Racial and Ethnic Differences in Cannabis Use Following Legalization in US States With Medical Cannabis Laws

Risk factors and health behaviors associated with loneliness among cancer survivors during the COVID-19 pandemic

Loneliness may exacerbate poor health outcomes particularly among cancer survivors during the COVID-19 pandemic. Little is known about the risk factors of loneliness among cancer survivors. We evaluated the risk factors of loneliness in the context of COVID-19 pandemic-related prevention behaviors and lifestyle/psychosocial factors among cancer survivors. Cancer survivors (n = 1471) seen at Huntsman Cancer Institute completed a survey between August-September 2020 evaluating health behaviors, medical care, and psychosocial factors including loneliness during COVID-19 pandemic. Participants were classified into two groups: 'lonely' (sometimes, usually, or always felt lonely in past month) and 'non-lonely' (never or rarely felt lonely in past month). 33% of cancer survivors reported feeling lonely in the past month. Multivariable logistic regression showed female sex, not living with a spouse/partner, poor health status, COVID-19 pandemic-associated lifestyle factors including increased alcohol consumption and marijuana/CBD oil use, and psychosocial stressors such as disruptions in daily life, less social interaction, and higher perceived stress and financial stress were associated with feeling lonely as compared to being non-lonely (all p < 0.05). A significant proportion of participants reported loneliness, which is a serious health risk among vulnerable populations, particularly cancer survivors. Modifiable risk factors such as unhealthy lifestyle behaviors and psychosocial stress were associated with loneliness. These results highlight the need to screen for unhealthy lifestyle factors and psychosocial stressors to identify cancer survivors at increased risk of loneliness and to develop effective management strategies.

Evolving Disparities in Cannabis Use Among Youth by Demographics and Tobacco and Alcohol Use in the U.S.: 2013-2021

INTRODUCTION

This study investigated the prevalence of past 30-day cannabis use among U.S. youth by cigarette use, alcohol use, demographics, and state-of-residence cannabis legal status in 2021 and examined whether changes in cannabis use prevalence were modified by these factors from 2013 to 2021.

METHODS

Data were drawn from the 24 states that collected cannabis use data participating in the Youth Risk Behavior Surveillance System from 2013 to 2021. Logistic regression analyses estimated past 30-day cannabis prevalence in 2021 and produced AORs by current cigarette, alcohol, and state-of-residence cannabis legal status. The same method was used with year as the exposure, adjusting for sex, race, and ethnicity, to assess trends in prevalence from 2013 to 2021.

RESULTS

In 2021, cannabis use was more common among female youth (16.75% vs 13.83% [AOR=1.26, 95% CI=1.16, 1.37]) and non-Hispanic Black and Hispanic youth than among non-Hispanic White youth (17.19%, 16.14% vs 14.60% [AOR=1.25, 95% CI=1.12, 1.39 and AOR=1.16, 95% CI=1.04, 1.29, respectively]). Cannabis use was much more common among youth who reported any past 30-day cigarette or alcohol use (44.90% vs 6.48% [AOR=11.80, 95% CI=10.57, 13.18]). Declines in cannabis use were observed independent of state-level cannabis law from 2013 to 2021, and cannabis use prevalence did not differ significantly by state-of-residence cannabis legal status among the 24 participating states in 2021.

CONCLUSIONS

Public health officials should carefully consider the potential impact of expanding commercialization of cannabis as a wellness product on youth cannabis use, especially with regard to minoritized populations and co-use with tobacco and alcohol. National and state-level public health education on cannabis use and youth-oriented prevention of cannabis uptake are long overdue.

The Puzzle of Marijuana Use and Forced Vital Capacity

In study after study, marijuana use has been found to be associated with increased forced vital capacity (FVC). This is puzzling, because marijuana is commonly consumed by inhalation of its smoke, and smoke exposure of any kind is not generally considered a cause of increased FVC. Although this observation was first made decades ago, a satisfactory explanation remains elusive. In this review we survey the evidence supporting the relationship between marijuana use and increased FVC, discuss potential threats to validity when inferring causation, and, presupposing a possible causal relationship, pose two key questions. First, what are possible physiologic or pathophysiologic mechanisms by which marijuana use might increase FVC? Second, why might this effect be consistently observed with marijuana use but not with tobacco use? Explanations for the first question include lung and chest growth and remodeling from strenuous marijuana smoke inhalation and reductions in lung elastic recoil from marijuana smoke exposure. Explanations for the second include differences between marijuana and tobacco in smoke composition and patterns of consumption, such as smoking topography. Finally, the possibility that smoke, whether from marijuana or tobacco, might have nonmonotonic effects on FVC depending on the degree of exposure is explored. In synthesizing a curated breadth of epidemiologic and physiologic science, we leverage a perplexing observation to generate potential insights and avenues for further research into the biological effects of smoke, from marijuana or otherwise, on the respiratory system.

Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline

PURPOSE

To guide clinicians, adults with cancer, caregivers, researchers, and oncology institutions on the medical use of cannabis and cannabinoids, including synthetic cannabinoids and herbal cannabis derivatives; single, purified cannabinoids; combinations of cannabis ingredients; and full-spectrum cannabis.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and cohort studies on the efficacy and safety of cannabis and cannabinoids when used by adults with cancer. Outcomes of interest included antineoplastic effects, cancer treatment toxicity, symptoms, and quality of life. PubMed and the Cochrane Library were searched from database inception to January 27, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 13 systematic reviews and five additional primary studies (four RCTs and one cohort study). The certainty of evidence for most outcomes was low or very low.

RECOMMENDATIONS

Cannabis and/or cannabinoid access and use by adults with cancer has outpaced the science supporting their clinical use. This guideline provides strategies for open, nonjudgmental communication between clinicians and adults with cancer about the use of cannabis and/or cannabinoids. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. Cannabis and/or cannabinoids may improve refractory, chemotherapy-induced nausea and vomiting when added to guideline-concordant antiemetic regimens. Whether cannabis and/or cannabinoids can improve other supportive care outcomes remains uncertain. This guideline also highlights the critical need for more cannabis and/or cannabinoid research.Additional information is available at www.asco.org/supportive-care-guidelines.

Risk factors associated with driving after marijuana use among West Virginia college students during the COVID-19 pandemic

OBJECTIVES

The purpose of this study was to assess sociodemographic and behavioral risk factors associated with driving after marijuana use (DAMU) among West Virginia college students.

METHODS

Participants were recruited from West Virginia University between September and November 2022. The study sample was restricted to students who were ≥18 years of age; reported recently driving; possessed a current, valid driver's license from any US state; and were enrolled for at least one credit hour in the Fall 2022 semester.

