Accuracy of Verbal Screening for Nicotine Exposure in Pregnancy in Acute Care Settings

Prenatal nicotine exposure leads to adverse health effects for infants. Acute unscheduled care visits are an opportunity to identify prenatal nicotine exposure. This study evaluated the accuracy of Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) screening for nicotine use of pregnant patients in acute care settings.

Adult pregnant patients without prior prenatal care who presented for unscheduled care at a tertiary care academic medical center were eligible for inclusion. Enrollment of a convenience sample occurred in the emergency department (ED) and the obstetric care triage unit (OB). Participants completed the TAPS screening tool (created by NIDA) and provided urine samples for immunoassay testing for cotinine (nicotine metabolite). TAPS responses and cotinine immunoassay results were reported as proportions with 95% CIs and compared using a two sample Z-test with p<0.05 being considered statistically significant. Responses for cannabis were also evaluated, as cannabis smoking has been associated with positive cotinine testing in recent studies.

One hundred twenty-five pregnant patients were enrolled (89 ED, 36 OB). Only 22% (15 - 31%) of participants reported tobacco use in the past 3 months, but 50% (41 – 59%) of participants tested positive for cotinine (p<0.001). Of the participants that were cotinine positive, only 38% (26 - 51%) reported tobacco use in the past three months. Cannabis use in the past three months was self-reported by 49% (36 - 62%) of cotinine-positive participants. When combined, self-reported tobacco and cannabis use accounted for 87% (77 – 94%) of cotinine positive results. No substance use was reported by 13% (6 - 24%) of cotinine-positive participants. There were no significant differences in TAPS survey responses and cotinine positivity between ED and OB participants.

Among newly diagnosed pregnant patients in acute care settings, TAPS survey self-report of nicotine use alone identified less than half of participants with cotinine positivity. This may partially be explained by an association of positive cotinine testing with cannabis smoking observed in recent studies. Since the TAPS survey specifically focuses on tobacco use, other forms of nicotine exposure may contribute to this discrepancy as well. Survey-based screening alone may be insufficient to identify prenatal nicotine exposure risk.