Screening Pregnant Patients for Cannabis: A Critical Look at ACOG’s Recommendations
Cannabis is now the most commonly used illicit substance in pregnancy, its perception of safety has grown with legalization, and data consistently link prenatal exposure with complication
The American College of Obstetricians and Gynecologists (ACOG) recently issued a Clinical Consensus addressing cannabis use during pregnancy and lactation. In many ways, this is overdue. Cannabis is now the most commonly used illicit substance in pregnancy, its perception of safety has grown with legalization, and data consistently link prenatal exposure with low birth weight, preterm birth, and neurodevelopmental concerns. We should be talking about this.
Yet, the document’s recommendations on screening tools leave a troubling gap. ACOG endorses the use of three validated instruments: TAPS (Tobacco, Alcohol, Prescription Medications, and other Substances), S2BI (Screening to Brief Intervention), and CRAFFT. On paper, this looks like progress—an evidence-based framework to replace unreliable “eyeball” screening or punitive toxicology testing. But a closer look reveals that none of these tools were actually validated in pregnant populations, and two were developed primarily for adolescents.
What ACOG Recommends
ACOG rightly discourages biological testing, such as urine or meconium drug screens, as a first-line approach. These tests often ensnare patients in legal jeopardy, reinforce racial disparities, and discourage prenatal care. Instead, the guideline advises universal verbal screening with validated questionnaires.
The three recommended tools are:
TAPS: a two-step screener developed for adults in primary care. It covers tobacco, alcohol, prescription drugs, and illicit substances including cannabis.
S2BI: a rapid three-question tool developed for adolescents, mapping frequency of use onto DSM-5 risk levels.
CRAFFT: a six-question screen, also for adolescents, focused on consequences of substance use (Car, Relax, Alone, Forget, Friends, Trouble).
The Problem of Validation
The challenge is that none of these tools were designed with pregnant populations in mind. Pregnancy is not just another clinical setting. Substance use in this context carries unique biological risks, profound ethical implications, and serious legal and social consequences. A screening tool validated in adolescents or general adult primary care cannot be assumed to function equivalently in prenatal care.
CRAFFT and S2BI: Both were developed for adolescents and young adults, primarily in school-based or pediatric practices. While relevant for a pregnant teenager, they are hardly suitable for the average obstetric population, where the median age is late 20s to early 30s.
TAPS: The most applicable of the three, but still validated only in adult primary care clinics, not in obstetrics. Its scoring thresholds for “risk” may not align with what is clinically relevant in pregnancy, where even low-level use may have consequences.
This is the central issue: pregnancy changes the calculus. The threshold for “problematic use” is lower, because any cannabis exposure can matter. Tools validated in non-pregnant populations cannot simply be imported wholesale.
Missing the “How”
Another gap is implementation. ACOG names these tools but provides no guidance on how they should be used in obstetric settings. Who administers them—physician, nurse, intake coordinator? At what point—initial prenatal visit, every trimester, postpartum? How are results documented? How are positive screens followed up?
Without operational specificity, the recommendation risks being reduced to a check-box exercise: ask a few questions, note the score, move on. That may meet documentation standards, but it does not improve care. Screening only matters if it leads to meaningful, supportive, non-punitive interventions.
After Disclosure: What Happens When a Pregnant Patient Admits Cannabis Use
Screening is only the first step. The more important—and often less discussed—question is: what happens after a patient discloses cannabis use during pregnancy? The answer varies widely by state law, hospital policy, and clinician practice.
Clinical Response and Counseling
Currently, there are no FDA-approved pharmacologic treatments for cannabis use disorder. Management is almost entirely behavioral:
Counseling and education on potential risks such as low birth weight, preterm birth, and possible neurodevelopmental effects.
Motivational interviewing to help patients explore ambivalence and set goals for reduction or cessation.
Referral to behavioral health services for structured therapy (e.g., cognitive-behavioral therapy, contingency management), though availability is inconsistent.
Harm-reduction strategies, such as advising cessation of smoking or vaping methods, even if abstinence is not immediately achievable.
Unlike opioid use disorder, where medications like methadone or buprenorphine exist, cannabis-related interventions lack robust evidence and infrastructure. This makes the “what next” of screening frustratingly vague for clinicians and patients alike.
Social Work Involvement
In many hospitals, disclosure of cannabis use triggers an automatic referral to social work. The intent is supportive—connecting patients with resources, counseling, or substance use treatment. But in practice, this referral can feel punitive. Patients may be questioned about their living situation, partner support, or financial stability, with the implicit suggestion that their parenting ability is under scrutiny.
