Cannabis Retailer Advice on Blunt, Tobacco, and Cannabis Use During Pregnancy

Authors: Kelly C. Young-Wolff, Monique B. Does, Rahel Negusse, Shannon N. Ogden, Joshua R. Nugent, Lynn D. Silver, Aurash J. Soroosh, Torri D. Metz

Affiliations: Division of Research, Kaiser Permanente Northern California, Pleasanton; Department of Psychiatry and Behavioral Sciences, University of California, San Francisco; Prevention Policy Group Public Health Institute, Oakland, California; University of Colorado School of Medicine, Aurora; Denver Health and Hospital Authority, Denver, Colorado

License: Copyright 2025 Young-Wolff KC et al. JAMA Network
Open. CC BY 4.0 This is an open access article distributed under the terms of the CC-BY License.

Article links: DOI: 10.1001/jamanetworkopen.2025.48373  |  PubMed: 41370076  |  PMC: PMC13372022

Relevance: Moderate: mentioned 3+ times in text

Full text: PDF (13 KB)

Introduction

While rates of prenatal cigarette use have declined,^1,2 rates of prenatal cannabis use are increasing.^3,4,5,6 During 2021 to 2023, the prevalence of past 30-day cannabis use among pregnant women in the US (6.5%) was similar to tobacco use (7.5%).⁷ Prenatal cannabis use is associated with adverse maternal (eg, gestational hypertension), neonatal (eg, low birthweight), and offspring neurodevelopmental outcomes,^{8,9,10,11,12,13} and medical organizations advise against prenatal cannabis use.^10,14

Blunts (ie, hollowed out cigar wrappers filled with cannabis) are increasingly used by women,¹ and are a common mode of cannabis administration before and during pregnancy.^1,15 Co-use of cannabis and tobacco (vs cannabis only) is related to worse health outcomes and a lower likelihood of cannabis cessation.^16,17,18 Compared with other ways of using cannabis, blunts have higher levels of carbon monoxide absorption and greater risk of intoxication, withdrawal, and cannabis use disorder, especially in women.^{19,20,21,22,23,24,25} Thus, blunt smoking has significant risks for pregnant individuals and their children.²⁶ However, blunts may be perceived as safer than smoking cigarettes,²⁷ some may not realize they contain tobacco,²⁸ and flavored blunts may appeal to pregnant women who are sensitive to tobacco smell and flavor.²⁹

Cannabis legalization has decreased perceptions of risk, while increasing intentions to use and providing greater acceptability and access.^{30,31,32,33,34,35,36,37,38,39,40} Pregnant individuals who use cannabis view budtenders (individuals who work at cannabis retailers) as experts on its safety and benefits during pregnancy.⁴¹ However, California budtenders are not required to complete job training addressing the potential harms of cannabis use, and we know little about what advice budtenders give pregnant individuals. A 2018 mystery shopper study⁴² in Colorado found that 69% of budtenders recommended cannabis to a pregnant woman for morning sickness, 36% said prenatal cannabis was safe, and 32% recommended that she speak to her clinician without prompting. Most recommendations were based on opinion rather than scientific evidence or consultation with clinicians. Another study⁴³ across 5 cities in different US states found that 54.3% of retailers endorsed cannabis use for pregnancy-related nausea, and only 26.4% warned against prenatal use. Understanding how budtenders counsel pregnant individuals about cannabis, tobacco, and blunts is critical because pregnant individuals who use cannabis seek budtender advice about products, modes of use, and dosage, and their recommendations may shape risk perceptions and prenatal substance use behaviors.⁴¹

This mystery shopper cross-sectional study builds on prior research by characterizing actual recommendations given by budtenders in California regarding the safety of blunt, tobacco, and cannabis use during pregnancy and examining whether responses varied by stated indication for prenatal use (mental health vs none). Furthermore, because delivery availability varies across California’s storefront retailers and can reach pregnant women who avoid shopping in-person, we also tested whether budtender recommendations differed by retailers’ delivery status.

