Development and internal validation of the NOTICE assessment as a non-biological measure of prenatal nicotine, tobacco, and cannabis use and exposure.

Burmeister E.; Weng M.; Steadman K.; Miles J.; Zheng Q.; Ratsch A. · Journal of clinical epidemiology · 2026

**Background & Methods** This study developed and internally validated the NOTICE (Nicotine, Tobacco and Cannabis Use and Exposure) assessment, a non-invasive behavioral tool for measuring prenatal substance use and exposure. The research employed a longitudinal cohort design in Australian First Nations pregnant women, collecting repeated NOTICE assessments across pregnancy alongside multiple biochemical reference standards including exhaled carbon monoxide, saliva cotinine, urinary cotinine, and urinary THC-COOH metabolite, with validation using receiver operating characteristic analysis and generalized estimating equations. **Key Findings** • The composite NOTICE score demonstrated very high discrimination for tobacco and nicotine exposure relative to creatinine-corrected cotinine ≥5 ng/mg cr (AUC = 0.99; 95% CI 0.98-1.00), indicating excellent performance as a screening tool. • Cannabis exposure showed high discrimination relative to creatinine-corrected THC-COOH ≥80 ng/mg cr (AUC = 0.92; 95% CI 0.83-1.00), demonstrating strong criterion validity for detecting cannabis use. • Weekly NOTICE scores outperformed daily scores in discriminative validity, and the tool remained superior to exposure-only measures across alternative biomarker thresholds. **Dosage & Administration** Not reported. The assessment is designed as a repeated behavioral questionnaire measuring weekly self-use and exposure scores combined into a weighted, standardized composite score; specific administration frequency or timing details were not provided in the abstract. **Safety & Adverse Effects** Not reported. This is a measurement assessment tool rather than an intervention; no adverse effects are applicable. **Evidence Quality** This internal validation study represents preliminary evidence with several limitations. The research was conducted in a specific population (Australian First Nations pregnant women), limiting generalizability to other ethnic or geographic populations. As a validation study only, external validation in independent cohorts remains necessary before widespread clinical implementation. The study's reliance on self-report combined with biochemical validation addresses measurement validity but cannot establish clinical outcomes. The use of creatinine-corrected thresholds for cannabis detection may vary by individual renal function. The study demonstrates moderate to high quality internal validity evidence but requires prospective external validation and assessment of clinical utility in diverse populations before recommendation for routine clinical practice.

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