RESULTS

Among respondents (N = 772), 28.9% reported DAMU. Students who had a GPA of B (adjusted odds ratio [AOR]: 2.17, 95% confidence interval [CI]: 1.06-4.42), smoked or ingested marijuana in the past year (AOR: 26.51, 95% CI: 10.27-68.39), drove after drinking (AOR: 2.38, 95% CI: 1.18-4.79), and used both marijuana and alcohol concurrently and then drove (AOR: 10.39, 95% CI: 2.32-46.54) associated with DAMU. Individuals who felt the behavior was somewhat dangerous or not dangerous or thought their peers approved of DAMU showed significant associations with DAMU.

CONCLUSIONS

As DAMU was prevalent, future interventions that raise awareness of the danger and potential consequences of DAMU may be needed to reduce this risky behavior on college campuses.

Acute Effects of Ad Libitum Use of Commercially Available Cannabis Products on the Subjective Experience of Aerobic Exercise: A Crossover Study

OBJECTIVE

The present study aimed to examine the acute effects of legal-market cannabis on regular cannabis users' subjective responses to exercise in a controlled laboratory environment.

BACKGROUND

Given the stereotype that cannabis is associated with extreme sedentary behavior, there are concerns that cannabis legalization may exacerbate the US physical inactivity epidemic. However, despite these concerns, recent years have seen considerable public interest in the use of cannabis concurrently with exercise (e.g., running).

METHODS

The present study compared participants' experiences of exercise without cannabis to their experiences of exercise after acute ad libitum use of one of two commercially available cannabis flower products: a Δ9-tetrahydrocannabinol-dominant or a cannabidiol-dominant product. Participants (N = 42) were regular cannabis users between the ages of 21 and 39 years (mean = 30.81 years, standard deviation = 4.72 years).

RESULTS

Although participants reported a more positive affect (p < 0.001), enjoyment (p < 0.001), and runner's high symptoms (p < 0.001) during their cannabis (vs non-cannabis) exercise appointment, they also reported more exertion (p = 0.04). Pain levels were very low and did not differ between appointments (p = 0.45). Effects appeared to depend, in part, on cannabinoid content; there was a larger difference in enjoyment (p = 0.02), and a smaller difference in exertion (p = 0.02), between the cannabis and non-cannabis exercise appointments among participants in the cannabidiol (vs Δ9-tetrahydrocannabinol) condition.

CONCLUSIONS

To our knowledge, this is the first study to investigate the acute effects of commercially available cannabis on subjective responses to exercise in a laboratory environment. Our findings suggest that, among regular cannabis users who use cannabis in combination with exercise, cannabis use prior to exercise may lead to increases in both positive and negative aspects of the subjective exercise experience. Research using diverse samples, exercise modalities, and methodologies (e.g., placebo-controlled trials) is needed to establish the generalizability of these findings.

Associations between cannabis policies and state-level specialty cannabis use disorder treatment in the United States, 2004-2019

BACKGROUND

Cannabis use disorder (CUD) treatment prevalence decreased in the US between 2002 and 2019, yet structural mechanisms for this decrease are poorly understood. We tested associations between cannabis laws becoming effective and self-reported CUD treatment.

METHODS

Restricted-use 2004-2019 National Surveys on Drug Use and Health included people ages 12+ classified as needing CUD treatment (i.e., past-year DSM-5-proxy CUD or last/current specialty treatment for cannabis). Time-varying indicators of medical cannabis laws (MCL) with/without cannabis dispensary provisions differentiated state-years before/after laws using effective dates. Multi-level logistic regressions with random state intercepts estimated individual- and state-adjusted CUD treatment odds by MCLs and model-based changes in specialty CUD treatment state-level prevalence. Secondary analyses tested associations between CUD treatment and MCL or recreational cannabis laws (RCL).

RESULTS

Using a broad treatment need sample definition in 2004-2014, specialty CUD treatment prevalence decreased by 1.35 (95 % CI = -2.51, -0.18) points after MCL without dispensaries and by 2.15 points (95 % CI = -3.29, -1.00) after MCL with dispensaries provisions became effective, compared to before MCL. Among people with CUD in 2004-2014, specialty treatment decreased only in MCL states with dispensary provisions (aPD = -0.91, 95 % CI = -1.68, -0.13). MCL were not associated with CUD treatment use in 2015-2019. RCL were associated with lower CUD treatment among people classified as needing CUD treatment, but not among people with past-year CUD.

CONCLUSIONS

Policy-related reductions in specialty CUD treatment were concentrated in states with cannabis dispensary provisions in 2004-2014, but not 2015-2019, and partly driven by reductions among people without past-year CUD. Other mechanisms (e.g., CUD symptom identification, criminal-legal referrals) could contribute to decreasing treatment trends.

Systematic Review and Meta-Analysis: Medical and Recreational Cannabis Legalization and Cannabis Use Among Youth in the United States

OBJECTIVE

Dramatic changes in state-level cannabis laws (CL) over the past 25 years have shifted societal beliefs throughout the United States, with unknown implications for youth. In the present study, we conducted an updated systematic review and meta-analysis examining estimated effects of medical cannabis legalization (MCL) and recreational cannabis legalization (RCL) on past-month cannabis use among US youth.

METHOD

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, followed by a subsequent meta-analysis investigating the associations between state-level cannabis laws (ie, MCL vs non-MCL, and RCL vs non-RCL) and past-month cannabis use prevalence among US adolescents and young adults. Supplemental analyses examined age-group effects and design-related factors.

RESULTS

Our search identified 4,604 citations, 34 and 30 of which were included in qualitative and quantitative analyses, respectively. Meta-analysis of MCL studies identified no significant association between MCL and change in past-month youth cannabis use (odds ratio [OR] = 0.981, 95% CI = 0.960, 1.003). Meta-analysis of RCL studies showed significantly increased odds of past-month cannabis use (OR = 1.134, 95% CI = 1.116-1.153). Meta-analysis of more recent studies, however, showed a significantly increased odds of past-month cannabis use among both adolescents and young adults (OR = 1.089, 95% CI = 1.015,1.169, and OR = 1.221, 95% CI = 1.188,1.255, respectively).

CONCLUSION

Cannabis legalization has complex and heterogenous effects on youth use that may differ across law types. Our meta-analytic results showed modest positive effects of RCL on past-month cannabis use (more so in young adults than in adolescents) and minimal effects of MCL on these outcomes in US youth. Given the shift toward recreational legalization, additional focus on RCL effects is warranted.

United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic

BACKGROUND

To determine if marijuana legalization was associated with reduced opioid mortality.

STUDY DESIGN

The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions.

METHODS

Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates.

RESULTS

The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01).

CONCLUSIONS

During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.