Methods

Setting

The Kaiser Permanente Northern California institutional review board reviewed and approved the research, and the requirement for informed consent was waived. Minor deception was necessary to obtain a realistic assessment of what cannabis retailers recommend for pregnant individuals. All retailers in California were informed of the results upon publication of the study. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.

Procedures

This cross-sectional population-based survey study used a mystery caller approach following methods similar to Dickson et al.⁴² The study team developed 2 scripts to examine recommendations from California budtenders around prenatal use of blunts, tobacco, and cannabis based on the literature and study team expertise (Box and Table 1). The script queried about the safety of prenatal blunt use; if a budtender stated that blunts were not safe during pregnancy, the caller further clarified whether it was the tobacco, cannabis, or both that was unsafe. The script solicited recommendations for what type of cannabis to use during pregnancy, which modes are safer or more harmful during pregnancy, whether one should talk to their health care practitioner about prenatal cannabis use, and whether the retailer provides delivery services (ie, “do you deliver?”). Additionally, mystery shoppers coded whether the retailers noted the source of the recommendation offered (eg, personal experience, research studies, or warning labels). To test whether budtender responses were different when there was a mental health reason for prenatal cannabis use, one script emphasized that the caller was using blunts for mental health reasons and the other did not. We hypothesized that budtenders would be more supportive of prenatal cannabis use for mental health vs non–mental health reasons.

Three mystery shoppers from the study team (K.Y.W., M.B.D., and R.N.) conducted the calls using REDCap, a secure web application. Calls were conducted from February 26, 2024, to January 28, 2025, and a maximum of 3 calls were made to each retailer. Due to California laws, calls were not recorded, but mystery shoppers took near verbatim notes (directly into REDCap) and coded responses in REDCap using predetermined categories (see Table 1). Callers did not request or record any identifying information from budtenders. Scripts were developed iteratively and tested across 22 Oregon retailers before they were finalized. All callers completed standardized training, including practice calls and role-playing to ensure consistency of delivery and documentation. Callers met regularly to review notes, compare budtender responses, and discuss codes. The lead caller (M.B.D.) reviewed notes and codes for all calls for completion, accuracy, and consistency. All coding discrepancies were resolved through discussion and consensus.

Sample

The target population consisted of all 1167 storefront retailers with a medical and adult-use cannabis license in California as of November 17, 2023, using license data from the California Department of Cannabis Control (DCC) website. To achieve feasible call volume, we randomly selected 800 storefront retailers and assigned them to 1 of the 2 scripts using block randomization by county and then randomized to the 3 mystery callers. Two retailers subsequently identified as duplicates at the same physical address were removed, yielding a final randomly selected sample of 798 retailers. Retailer telephone numbers were obtained by the callers through an online search of the retailer’s name cross-checked against the corresponding address in the DCC list, as the telephone number listed by DCC was typically for the retailer owner rather than the retailer.

Statistical Analysis

The primary outcome was the percentage of retailers who advised that blunt use, tobacco use, and cannabis use were unsafe during pregnancy. Secondary outcomes included recommendations given, safer or more harmful modes of cannabis use, and the percentage who recommended the caller speak with their health care practitioner (with or without prompting). Responses from the mental health vs non–mental health scripts and delivery services vs nondelivery services retailers (based on budtender’s responses) were compared using exact Pearson χ² tests using SAS version 9.4 (SAS Institute); 95% CIs were computed using the Quesenberry and Hurst method. A 2-sided P < .05 was considered statistically significant. Analyses were conducted from March to June 2025. Representative quotations from retailers were selected to supplement the quantitative findings.

Results

Of the 798 retailers to whom calls were attempted, 293 (36.7%) were not completed (213 [26.7%] had no working number, 76 [9.5%] had no answer, 4 [0.5%] refused or were ineligible). Valid calls were achieved for 505 retailers (63.3%; 243 mental health, 262 non–mental health scripts) (eFigure in Supplement 1); the Figure shows the distribution of retailers with valid calls across California.

