Tobacco, Alcohol, and Caffeine Use and Cessation in Early Pregnancy Phyllis L. Pirie, PhD, Harry Lando, PhD, Susan J. Curry, PhD, Colleen M. McBride, PhD, Louis C. Grothaus, MA Objectives: Little is known about what happens when individuals attempt to make multiple behavior changes simultaneously. Pregnant women in particular are often in the position of needing to change several behaviors at once, including giving up more than one pleasurable substance. We investigated the success of pregnant women in spontaneously quitting tobacco, alcohol, or caffeine, alone or in combination. Methods: Pregnant women (n = 7489) were identified in the practices of large health maintenance organizations in Seattle and Minneapolis and were interviewed by telephone. Analyses examined the patterns of using and quitting more than one substance, and the extent to which using more than one substance predicts ability to quit other substances. Results: Use of the three substances tended to cluster within individuals. Users of multiple substances were less likely to quit each substance than users of single substances. However, in the subgroup of multiple substance users who had quit one substance, having quit a second substance was more, rather than less, common. In multivariate analyses predicting quitting, demographic variables, and not having been pregnant previously were significant predictors of quitting each substance; being a nonsmoker predicted quitting alcohol, and being a nonsmoker and nondrinker predicted quitting caffeine. Conclusions: The reasons for difficulty in quitting more than one substance are unknown but may include the difficulty of formulating appropriate behavioral strategies or less concern about healthy behavior in pregnancy. Many women in the study successfully quit using two substances, however, and counseling should focus on achieving that outcome. Medical Subject Headings (MeSH): pregnancy, smoking, alcohol, caffeine, risk behavior, life change (Am J Prev Med 2000;18(1):54 – 61) © 2000 American Journal of Preventive Medicine Introduction D espite widespread concern and media attention to the problem of illicit substance use during pregnancy, the use of legal substances such as tobacco, alcohol, and caffeine affect a far greater number of pregnancies each year 1,2 and may have more significant health effects. 3 Tobacco use during preg- nancy has been shown to be causally related to intra- uterine growth retardation, prematurity, and low birth- weight, 4 as well as to late fetal and infant mortality 5 and possibly to developmental delays. 6,7 Alcohol use during pregnancy is a major cause of preventable mental retardation 8,9 and has been linked to a constellation of physical and neurologic defects collectively known as fetal alcohol syndrome. 10 Lower levels of alcohol use during pregnancy are also known to be linked to neurobehavioral deficits and intrauterine growth retar- dation. 11–13 Caffeine has been demonstrated to pro- duce birth defects and fetal mortality in animal models, but its effects in humans at normal levels of consump- tion are much less certain. There is some evidence that caffeine may be related to low birthweight, possibly due to intrauterine growth retardation. 14 Some evidence suggests an interactive effect on fetal growth when cigarettes, alcohol, and caffeine are all used. 15 Pregnant women are often advised to avoid all three substances, which places some women in the unenvi- able position of being asked to give up two or three pleasurable substances simultaneously. The problem of trying to change several behaviors at once has not been extensively studied. Although it is well known that certain unhealthy behaviors tend to co-occur or “clus- ter” within individuals, both during pregnancy 2 and in the general population, 16,17 little attention has been From the Division of Epidemiology, University of Minnesota (Pirie, Lando), Minneapolis, Minnesota; Group Health Cooperative of Puget Sound, Center for Health Studies (Curry, Grothaus), Seattle, Washington; Duke University Medical Center, Comprehensive Can- cer Center (McBride), Durham, North Carolina Address correspondence and reprint requests to: Phyllis L. Pirie, PhD, Division of Epidemiology, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454-1015. E-mail: pirie001@tc.umn.edu. 54 Am J Prev Med 2000;18(1) 0749-3797/00/$–see front matter © 2000 American Journal of Preventive Medicine PII S0749-3797(99)00088-4