Is legalization of recreational cannabis associated with levels of use and cannabis use disorder among youth in the United States? A rapid systematic review

Cannabis legalization policies are rapidly changing in the United States. While there are concerns that recreational legalization will negatively affect young people, previous reviews have not provided clear indication of such effects. The purpose of this rapid systematic review was to examine whether recreational legalization was associated with increases in prevalence of cannabis use and use disorder among adolescents and young adults. PubMed/MEDLINE, Embase, Scopus, PsycInfo, Web of Science, Dissertations & Theses Global, the Trip Database, and OpenGrey were searched from date of inception through Marcy 17, 2022 to retrieve all relevant records. English language and human subject filters were applied. Two reviewers screened abstracts and titles, assessed full text articles, and coded the final included articles. Studies including primarily 10- to 19-year-olds were classified as adolescent, and those between 18 and 26 years as young adult. Our search identified 33 research reports (22 with adolescent samples; 14 young adult). For adolescents, ten studies reported no change in use prevalence associated with legalization, six reported a decrease, and seven reported an increase. Among young adults, most studies (8) showed an increase in at least one prevalence measure, four showed no change, and one showed a decrease. Only two adolescent and one young adult study examined cannabis use disorder, both adolescent studies showed an increase, and the young adult showed no change. The majority of studies had risk of bias. Recreational legalization may be associated with increases in prevalence of cannabis use in young adults while results for adolescents are mixed. Policymakers and practitioners should consider appropriate prevention and treatment options for young people.Trial Registration: PROSPERO #CRD42021276984.

Lifetime use of alcohol and cannabis among U.S. adolescents across age: Exploring differential patterns by sex and race/ethnicity using the 2019 NSDUH data

Background

Early use of alcohol and cannabis is associated with health and social problems. It is unclear how lifetime use changes for each additional year of age during adolescence, and whether this change varies by sex and race/ethnicity. This study characterized lifetime rates of alcohol and cannabis use by age among 12- to 17-year-old American youth and explored differential patterns by sex and race/ethnicity.

Methods

Data were obtained from the 2019 National Survey on Drug Use and Health. Analyses were restricted to 12-17-year-olds who were non-Hispanic White, non-Hispanic Black, or Hispanic/Latino (n = 11,830). We estimated the increase in lifetime use of alcohol and cannabis by age for the full sample and stratified by sex and race/ethnicity. Slopes of the regression lines were compared to assess differential patterns across groups.

Results

In these cross-sectional analyses, reported lifetime use increased substantially from age 12 to 17 for alcohol (6.4 % to 53.2 %) and cannabis (1.3 % to 35.9 %). The increase in lifetime alcohol use was slightly, but not significantly, steeper among girls than boys (F1,8 = 3.40, p = 0.09). White and Latino youth showed similar rates of increase in lifetime alcohol use, which was significantly flatter among Black youth (F2,12=21.26, p<0.0001). Latino youth had a slightly, but not significantly, steeper increase in lifetime cannabis use than White and Black youth (F2,12=3.17, p = 0.07).

Conclusions

Reports of lifetime alcohol and cannabis use substantially increase from age 12 to 17 and the rates are different according to sex and race/ethnicity, highlighting the need for early and tailored substance use prevention in adolescents.

Associations between simultaneous use of alcohol and cannabis and cannabis-related problems in 2014-2016: evidence from the Washington panel survey

BACKGROUND

To address the research question of how simultaneous users of alcohol and cannabis differ from concurrent users in risk of cannabis use problems after the recreational marijuana legalization in Washington State.

METHODS

We used generalized estimating equations with a Poisson distribution to analyze the association between simultaneous use of alcohol and marijuana (SAM) and cannabis-related problems compared to concurrent use. The data is a longitudinal sample of drinkers and cannabis users (n = 257, 47% female) aged 18 years and older from Washington State in 2014-2016. We adjusted for survey weights to account for differential probability of selection and response rates. The primary outcome is the past-six-month CUDIT problem subscale (ranging from 0 to 28), which is the total score for seven CUDIT problem items, after excluding the three items that covered marijuana use frequency. Covariates include marijuana use frequency (daily/near daily use, regular use, or infrequent use), marijuana daily quantity, alcohol daily volume, panel survey cycle, medical marijuana recommendation, driving time to nearest marijuana outlet, age of marijuana use onset, and other demographics.

RESULTS

After adjusting for covariates, we found that compared to concurrent use, SAM was significantly positively associated with CUDIT problem subscale (IRR = 1.68, 95% CI: 1.25-2.27, p < 0.001); daily/near daily use of marijuana was strongly significantly associated with CUDIT problem subscale compared with infrequent use (IRR = 5.1, 2.71-9.57, p < 0.001) or regular use (IRR = 3.05, 1.91-4.85, p < 0.001). Secondary analyses using CUDIT total score as the outcome also showed a significant positive association with SAM compared to concurrent use (IRR = 1.17, 1.02-1.34, p < 0.05).

CONCLUSIONS

This study highlighted the importance of SAM, in addition to cannabis use frequency for predicting cannabis-related problems.

Association of Cannabis Use Disorder with Major Adverse Cardiac and Cerebrovascular Events in Older Non-Tobacco Users: A Population-Based Analysis

BACKGROUND

Tobacco use disorder (TUD) adversely impacts older patients with established cardiovascular disease (CVD) risk. However, CVD risk in chronic habitual cannabis users without the confounding impact of TUD hasn't been explored. We aimed to determine the risk of major adverse cardiac and cerebrovascular events (MACCE) in older non-tobacco smokers with established CVD risk with vs. without cannabis use disorder (CUD).

METHODS

We queried the 2019 National Inpatient Sample for hospitalized non-tobacco smokers with established traditional CVD risk factors aged ≥65 years. Relevant ICD-10 codes were used to identify patients with vs. without CUD. Using multivariable logistic regression, we evaluated the odds of MACCE in CUD cohorts compared to non-CUD cohorts.

RESULTS

Prevalence of CUD in the sample was 0.3% (28,535/10,708,815, median age 69), predominantly male, black, and non-electively admitted from urban teaching hospitals. Of the older patients with CVD risk with CUD, 13.9% reported MACCE. The CUD cohort reported higher odds of MACCE (OR 1.20, 95% CI 1.11-1.29, p < 0.001) compared to the non-CUD cohort. Comorbidities such as hypertension (OR 1.9) and hyperlipidemia (OR 1.3) predicted a higher risk of MACCE in the CUD cohort. The CUD cohort also had higher unadjusted rates of acute myocardial infarction (7.6% vs. 6%) and stroke (5.2% vs. 4.8%).

CONCLUSIONS

Among older non tobacco smokers with known CVD risk, chronic cannabis use had a 20% higher likelihood of MACCE compared to those who did not use cannabis.

Mobile Intervention to Address Cannabis Use Disorder Among Black Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

African American or Black (hereafter referred to as Black) adults who use cannabis use it more frequently and are more likely to meet criteria for cannabis use disorder (CUD) than both White and Hispanic or Latin individuals. Black adults may be more apt to use cannabis to cope with distress, which constitutes a false safety behavior (FSB; a behavior designed to reduce psychological distress in the short term). Although FSB engagement can perpetuate the cycle of high rates of CUD among Black individuals, limited work has applied an FSB elimination treatment approach to Black adults with CUD, and no previous work has evaluated FSB reduction or elimination in the context of a culturally tailored and highly accessible treatment developed for Black individuals.