Overall, 0.8% (95% CI, 0.2%-2.9%) of budtenders advised that prenatal blunt use was safe, 79.6% (95% CI, 74.2%-84.2%) advised that it was unsafe, 3.0% (95% CI, 1.5%-5.9%) said they were unsure, and 16.6% (95% CI, 12.5%-21.8%) said they could not provide medical recommendations (eg, “I am not a doctor and cannot advise you on this”) (Table 1). Similarly, when probed specifically about safety of tobacco and cannabis (2 main components of blunts), 0.8% (95% CI, 0.2%-2.9%) advised that prenatal tobacco use was safe, 79.2% (95% CI, 73.7%-83.8%) advised it was unsafe, 5.7% (95% CI, 3.5%-9.4%) were unsure, and 14.3% (95% CI, 10.5%-19.2%) said they could not provide medical advice. In contrast, when probed, 20.6% (95% CI, 16.0%-26.1%) advised that prenatal cannabis use was safe, 40.4% (95% CI, 34.5%-46.6%) advised that it was unsafe, 19.2% (95% CI, 14.8%-24.6%) were unsure, and 19.8% (95% CI, 15.3%-25.2%) said they could not provide medical advice. When addressing safety concerns, 89 (17.6%; 95%CI, 13.7%-22.1%) mentioned potential harms for the baby and 12 (2.4%; 95%CI, 1.2%-4.7%) mentioned potential harms for mother and baby. Table 2 includes representative quotes from budtenders in response to phone script questions, highlighting the inconsistent advice given. Overall, 36.6% (95% CI, 32.6%-40.9%) recommended low- or no-tetrahydrocannabinol (THC) cannabis products containing other cannabinoids (eg, cannabidiol), 22.0% (95% CI, 18.6%-25.8%) recommended other harm reduction strategies (eg, consuming less frequently), and 6.1% (95% CI, 4.4%-8.6%) recommended noncannabis strategies (eg, mindfulness).

Overall, 41.8% (95% CI, 35.2%-48.6%) endorsed that some modes of prenatal use are safer or more harmful (including those who originally said use is not safe, but went on to suggest something; eg, “No use is best, but if need to use, then edibles are probably safest”), 24.0% (95% CI, 18.6%-30.3%) did not know, 6.9% (95% CI, 4.2%-11.3%) said safety or risk does not vary by mode, and 13.9% (95% CI, 9.8%-19.3%) said no modes are safe. Edibles were the most endorsed safer mode (160 respondents [31.7%]), followed by smoking (28 respondents [5.5%]), topicals (26 respondents [5.2%]), vaping (11 respondents [2.2%]), sublingual (5 respondents [1.0%]), and dabbing (4 respondents [0.8%]). Smoking was most endorsed as a less safe mode (128 respondents [25.4%]) followed by vaping (31 respondents [6.1%]), edibles (24 respondents [4.8%]), dabbing (5 respondents [1.0%]), and sublingual ( respondent [0.2%]). This question was not asked when the budtender had clearly advised against any prenatal cannabis use and the caller perceived this question might cause discomfort (68 respondents).

During the call, 222 budtenders (44.0%) recommended speaking to a physician without prompting, and 233 (46.1%) recommended it when asked if the caller should talk to her physician about prenatal cannabis use (455 overall [90.1%]). While almost half did not spontaneously share their source of information for their recommendation (228 respondents [45.2%]), personal experience was most common (180 respondents [35.6%]), followed by general knowledge (eg, “most people say”; 46 respondents [9.1%]), online sources (eg, search engines, social media, and blogs; 40 respondents [7.9%]), and published research (35 respondents [6.9%]). Only 29 [5.7%] mentioned product or store warnings.

