demonstrate that although the value of the county’s agricultural output and natural resource extraction is declining, these cultural livelihoods still shape the area’s dominant rural values of self-reliance, hard work and property rights . For instance, one county document stated that Siskiyou’s cultural-economic stability depends on nonintervention from “outside groups and governments” and residents should be “subject only to the rule of nature and free markets” . Another document, a “Primer for living in Siskiyou County” from the county administrator, outlined “the Code of the West” for “newcomers,” asserting that locals are “rugged individuals” who live “outside city limits,” and that the “right to be rural” protects and prioritizes working agricultural land for “economic purpose[s]” . We heard a common refrain that localities will eventually succumb to the allure of a taxable, profitable cannabis industry. Indeed, interviewees in Siskiyou universally reported economic contributions from cannabis cultivation, especially apparent in rising property values and tax rolls and booming business at horticultural, farm supply, soil, generator, food and hardware stores . However, a belief in an inevitable free market economic rationality may underestimate the deep cultural logics that have historically superseded economic gains in regional resource conflicts . As one local store owner told us, “I’d give up this new profit in a heartbeat for the benefit of our society.” Many long-time farming and ranching families remain committed to agricultural livelihoods for cultural reasons , even as the economic viability of family farms is threatened by increasing farmland financialization , corporate consolidation and biophysical decline . Many interviewees felt that the recent rapid expansion of county cannabis cultivation and corresponding demographic changes were a visible marker of broader tensions of cultural continuity and endangerment. As the sheriff expressed, cannabis cultivation would “jeopardize our way of life … [and] the future of our children” . This sense of cultural jeopardy , echoed by numerous interviewees, materialized in a range of negative quality-of-life comments about cannabis cultivation: noisy generators, increased traffic, litter and blighted properties, and unsafe conditions for residents. Non-cannabis farmers also reported farm equipment and water theft, livestock killed by abandoned dogs, wildfire danger, illicit chemical use and poisoned wildlife. Some non-cannabis farmers expressed a sense of regulatory unfairness — that their farms were subject to onerous water and chemical use regulations while cannabis growers “don’t need to follow the government’s regulations.” Enabling cannabis cultivators to pursue state licensure would facilitate just such civil regulation, but some feared that regulating this crop as agriculture would threaten “the loss of prime agriculturally productive lands for traditional pursuits” .