Risk factors for young adult substance use among women who were teenage mothers
Introduction
Adolescence is a period of vulnerability for substance use and substance use disorders: some adolescents start engaging in substance use earlier than their peers, and early substance use is associated with a higher risk of adult dependence (Brook et al., 2007, Grant and Dawson, 1997, Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies, 2007, Winters and Lee, 2008). Sexual intercourse is also common among teens (Abma and Sonenstein, 2001, Eaton et al., 2006, June 9); and although the rate of teenage pregnancy had been steadily declining since 1991 (Martin et al., 2005), it increased again in 2006 (Hamilton, Martin, & Ventura, 2007). Moreover, the rate of teenage births in the US remains significantly higher than in other developed countries (Centers for Disease Control and Prevention (CDC), 2005, Panchaud et al., 2000). Therefore, there is a subset of American adolescents who transition into risky behavior at younger ages than their peers, and these early transitions may be associated with negative health outcomes during adulthood.
According to Problem Behavior Theory, early transitions are inter-related because of underlying deviance proneness in these youth, and both risk and protective factors may account for variability in change in substance use and other risky behaviors over time (Donovan, 2005, Donovan and Jessor, 1985, Jessor, 1991, Jessor et al., 1991, Jessor and Jessor, 1977). Similarly, other authors have suggested that drug use is associated with a premature adoption of adult roles, and that drug use impairs the normal progression and completion of adolescent developmental tasks (Newcomb, 1987, Newcomb and Bentler, 1988). This premature or pseudo-maturity may be especially evident in girls who become pregnant as adolescents, many of whom take on the role of parent at a very young age. In fact, smoking is prevalent among pregnant teenagers (Cornelius et al., 1995, Delpisheh et al., 2007, Trollestrup et al., 1992), and both tobacco and marijuana use are common among pregnant teenagers (Albrecht et al., 1999) and young adult women who gave birth during adolescence (Gillmore et al., 2006, Moffitt, 2002).
Moreover, patterns of substance use and pregnancy in adolescents differ substantially from that seen in adult women. In a study comparing pregnant teenage and adult women's drinking patterns, although adult women drank more alcohol per day on average, teenage girls were more likely to participate in more sporadic or binge drinking than adult drinkers (Cornelius, Leech, & Goldschmidt, 2004). Furthermore, teenage mothers are at high risk for repeated conception during adolescence (Kalmuss and Namerow, 1994, Meade and Ickovics, 2005, Seitz and Apfel, 1993). Consequently, substance use in pregnant and childbearing teenagers is a major public health problem: not only are these young women shortening and reducing the quality of their own lives, but they are also placing multiple children at risk of prenatal substance exposure and secondhand smoke.
Although there are few prospective, longitudinal studies of teenage mothers, results from previous studies of this high-risk group suggest that their developmental patterns of substance use differ from other young women. Specifically, they do not appear to “age out” of substance use as they reach adulthood (Cornelius et al., 2004, Gillmore et al., 2006). Teenage motherhood is also associated with negative outcomes that may contribute to the continuity of problem behaviors into adulthood. For example, women who were pregnant teenagers are more likely to experience low socioeconomic status (SES) and to suffer from more mental health problems as adults (Boden et al., 2008, Deal and Holt, 1998, Horwitz et al., 1996). These circumstances may explain some or all of the effect of early motherhood on persistent substance use. Furthermore, racial/ethnic differences between women who give birth as adolescents and other young women may also promote differences in their adult patterns of substance use.
In one multi-ethnic (51% White, 28% Black, 21% Other) cohort of pregnant teenagers that has been followed over time, marijuana use declined substantially during pregnancy, increased slightly by 6 months post-partum, and then leveled off significantly below pre-pregnancy rates (Gilchrist, Hussey, Gillmore, Lohr, & Morrison, 1996). Tobacco use was more prevalent in this sample than marijuana use, increased markedly at 6 months post-partum, and then increased at a much slower rate 12 and 18 months after pregnancy. Long term follow-up of these young mothers revealed that their cigarette and drug use did not change significantly from 3.5 to 11.5 years post-partum. Although they were twice as likely to smoke tobacco and use marijuana as other young women their age, they reported significantly less alcohol use (Gillmore et al., 2006). In another study of this cohort (Oxford et al., 2003), there were distinct trajectories in alcohol use 10 years after the teenage pregnancy, in which early users were significantly more likely to increase both the quantity and frequency of use, consistent with epidemiological data on early users (Grant and Dawson, 1997, Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies, 2007, Winters and Lee, 2008). Their results also suggest that teenage mothers who are slow to decrease their alcohol use over time and teenage mothers who increase their alcohol use over time are significantly more likely to use illicit drugs and to be involved in crime, consistent with Problem Behavior Theory.