Responses were generally similar for the mental and non–mental health scripts, with a few key differences. Budtenders who received the mental health script were less likely to endorse prenatal tobacco use as safe (1 respondent [0.4%] vs 3 [1.2%]) and more likely to say they could not say whether tobacco is safe (44 respondents [18.1%] vs 28 [10.7%]) (Table
1). They were also more likely to report they could not say whether prenatal cannabis is safe (66 respondents [27.2%] vs 34 [13.0%]), but less likely to say they were unsure (28 respondents [11.5%] vs 69 [26.3%]). Budtenders with the mental health script were also more likely to recommend low or no THC products (119 respondents [49.0%] vs 66 [25.2%]), less likely to have no recommendations (90 respondents [37.0%] vs 149 [56.9%]), and less likely to cite published research as a source of their information (10 respondents [4.1%] vs 25 [9.5%]). Responses were similar among retailers with and without delivery services (eTable in Supplement 1).

All callers noted empathy among budtenders (eg, acknowledging that prenatal use is a personal decision and can be a difficult choice if cannabis is helping with mental and physical health). For example, one budtender stated: “I recognize how complicated a question like this is. If you need any help at all and want to come in, I’m happy to work personally with you.”

Discussion

In this cross-sectional mystery caller study of 505 randomly selected storefront cannabis retailers across California, we characterized budtender recommendations around prenatal blunt, tobacco, and cannabis use. Less than 1% said that prenatal blunt or tobacco use was safe, while 20% said that prenatal cannabis use was safe. A lower percentage said they were unsure about the safety of prenatal blunt or tobacco use vs prenatal cannabis use, only 40% advised that prenatal cannabis use was unsafe, and more stated that they could not give advice about the safety of prenatal cannabis vs blunt or tobacco use. Overall, edibles were endorsed as a safer mode of prenatal cannabis use and smoking was endorsed as a more harmful mode of use. Responses were inconsistent across retailers, with some indicating prenatal smoking was safest. This discrepancy highlights the lack of research and education on the relative harms of different modes of prenatal cannabis use.

Despite required budtender training in California, pregnant individuals who used cannabis report viewing them as experts on the safety and benefits of prenatal cannabis use and view them as a trusted source for accurate advice about products.⁴¹ Our findings complement results from a mystery caller study in Colorado that found that 69% of budtenders recommended cannabis to a pregnant woman for morning sickness, 36% said prenatal cannabis was safe, and only 32% recommended that she speak to her clinician without prompting (80% ultimately recommended discussion following a direct query). Results are also consistent with a recent study across 5 cities in different US states that found 54.3% of retailers endorsed cannabis use for pregnancy-related nausea, and only 26.4% warned against prenatal use.

Recommendations from budtenders included low or no THC cannabis products, other harm-reduction related advice (eg, use less frequently, avoid additives and pesticides, and use clean methods like flower from a bong or pipe), and health strategies not involving cannabis (eg, mindfulness or herbal tea). Overall, 90.1% ultimately recommended speaking with a physician, with about half (44.0%) recommending this without prompting. Notably, most budtenders conveyed warmth and empathy and acknowledged the complex factors that go into decision-making about prenatal cannabis use even as they often provided incorrect guidance.

Our study is novel in its examination of whether retailer responses varied based on callers’ reasons for prenatal cannabis use. Callers who reported using cannabis for mental health indications received more cautious budtender recommendations, including advice to use low or no THC products. Budtenders may be more careful about making recommendations when pregnant customers use cannabis for mental health reasons vs recreationally. Furthermore, budtenders may believe THC is the only harmful cannabinoid or consider other cannabinoids as only having medicinal properties. Additional studies are needed to further investigate the factors underlying differences in advice.