OBJECTIVE

This study aims to develop and pilot-test a culturally tailored adaptive intervention that integrates FSB reduction or elimination skills for cannabis reduction or cessation among Black adults with probable CUD (Culturally Tailored-Mobile Integrated Cannabis and Anxiety Reduction Treatment [CT-MICART]).

METHODS

Black adults with probable CUD (N=50) will complete a web-based screener, enrollment call, baseline assessment, 3 daily ecological momentary assessments (EMAs) for 6 weeks, and a follow-up self-report assessment and qualitative interview at 6 weeks after randomization. Participants will be randomized into 1 out of the 2 conditions after baseline assessment: (1) CT-MICART+EMAs for 6 weeks or (2) EMAs only for 6 weeks.

RESULTS

The enrollment started in June 2023 and ended in November 2023. Data analysis will be completed in March 2024.

CONCLUSIONS

No culturally tailored, evidence-based treatment currently caters to the specific needs of Black individuals with CUD. This study will lay the foundation for a new approach to CUD treatment among Black adults that is easily accessible and has the potential to overcome barriers to treatment and reduce practitioner burden in order to support Black individuals who use cannabis with probable CUD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05566730; https://clinicaltrials.gov/study/NCT05566730.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52776.

Adverse Impact of Cannabis on Human Health

Cannabis, the most commonly used recreational drug, is illicit in many areas of the world. With increasing decriminalization and legalization, cannabis use is increasing in the United States and other countries. The adverse effects of cannabis are unclear because its status as a Schedule 1 drug in the United States restricts research. Despite a paucity of data, cannabis is commonly perceived as a benign or even beneficial drug. However, recent studies show that cannabis has adverse cardiovascular and pulmonary effects and is linked with malignancy. Moreover, case reports have shown an association between cannabis use and neuropsychiatric disorders. With growing availability, cannabis misuse by minors has led to increasing incidences of overdose and toxicity. Though difficult to detect, cannabis intoxication may be linked to impaired driving and motor vehicle accidents. Overall, cannabis use is on the rise, and adverse effects are becoming apparent in clinical data sets.

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

Cannabis use among cancer patients and survivors in the United States: a systematic review

BACKGROUND

How cannabis products are being used by cancer patients and survivors in the United States is poorly understood. This study reviewed observational data to understand the modes, patterns, reasons, discontinuation, and adverse experiences of cannabis use.

METHODS

PubMed and PsycINFO database searches were conducted between May 2022 and November 2022. Of the 1162 studies identified, 27 studies met the inclusion criteria. The intercoder agreement was strong (0.81).

RESULTS

The majority (74%) of the studies were cross-sectional in design. Study samples were approximately equal proportions of men and women and majority White participants. The prevalence of cannabis use based on national samples ranged between 4.8% and 22%. The most common modes of cannabis intake were topical application (80%), smoking (73%), vaping (12%), and ingestion of edible products (10%). Younger age, male gender, being a current or former smoker, and higher socioeconomic status were associated with greater likelihood of cannabis use. The main motive for cannabis use was management of symptoms due to cancer or cancer treatment such as pain, nausea, lack of sleep, and anxiety. A majority of the participants across studies reported that cannabis helped reduce these symptoms. Lack of symptom improvement, side effects such as fatigue and paranoia, cost, and social stigma were identified as some of the reasons for discontinuing cannabis use.

CONCLUSIONS

It appears that cannabis may help cancer patients and survivors manage symptoms. However, more longitudinal studies are needed to determine whether positive experiences of cannabis use outweigh adverse experiences over time in this vulnerable population.

Cannabis Use Differences Among Sexual Minority Versus Heterosexual Females and Males in Oklahoma: The Roles of Mental Health, Cannabis Perceptions, and Cannabis Marketing Exposure

INTRODUCTION

Despite the high cannabis use rates among sexual minority (SM) individuals, less research has examined factors related to cannabis use among SM (vs. heterosexual) individuals, especially in places with legal medical cannabis retail markets and high structural stigma, like Oklahoma.

METHODS

Data were from a survey of Oklahoma adults, including 3020 females (18.6% SM) and 2279 males (10.1% SM). Bivariate analyses examined associations of sexual identity with cannabis-related factors (i.e., perceived harm, positive attitudes, marketing exposure, depressive symptoms, anxiety symptoms) and cannabis use and use severity (i.e., past 30-day use, daily/near-daily use, cannabis use disorder [CUD] symptoms). Logistic regression examined associations of sexual identity and cannabis-related factors with cannabis use and use severity among females and males, separately.

RESULTS

SM (vs. heterosexual) females reported greater odds of past 30-day cannabis use and daily/near-daily use, lower harm perceptions, greater marketing exposure, and higher rates of depressive/anxiety symptoms. Lower harm perceptions and greater marketing exposure were associated with greater odds of past 30-day use, whereas marketing exposure was associated with greater odds of daily/near-daily use. SM (vs. heterosexual) males reported greater odds of daily/near-daily use and higher rates of depressive/anxiety symptoms.

CONCLUSIONS

SM (vs. heterosexual) females reported higher rates of cannabis use, whereas SM (vs. heterosexual) females and males reported higher rates of daily/near-daily cannabis use. Potential targets for cannabis-related health campaigns aimed at reducing use differences include correcting misinterpretations of harm that may emanate from cannabis marketing efforts among females and addressing depressive symptoms among males.

Limited psychological and social effects of lifetime cannabis use frequency: Evidence from a 30-year community study of 4,078 twins

BACKGROUND

Cannabis use is associated with outcomes like income, legal problems, and psychopathology. This finding rests largely on correlational research designs, which rely at best on statistical controls for confounding. Here, we control for unmeasured confounders using a longitudinal study of twins.

METHOD

In a sample of 4,078 American adult twins first assessed decades ago, we used cotwin control mixed effects models to evaluate the effect of lifetime average frequency of cannabis consumption measured on substance use, psychiatric, and psychosocial outcomes.

RESULTS

On average, participants had a lifetime cannabis frequency of about one to two times per month, across adolescence and adulthood. As expected, in individual-level analyses, cannabis use was significantly associated with almost all outcomes in the expected directions. However, when comparing each twin to their cotwin, which inherently controls for shared genes and environments, we observed within-pair differences consistent with possible causality in three of the 22 assessed outcomes: cannabis use disorder symptoms (βW-Pooled = .15, SE = .02, p = 1.7 × 10-22), frequency of tobacco use (βW-Pooled = .06, SE = .01, p = 1.2 × 10-5), and illicit drug involvement (βW-Pooled = .06, SE = .02, p = 1.2 × 10-4). Covariate specification curve analyses indicated that within-pair effects on tobacco and illicit drug use, but not cannabis use disorder, attenuated substantially when covarying for lifetime alcohol and tobacco use.