In a second cohort of pregnant teenagers that has been prospectively followed (two-thirds Black and one-third White), tobacco use persisted during pregnancy and few (7%) of the teenage mothers managed to quit by the 6-year follow-up (Cornelius et al., 2004). Moreover, a significant portion (20%) of the young mothers started smoking after the index pregnancy and most (61%) of these young women reporting daily smoking 6 years later, as young adults. Peer adolescent tobacco use and White race were the best predictors of tobacco use at both time points in this lower SES sample.
Although the Reach for Health Longitudinal Study is not a study of teenage mothers per se, their findings are germane because roughly half their sample of disadvantaged Black and Hispanic women from Brooklyn, NY became pregnant during adolescence (Stueve & O'Donnell, 2007). In this sample, there was an increase in smoking from middle school (14%) to high school (26%) and then a slight decrease in smoking as young adults (22%). However, young women who were raising children were significantly more likely to be smokers at the last time point, consistent with the previous studies of teenage mothers. Nevertheless, the effect of teenage parenthood on smoking lost statistical significance after smoking history was entered in a stepwise logistic regression. Therefore, it is likely that the young mothers who smoked during young adulthood were also more likely to have smoked at the earlier time points than their non-childbearing peers, consistent with Problem Behavior Theory. However, little is known about the long-term risk factors for smoking, alcohol use, or marijuana use among young women who were pregnant teenagers.
The goals of the current study were to examine tobacco, alcohol and marijuana use in teenage mothers 6 years and 10 years post-partum in order to (1) identify antecedent risk factors for substance use during young adulthood, and (2) identify risk factors for late-onset and persistent use of tobacco, binge drinking, and use of marijuana. We hypothesized that White race, peer adolescent use, lower SES, and higher levels of psychological problems would predict smoking and binge drinking 6 and 10 years after a teenage pregnancy and persistent tobacco use across the decade. We hypothesized that Black race, peer adolescent use, lower SES, and higher levels of psychological problems would predict marijuana use 6 and 10 years after a teenage pregnancy.
Section snippets
Study sample
In this cohort study, 445 pregnant adolescents (12–18 years old) were recruited from an outpatient prenatal clinic at a teaching hospital (448 were asked to participate and only 3 refused). The 413 adolescents who gave birth to live, singletons were eligible for follow-up visits 6 and 10 years later. Of the 32 who did not participate in the study at delivery, there was 1 refusal, 15 girls who moved out of the area, 3 gave birth to twins, 7 instances of miscarriage/fetal death, and 6 whose
Sample characteristics
The participants' average age was 16.32 years (SD = 1.89) at entry into the study, 23.07 years (SD = 1.38) at the 6-year follow-up visit, and 27.12 years (SD = 1.32) at the 10-year follow-up visit, permitting us to examine substance use patterns across the important transition to young adulthood. Although one-third of the teenagers dropped out of school while pregnant, only 6% of the sample reported that they had completed less than 12 years of education when they were seen ten years later,
Discussion
The high rates of tobacco use, binge drinking, and marijuana use 10 years after the teenage pregnancy are remarkable compared to other women of similar age in the state (PA Department of Health, 2000). For example, 55% of Black mothers and 70% of white mothers reported cigarette use a decade after their teenage pregnancy, compared to 30% of 18–29 year olds across the state, and 22% of all female adults. Half of Black mothers and 45% of White mothers reported binge-drinking in young adulthood,
Role of funding source
This study was supported by grants from the National Institute of Drug Abuse (NIDA 009275) and National Institute on Alcohol Abuse and Alcoholism (NIAAA 08284) awarded to MC. ND was supported by a training grant from the National Institute of Alcohol Abuse and Alcoholism, (NIAAA T32 07453 PI: MC) as well as the University of Pittsburgh. NIDA, NIAAA and the University of Pittsburgh had no further role in study design; in the collection, analysis and interpretation of data; in writing of the
Contributors
Dr. Cornelius is the Principal Investigator of the Teen Mother study. As such, she oversaw all aspects of the design, implementation, and conduct of the study and takes responsibility for the integrity of the data. Dr. De Genna developed the research questions for this paper, undertook the statistical analyses, and wrote the first draft of the manuscript. Drs. Cornelius and Donovan contributed substantially to the hypotheses and interpretation of the findings. All authors revised the manuscript
Conflict of interest
All authors declare that they have no conflicts of interest that could inappropriately influence their work.
Acknowledgements
Young Shim Jhon, Lidush Goldschmidt and Sharon Leech provided assistance with data management and statistical analyses. The authors would also like to thank the young women who made this study possible by contributing their time and candidly sharing their experiences with our interviewers.
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