Legal and Reporting Obligations
The most consequential—and ethically fraught—dimension arises from state-level mandatory reporting laws. Some states require clinicians to notify child protective services (CPS) when a pregnant patient discloses substance use, or when a newborn tests positive for THC metabolites. Others mandate reporting only when there is evidence of harm or neglect. Enforcement is uneven, and racial disparities are well-documented: Black and Latina women are more likely to be reported even when prevalence of cannabis use is comparable across groups.
For the patient, disclosure can mean:
Nothing more than a counseling conversation in supportive settings.
Intensive involvement from social work and behavioral health.
Or, in the worst cases, surveillance by child protective services and possible legal action.
The Clinical Dilemma
This landscape leaves obstetricians in a bind. We are asked to screen universally, but there is no standardized treatment pathway, and disclosure may expose patients to stigma and punitive consequences. For some women, the rational choice is to deny use, even if disclosure might have led to counseling. The lack of a clear, supportive, and non-punitive system undermines the very purpose of screening.
The Ethical Dimension
Pregnancy screening also intersects with ethics in ways that ACOG only gestures at. Unlike alcohol or tobacco, cannabis now occupies a unique space: it is legal for adults in many states, widely marketed as “natural,” and often perceived as benign. When obstetricians ask about cannabis, they are not simply collecting a neutral health history. They are probing behaviors that—even if fully lawful—may expose patients to stigma, biased treatment, child protective services referrals, or even criminal prosecution in certain jurisdictions. Without robust safeguards, universal screening risks doing more harm than good by driving pregnant women away from prenatal care, particularly those who are already marginalized.
This concern is magnified by evidence of racial disparities in how cannabis use is screened, documented, and reported. National survey data show that cannabis use in pregnancy occurs across all racial and ethnic groups, with only modest differences in frequency. Yet research has consistently demonstrated that Black and Latina women are disproportionately more likely to be screened, subjected to toxicology testing, and reported to authorities than their White counterparts, even when self-reported use rates are the same or lower. This disconnect highlights that the greatest inequity lies not in patterns of use, but in how screening is operationalized and how results are acted upon.
Validated or not, tools like CRAFFT and S2BI cannot substitute for the ethical duty of the obstetrician. That duty is to provide directive but compassionate counseling, to communicate evidence of risk with clarity and respect, and to advocate against punitive responses that criminalize patients for lawful behavior. Screening instruments designed for adolescents or non-pregnant adults cannot correct the deeper problem: the structural inequities in how cannabis use in pregnancy is monitored, reported, and penalized.
Until there are clear protections that separate medical inquiry from legal jeopardy, screening cannot be ethically neutral. The physician’s role must extend beyond administering a checklist. It must include active advocacy to ensure that pregnant patients are not punished for disclosure, that racial inequities in screening and reporting are confronted, that autonomy is respected even when counseling is directive, and that universal screening serves as a bridge to care rather than a barrier.
Where We Go From Here
If we take cannabis in pregnancy seriously, then we need tools that are:
Validated in pregnant populations across ages, races, and socioeconomic backgrounds.
Sensitive to low-level use, since even occasional exposure may matter for fetal growth and development.
Operationally clear, with protocols for timing, documentation, and follow-up.
Ethically grounded, ensuring confidentiality and avoiding legal jeopardy for patients.
This is not impossible. Large, diverse obstetric cohorts exist in research databases. We could test TAPS or S2BI thresholds against perinatal outcomes and recalibrate risk scoring. We could design pregnancy-specific questions (for example, about use in the first trimester, or about attempts to quit when learning of pregnancy). Yet until that work is done, ACOG’s endorsement of tools without pregnancy validation feels like a stopgap at best, and an abdication at worst,
Conclusion
ACOG’s call for validated screening tools is well-intentioned, and its rejection of biological testing is important. But naming three instruments—two designed for adolescents and none validated in pregnancy—risks giving a false sense of rigor. Obstetricians deserve better tools, and pregnant patients deserve care grounded in both evidence and ethics. Until then, cannabis screening will remain an uneasy mix of improvisation, stigma, and incomplete science.
The challenge is clear: we need not only more data, but also a willingness to build pregnancy-specific approaches, rather than borrowing from pediatrics or primary care. ACOG has started the conversation. It is now our responsibility, as clinicians and researchers, to finish it.