Existing research not specific to pregnancy shows that budtenders self-report lack of training related to cannabis therapeutics (with training focused more on sales/profit vs health promotion) and would like high-quality training opportunities.⁴⁴ Budtenders report making recommendations to cannabis buyers based on other customer experiences and their own experiences.⁴⁵ A study in Washington found that budtenders were amenable to handing out or posting information from the state related to risky use behaviors (eg, use while driving or during pregnancy).⁴⁶ In this study, most budtenders who mentioned their source of information reported that their advice was based on personal experience or opinion. While the exact factors underlying the inconsistent recommendations around the safety of prenatal cannabis use are unknown, it is possible that knowledge gaps, misinformation, personal beliefs, the influence of the cannabis industry, or desire to sell products may be contributing factors. Budtenders may not feel confident answering questions related to the safety of prenatal cannabis use but may feel pressured by customers’ expectations or the desire to sell cannabis. Understanding the mechanisms underlying inconsistent recommendations can lead to the development of more informed training, communication, and regulatory strategy interventions.

Notably, only 5.7% of retailers mentioned on-package or in-retailer warnings about prenatal cannabis use, highlighting the need for improved awareness and visibility of warnings. Results suggest that the required health warnings on cannabis product packaging in California, which can be in size 6 font, including one stating, “CANNABIS USE WHILE PREGNANT OR BREASTFEEDING MAY BE HARMFUL,” may be overlooked or not taken seriously by budtenders. Findings underscore the need for educational interventions aligned with California Senate Bill 540 (effective March 1, 2025, after our calls were completed) which requires that all California licensed cannabis retailers prominently display a brochure on the health risks of cannabis, including during pregnancy, at the point of sale or upon delivery and offer a printed copy to every new customer during their first purchase.⁴⁷ This policy has potential to improve knowledge and awareness of risks of prenatal use for both budtenders and individuals of reproductive age. Future research is needed to test the implementation and impact of this policy on changes in budtender and pregnant individual awareness of potential harms and prenatal use. Policy enforcement, training opportunities, and national guidance related to product messaging and consumer protections may be useful ways to improve oversight and standardization of budtender recommendations.

Younger women, Black and Hispanic women, and those with lower socioeconomic status have higher rates of prepregnancy and prenatal cannabis use, more frequent cannabis use, and greater tobacco use.^{4,30,40,48,49} There are also existing inequities in access to high-quality health information. Future research is needed to assess whether policy changes, including implementation of more visible warnings around prenatal cannabis use, retailer training, and education reduce disparities in use.

Strengths and Limitations

Strengths of this study include a novel, telephone-based randomized mystery caller survey study across California, with a robust sample, an adequate response rate, and use of scripts with and without mental health indications for use. Furthermore, this is the first study we know of to assess budtender recommendations about prenatal blunt use and the relative safety of different modes of prenatal cannabis use and to test whether responses varied by availability of delivery. Finally, the study took place during the seventh year of legal adult-use sales in California when most retailers were well-established, and we contextualized our findings using budtender quotes.

This study also had limitations. Calls were limited to storefront retailers with a California license to sell medical and adult-use cannabis and did not include retailers from others states or those operating without a retail license. We were not able to reach all retailers, primarily due to inactive or incorrect phone numbers, and results may not generalize to all licensed retailers if unreachable stores differed systematically from those contacted. Budtender recommendations may vary depending on the caller and who answered the phone, and single call snapshots may miss intrastore variability across staff and shifts. We did not collect budtender sociodemographics, and we were unable to assess whether advice varied with these factors. Calls were conducted over an 11-month period, during which social norms and the cannabis retail landscape may have changed, potentially influencing budtender perceptions. Finally, causal inferences about the effects of budtender advice on pregnant individuals’ behavior cannot be made in this cross-sectional study.

Conclusions

This cross-sectional study was the first to examine budtender recommendations about prenatal blunt use. While most budtenders advised against prenatal blunt or tobacco use, 1 in 5 endorsed prenatal cannabis use as safe, highlighting the need for standardized budtender education about the health risks of prenatal use. Findings underscore the importance of accurate public policy information for pregnant individuals given that budtender advice may not align with medical guidelines or evidence-based research.

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