CONCLUSIONS

The cotwin control results suggest that more frequent cannabis use causes small increases in cannabis use disorder symptoms, approximately 1.3 symptoms when going from a once-a-year use to daily use. For other outcomes, our results are more consistent with familial confounding, at least in this community population of twins. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceptions and Attitudes Related to Driving after Cannabis Use in Canadian and US Adults

BACKGROUND

This study examined the risk perceptions related to driving after cannabis use (DACU) among Canadian and US adults who used cannabis in the past six months.

METHODS

Perceptions of danger, normative beliefs, perceived likelihood of negative consequences, and other driving-related variables were collected via online surveys in Canadian (n = 158; 50.0% female, 84.8% White, mean age = 32.73 years [SD = 10.61]) and US participants (n = 678; 50.9% female, 73.6% White, mean age = 33.85 years [SD = 10.12]). Driving cognitions and DACU quantity/frequency were compared between samples using univariate analyses of variance, and Spearman's (ρ) correlations were performed to examine associations between driving cognitions and DACU quantity/frequency.

RESULTS

The two samples did not significantly differ in self-reported level of cannabis use, lifetime quantity of DACU, or the number of times they drove within two hours of cannabis use in the past three months (Ps > .12). Compared to US participants, Canadians perceived driving within two hours of cannabis use as more dangerous (P < 0.001, ηp2 = 0.013) and reported more of their friends would disapprove of DACU (P = 0.03, ηp2 = 0.006). There were no differences in the number of friends who would refuse to ride with a driver who had used cannabis (P = 0.15) or the perceived likelihood of negative consequences (Ps > 0.07). More favorable perceptions were significantly correlated with greater lifetime DACU and driving within two hours of use (ρ = 0.25-0.53, Ps < 0.01).

CONCLUSIONS

These findings reveal differences in distal risk factors for DACU between Canada and the US and may inform prevention efforts focusing on perceptions of risk and social acceptance of DACU.

Preconception health indicators among adult US men: Race/ethnicity variations and temporal trends

BACKGROUND

Preconception health is important for men as it is for women. However, optimizing preconception health is understudied among men.

OBJECTIVES

To examine the time trends and temporal shifts in preconception health risk indicators among 20-44-year-old adult US men in need of preconception care and their racial/ethnic variations.

MATERIALS AND METHODS

Data from the 2011-2019 National Survey of Family Growth male file was used to estimate the prevalence of nine preconception health indicators among men (20-44 years) intending to have a future pregnancy (n = 6813), stratifying by race/ethnicity, and assessing temporal changes across the study period. Binary logit and linear regression models estimated temporal trends from 2011-2013 to 2017-2019. Absolute and relative changes were estimated to detect temporal shifts in men's preconception health comparing 2011-2013 to 2017-2019.

RESULTS

Men in all groups exhibited substantial preconception health needs, with unique trends across race/ethnicity groups. Between 2011 and 2019, the prevalence of marijuana use (28.6%-39.4%, p = 0.001), overweight/obese status (60.7%-65.1%, p ≤ 0.001), and the mean number of preconception health indicators (M = 2.69-2.84, p = 0.018) increased. Among non-Hispanic White men, the prevalence of marijuana use (30.1%-41.4%, p = 0.028), overweight/obese status (60.6%-63.7%, p = 0.002), and mean number of preconception health risk indicators (M = 2.74-2.90, p = 0.033) increased. Among Hispanic men, the prevalence of inconsistent/no condom use (68.9%-81.4%, p = 0.022), marijuana use (18.9%-40.4%, p = 0.001), and the mean number preconception health risk indicators (M = 2.50-2.96, p = 0.014) increased. Among non-Hispanic Black men, sexually transmitted infections declined (5.4%-3.6%, p = 0.002). Significant temporal shifts, which varied by race/ethnicity, were also observed.

DISCUSSION AND CONCLUSION

Our study, which provides initial insight into men's preconception health development in the last decade, highlights a tremendous need for preconception health care among men. Their increasing preconception health needs, and their racial/ethnic variations, suggest additional contributors to racial/ethnic differences in men's reproductive outcomes and their long-term health.

Proximity to Cannabis Retailers and Recent Cannabis Use among a Diverse Sample of California Adolescents

Background: As of May 2023, 23 states and Washington, DC have legalized the sale of cannabis for adults aged 21+, and 38 states, three territories, and D.C. have legalized medical cannabis. Exposure to cannabis retailers could increase adolescent cannabis use. Few studies have examined the impact of residential proximity to cannabis retailers on adolescent cannabis use, and previous findings are inconsistent. Methods: This study examined associations between proximity to cannabis retailers and past 30-day cannabis use. Data were from Project Cal Teens, a statewide survey of California adolescents regarding cannabis-related opinions/behaviors (N = 1406, mean age = 15.5 years, 48% female, 38% Hispanic/Latinx, 33% White, 15% Asian/Pacific Islander, 10% Black/African American, 5% Other/Multiracial). Participants were recruited via schools/social media in 2018-2020. Results: For every additional 5 driving miles to the nearest cannabis retailer, the risk of past 30-day cannabis use was reduced by 3.6% [IRR: 0.964; 95% CI: 0.935-0.994]. For every additional 5 miles from a licensed retailer, the risk of past 30-day cannabis use was reduced by 4.3% [IRR: 0.957; 95% CI: 0.926-0.989]. Interaction analyses revealed that among Hispanic/Latinx students, every 5 miles from a licensed retailer was associated with an 11.9% reduction in the risk of past 30-day cannabis use [IRR: 0.881; 95% CI: 0.820-0.945]. Conclusions: As the number of cannabis retailers in the U.S. increases with the continued legalization of adult cannabis use, research examining the effects of these policies on underage use is crucial. Interventions could include enforcement of zoning laws in/near residential areas to reduce accessibility of adolescents to cannabis retailers.

Multi-ancestry genome-wide association study of cannabis use disorder yields insight into disease biology and public health implications

As recreational use of cannabis is being decriminalized in many places and medical use widely sanctioned, there are growing concerns about increases in cannabis use disorder (CanUD), which is associated with numerous medical comorbidities. Here we performed a genome-wide association study of CanUD in the Million Veteran Program (MVP), followed by meta-analysis in 1,054,365 individuals (ncases = 64,314) from four broad ancestries designated by the reference panel used for assignment (European n = 886,025, African n = 123,208, admixed American n = 38,289 and East Asian n = 6,843). Population-specific methods were applied to calculate single nucleotide polymorphism-based heritability within each ancestry. Statistically significant single nucleotide polymorphism-based heritability for CanUD was observed in all but the smallest population (East Asian). We discovered genome-wide significant loci unique to each ancestry: 22 in European, 2 each in African and East Asian, and 1 in admixed American ancestries. A genetically informed causal relationship analysis indicated a possible effect of genetic liability for CanUD on lung cancer risk, suggesting potential unanticipated future medical and psychiatric public health consequences that require further study to disentangle from other known risk factors such as cigarette smoking.

Cannabis and Alcohol Use by U.S. Young Adults, 2008-2019: Changes in Prevalence After Recreational Cannabis Legalization

INTRODUCTION

Young adults' cannabis and alcohol use patterns have changed after state recreational cannabis legalization according to studies based on college samples but not nationally representative samples. Associations between recreational cannabis legalization and changes in cannabis and alcohol use outcomes among young adults were examined, including differences by college enrollment and minor status (ages 18-20 vs 21-23 years).

METHODS

Repeated cross-sectional data (2008-2019) were collected from college-eligible participants aged 18-23 years in the National Survey on Drug Use and Health. Self-reported past-month cannabis use and frequent use (≥20 days) and a proxy for past-year DSM-5 cannabis use disorder were primary outcomes; past-month frequent alcohol use and binge drinking were secondary outcomes. Multilevel logistic regression models quantified changes in outcome prevalence from the study years before to after recreational cannabis legalization, adjusting for secular trends. Analyses were conducted on March 22, 2022.

RESULTS

Prevalence increased from before to after recreational cannabis legalization for past-month cannabis use (from 21% to 25%) and past-year proxy cannabis use disorder (from 11% to 13%); the increases were statistically significant [adjusted odds ratio (95% CI) = 1.20 (1.08-1.32) and 1.14 (1.003-1.30), respectively]. Increases were detected for young adults who were not in college and who were aged 21-23 years. Recreational cannabis legalization impacts were not detected for secondary outcomes.

CONCLUSIONS

Some young adults appear sensitive to state recreational cannabis legalization, including in terms of cannabis use disorder risk. Additional prevention efforts should be directed to young adults who are not in college and timed to occur before age 21 years.

Cannabis-Impaired driving: ethical considerations for the primary care practitioner

Background: Widespread cannabis consumption and recreational cannabis legalization is thought to have led to an increase in motor vehicle accidents, although there currently lacks ethical guidance for primary care practitioners on cannabis-impaired driving.Objective: The aim was to develop an ethical framework for primary care providers on cannabis-impaired driving.Methods: An ethical analysis in the form of a critical interpretive review was undertaken, using a systematic approach to determine the appropriate action to a given situation with evidence to substantiate its claims. The search strategy was designed to answer the research question: What are some ethical concerns for primary care providers to consider when cannabis-impaired driving is suspected? Four databases were searched in December 2021 using keywords related to cannabis, impaired driving, ethics, and primary care. The resulting evidence was synthesized as recommendations for primary care practice.Results: The ethical approach for primary care practitioners in addressing cannabis-impaired driving can be summarized as the duty to always inform, provide care through prevention and harm reduction strategies, and report when necessary. The prevention of cannabis-impaired driving should not fall on the sole responsibility of primary care practitioners. As this review offers a high-level discussion of the ethical considerations in cannabis-impaired driving, specific recommendations will depend upon the legal and policy designations of individual jurisdictions.Conclusion: Ultimately, the practitioner should manage cannabis-impaired driving in a way that fosters the therapeutic relationship in patient-centered care, through motivational discussions, collaboration with specialists, skills for self-management, patient empowerment, and support. KEY MESSAGES  Take-Home Points for Primary Care Practitioners in Cannabis-Impaired Driving  •  For patients who report driving frequently and using cannabis, the frequency of use, dosage, form of cannabis, tolerance levels, and withdrawal symptoms should be discussed, while informing the patient of the risks, harms, and legal consequences associated with cannabis-impaired driving.  •  The practitioner's primary responsibility in the cannabis-impaired driving context is to provide care to patients who drive and consume cannabis, which may include referring patients to mental health care to manage addictive or problematic behaviors associated with cannabis use.  •  Practitioners may have a duty to report cannabis-impaired driving to legal authorities (such as law enforcement) when the user engages in harmful behavior to themselves or others.

Cannabis Use Frequency is Associated with PrEP Cessation and Self-reported HIV Diagnosis

To achieve stated targets in the United States of Ending the HIV Epidemic by 2030, it is necessary to decrease rates of pre-exposure prophylaxis use (PrEP) cessation. In particular, it is key to assess PrEP use and cannabis use frequency given the recent wave of cannabis decriminalization across the U.S., particularly among sexual minority men and gender diverse (SMMGD) individuals. We used data from the baseline visit of a national study of Black and Hispanic/Latino SMMGD. Among participants reporting any lifetime cannabis use, we further assessed the association between frequency of cannabis use in the past 3 months and: (1) self-reported PrEP use, (2) recency of last PrEP dose, and (3) HIV status using adjusted regression models. Compared to those who never used cannabis, odds of PrEP cessation were higher among those who used it once or twice (aOR 3.27; 95% CI 1.38, 7.78), those who used it monthly (aOR 3.41; 95% CI 1.06, 11.01), and those who used it weekly or more frequently (aOR 2.34; 95% CI 1.06, 5.16). Similarly, those reporting cannabis use 1-2 times in the past 3 months (aOR 0.11; 95% CI 0.02, 0.58) and those reporting weekly or more frequent use (aOR 0.14; 95% CI 0.03, 0.68) were each more likely to report more recent PrEP cessation. These results suggest that cannabis users in general may be a population at elevated risk of HIV diagnosis although more research regarding these findings is needed with nationally representative populations.

Understanding Cannabis-Related Information Needs: An Analysis of Inquiries to the National Cancer Institute's Cancer Information Service

Purpose: Given increased cannabis use for medical and nonmedical purposes alike, there is growing public interest related to the potential risks and benefits of cannabis use, particularly related to cancer. The purpose of this descriptive study was to analyze cannabis inquiries to the National Cancer Institute's Cancer Information Service (CIS). Materials and Methods: From September 2018 to June 2023, 190,070 noncannabis and 425 cannabis inquiries were documented by the CIS. Cannabis inquiries were delineated into two categories: nonmedical cannabis (NMC, n=240) or medical cannabis (MC, n=185). Chi-square tests were performed to determine differences between noncannabis and cannabis inquiries and descriptive analyses were used to identify patterns within cannabis-specific inquiries. Results: Statistically significant differences between noncannabis and cannabis inquiries were observed. In addition, there were variations in MC and NMC inquiries. For example, 73% of MC inquiries originated from cancer survivors and caregivers, whereas almost half of NMC inquiries (48%) were from individuals identifying as tobacco users. MC and NMC inquiries also differed by CIS access channel (e.g., instant chat, telephone), language used (English vs. Spanish), discussions of cancer continuum phases and cancer sites, and referrals provided to individuals for additional information and resources. Conclusion: Cannabis-related information needs of the public-as documented by the CIS-varied by several factors. Health information sources such as the CIS can help address cannabis-related questions and concerns, while noting differences in who is inquiring, how, and why.

Cannabis use and sleep disturbances among White, Black, and Latino adults in the United States: A cross-sectional study of National Comorbidity Survey-Replication (2001-2003) data

OBJECTIVE

Research investigating cannabis use and sleep health is limited, and results are mixed. Few studies were nationally representative with racially-ethnically diverse samples or assessed potential modifiers. Our objective was to investigate cross-sectional associations between reported cannabis use and sleep disturbances by potential modifiers among non-Hispanic White, non-Hispanic Black, and Hispanic/Latino men and women in the United States.

METHODS

We used nationally representative National Comorbidity Survey-Replication data collected from 2001 to 2003 among 3929 adults. Poisson regression with robust variance estimated prevalence ratios (PR) and 95% confidence intervals of patterns of sleep disturbances identified through latent class analysis. Models adjusted for sociodemographic, health behavior, and clinical characteristics were stratified by race-ethnicity and by race-ethnicity along with sex/gender, and age, separately.

RESULTS

Over half of adults reported cannabis use (52%-ever/lifetime vs 48%-never). We identified two latent classes: multiple sleep disturbances with daytime sleepiness and no sleep disturbances with some daytime sleepiness. Prevalence of multiple sleep disturbances with daytime sleepiness was higher among participants reporting lifetime cannabis use (23% vs 20%). Associations did not vary by race-ethnicity or sex/gender. Lifetime vs never cannabis use was marginally associated with a higher prevalence of multiple sleep disturbances with daytime sleepiness only among adults aged 25-29years (PR=1.09 [95% confidence interval: 1.00-1.18]; eg, PRage 40+ years=1.00 [0.97-1.03], pinteraction=0.03).

CONCLUSIONS

Associations between cannabis use and sleep may vary by age. Replication with more recent data and prospective studies that investigate intersectional identities among diverse populations with objective assessments are warranted.

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use

INTRODUCTION

Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use.

METHODS

This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022.

RESULTS

Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7).

CONCLUSIONS

Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

Extending Gender- and Sex-Based Analyses in Cannabis Research: Findings from an Online Sample of Gender Diverse Young Adult Consumers

Background: Gender and sex can influence cannabis behaviors and consequences (Cannabis Use Disorder [CUD]). Research typically examines sex and gender independently. Gender analyses often exclude transgender and gender diverse (TGD) populations. The objectives of this study were to (a) replicate less frequent cannabis use among TGD young adults compared to cisgender counterparts (b) compare severity of CUD, and (c) examine the role of sex on cannabis outcomes. Method: Online survey participants between 18 and 34 (N=1213) from the United States who reported past-week cannabis consumption provided information on cannabis practices and CUD from February to April 2022. Bivariate analyses explored gender differences across frequency (daily frequency across routes of administration [ROAs]; daily use of 2+ ROAs, use throughout the day) and CUD. Adjusted regression models provided model-estimated marginal probabilities and means to examine differences across four gender-by-sex categories (cisgender men: n=385; cisgender women: n=681; male-at-birth TGD: n=26; female-at-birth TGD: n=121). Benjamini-Hochberg adjustments (10% false discovery rate) were applied. Results: Among past-week consumers, female-at-birth TGD participants demonstrated lower probability of daily flower smoking compared to cisgender men (0.54 vs. 0.67). Cisgender men reported greater probability of daily concentrate vaping (0.55) compared to cisgender women (0.45) and female-at-birth TGD participants (0.27); they were also more likely to report daily use of 2+ ROAs (cisgender men: 0.51 vs. cisgender women: 0.39 and female at-birth TGD: 0.27). TGD participants reported greater CUD severity compared to cisgender counterparts, t(1096)=-3.69, p=0.002. Model-estimated means found lower severity among cisgender women compared to cisgender men and female-at-birth TGD participants. Stratified regression models support positive associations between daily cannabis use and CUD in both TGD in cisgender groups. Among cisgender participants, greater severity was predicted by male sex, younger age, and younger age of onset. Conclusions: The present study replicates and extends a prior finding that among past-week cannabis consumers, TGD young adults report less frequent use than cisgender counterparts. Despite this, TGD participants demonstrated greater severity of CUD. While analyses were limited by the small sample of male-at-birth TGD participants, the article highlights the importance of expanding sex- and gender-focused analyses. Future work is expanding efforts to target hard-to-reach consumers.

Cannabis use among cancer survivors in 22 states: Results from the Behavioral Risk Factor Surveillance System, 2020

BACKGROUND

This study identified factors associated with recent cannabis use and cannabis use for medical purposes among cancer survivors relative to individuals without a history of cancer.

METHODS

Data from the Behavioral Risk Factor Surveillance System were analyzed for the 22 states completing the optional cannabis module in 2020. Weighted multiple logistic regression was performed to explore variables associated with past 30-day cannabis use and cannabis use for medical purposes, stratified by history of cancer. Covariates included state-level cannabis policy, sociodemographic characteristics, health status indicators, and substance use.

RESULTS

Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (7.57% vs. 10.83%). However, a higher proportion of cancer survivors reported use for medical purposes (82.23% vs. 62.58%). After adjusting for state-level policy, biological sex, age, educational attainment, self-reported race/ethnicity, home ownership, mental health status and physical health status, current smoking (odds ratio [OR], 5.14 vs. 3.74) and binge drinking (OR, 2.71 vs. 2.69) were associated with cannabis use in both groups. Characteristics associated with medical cannabis use varied for the two groups; however, daily use (20-30 days; OR, 1.72 vs. 2.43) was associated with cannabis use for medical purposes in both groups after adjusting for other variables in the model.

CONCLUSIONS

A high proportion of individuals report cannabis use for medical purposes with higher rates among cancer survivors. Findings support the urgent need for ongoing cannabis research to better understand and inform its use for medical purposes, as well as the development of high-quality standardized education materials and clinical practice guidelines.

Disparities in cannabis use and documentation in electronic health records among children and young adults

The legalizations of medical and recreational cannabis have generated a great deal of interest in studying the health impacts of cannabis products. Despite increases in cannabis use, its documentation during clinical visits is not yet mainstream. This lack of information hampers efforts to study cannabis's effects on health outcomes. A clear and in-depth understanding of current trends in cannabis use documentation is necessary to develop proper guidelines to screen and document cannabis use. Here we have developed and used a natural language processing pipeline to evaluate the trends and disparities in cannabis documentation. The pipeline includes a screening step to identify clinical notes with cannabis use documentation which is then fed into a BERT-based classifier to confirm positive use. This pipeline is applied to more than 23 million notes from a large cohort of 370,087 patients seen in a high-volume multi-site pediatric and young adult clinic over a period of 21 years. Our findings show a very low but growing rate of cannabis use documentation (<2%) in electronic health records with significant demographic and socioeconomic disparities in both documentation and positive use, which requires further attention.

Blood and Urinary Metal Levels among Exclusive Marijuana Users in NHANES (2005-2018)

BACKGROUND

Marijuana is the third most used drug in the world.

OBJECTIVES

Because the cannabis plant is a known scavenger of metals, we hypothesized that individuals who use marijuana will have higher metal biomarker levels compared with those who do not use.

METHODS

We combined data from the National Health and Nutrition Examination Survey (2005-2018) for n = 7,254 participants, classified by use: non-marijuana/non-tobacco, exclusive marijuana, exclusive tobacco, and dual marijuana and tobacco use. Five metals were measured in blood and 16 in urine using inductively coupled plasma mass spectrometry; urinary metals were adjusted for urinary creatinine.

RESULTS

Participants reporting exclusive marijuana use compared with non-marijuana/non-tobacco use had statistically significantly higher mean cadmium levels in blood [1.22 μ g / L (95% CI: 1.11, 1.34); p < 0.001 ] and urine [1.18 μ g / g (95% CI: 1.0, 1.31); p = 0.004 ] and statistically significantly higher mean lead levels in blood [1.27 μ g / dL (95% CI: 1.07, 1.50); p = 0.006 ] and urine [1.21 μ g / g (95% CI: - 0.006 , 1.50); p = 0.058 ].

DISCUSSION

Our results suggest marijuana is a source of cadmium and lead exposure. Research regarding cannabis use and cannabis contaminants, particularly metals, should be conducted to address public health concerns related to the growing number of cannabis users. https://doi.org/10.1289/EHP12074.

Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals

OBJECTIVE

To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement.

METHODS

Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression.

RESULTS

Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement.

CONCLUSIONS

Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.

Recreational cannabis legislation and binge drinking in U.S. adolescents and adults

BACKGROUND

Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.).

METHODS

We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies.

RESULTS

Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30.

CONCLUSIONS

Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019

Background

The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain.

Methods

Patients with ≥1 primary care, emergency, or mental health visit to the VHA and no hospice/palliative care within a given calendar year, 2005-2019 (yearly n=3,234,382 to 4,579,994) were analyzed using VHA electronic health record (EHR) data. To estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed CUD and whether this differed between patients with and without chronic pain, staggered-adoption difference-in-difference analyses were used, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, a chronic pain indicator, and patient covariates (age group [18-34, 35-64; 65-75], sex, and race and ethnicity). Pain was categorized using an American Pain Society taxonomy of painful medical conditions.

Outcomes

In patients with chronic pain, enacting MCL led to a 0·14% (95% CI=0·12%-0·15%) absolute increase in CUD prevalence, with 8·4% of the total increase in CUD prevalence in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·19% (95%CI: 0·16%, 0·22%) absolute increase in CUD prevalence, with 11·5% of the total increase in CUD prevalence in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in CUD prevalence (MCL: 0·037% [95%CI: 0·03, 0·05]; RCL: 0·042% [95%CI: 0·02, 0·06]), with 5·7% and 6·0% of the increases in CUD prevalence attributable to MCL and RCL. Overall, MCL and RCL effects were significantly greater in patients with than without chronic pain. By age, MCL and RCL effects were negligible in patients age 18-34 with and without pain. In patients age 35-64 with and without pain, MCL and RCL effects were significant (p<0.001) but small. In patients age 65-75 with pain, absolute increases were 0·10% in MCL-only states and 0·22% in MCL/RCL states, with 9·3% of the increase in CUD prevalence in MCL-only states attributable to MCL, and 19.4% of the increase in RCL states attributable to RCL. In patients age 35-64 and 65-75, MCL and RCL effects were significantly greater in patients with pain.

Interpretation

In patients age 35-75, the role of MCL and RCL in the increasing prevalence of CUD was greater in patients with chronic pain than in those without chronic pain, with particularly pronounced effects in patients with chronic pain age 65-75. Although the VHA offers extensive behavioral and non-opioid pharmaceutical treatments for pain, cannabis may seem a more appealing option given media enthusiasm about cannabis, cannabis commercialization activities, and widespread public beliefs about cannabis efficacy. Cannabis does not have the risk/mortality profile of opioids, but CUD is a clinical condition with considerable impairment and comorbidity. Because cannabis legalization in the U.S. is likely to further increase, increasing CUD prevalence among patients with chronic pain following state legalization is a public health concern. The risk of chronic pain increases as individuals age, and the average age of VHA patients and the U.S. general population is increasing. Therefore, clinical monitoring of cannabis use and discussion of the risk of CUD among patients with chronic pain is warranted, especially among older patients.

Research in Context

Evidence before this study: Only three studies have examined the role of state medical cannabis laws (MCL) and/or recreational cannabis laws (RCL) in the increasing prevalence of cannabis use disorder (CUD) in U.S. adults, finding significant MCL and RCL effects but with modest effect sizes. Effects of MCL and RCL may vary across important subgroups of the population, including individuals with chronic pain. PubMed was searched by DH for publications on U.S. time trends in cannabis legalization, cannabis use disorders (CUD) and pain from database inception until March 15, 2023, without language restrictions. The following search terms were used: (medical cannabis laws) AND (pain) AND (cannabis use disorder); (recreational cannabis laws) AND (pain) AND (cannabis use disorder); (cannabis laws) AND (pain) AND (cannabis use disorder). Only one study was found that had CUD as an outcome, and this study used cross-sectional data from a single year, which cannot be used to determine trends over time. Therefore, evidence has been lacking on whether the role of state medical and recreational cannabis legalization in the increasing US adult prevalence of CUD differed by chronic pain status.Added value of this study: To our knowledge, this is the first study to examine whether the effects of state MCL and RCL on the nationally increasing U.S. rates of adult cannabis use disorder differ by whether individuals experience chronic pain or not. Using electronic medical record data from patients in the Veterans Health Administration (VHA) that included extensive information on medical conditions associated with chronic pain, the study showed that the effects of MCL and RCL on the prevalence of CUD were stronger among individuals with chronic pain age 35-64 and 65-75, an effect that was particularly pronounced in older patients ages 65-75.Implications of all the available evidence: MCL and RCL are likely to influence the prevalence of CUD through commercialization that increases availability and portrays cannabis use as 'normal' and safe, thereby decreasing perception of cannabis risk. In patients with pain, the overall U.S. decline in prescribed opioids may also have contributed to MCL and RCL effects, leading to substitution of cannabis use that expanded the pool of individuals vulnerable to CUD. The VHA offers extensive non-opioid pain programs. However, positive media reports on cannabis, positive online "information" that can sometimes be misleading, and increasing popular beliefs that cannabis is a useful prevention and treatment agent may make cannabis seem preferable to the evidence-based treatments that the VHA offers, and also as an easily accessible option among those not connected to a healthcare system, who may face more barriers than VHA patients in accessing non-opioid pain management. When developing cannabis legislation, unintended consequences should be considered, including increased risk of CUD in large vulnerable subgroups of the population.

Cannabis Recreational Legalization and Prevalence of Simultaneous Cannabis and Alcohol Use in the United States

BACKGROUND

Simultaneous cannabis/alcohol use, using both substances within a short time interval so that their effects overlap, has a greater risk of potential negative consequences than single-substance use and is more common in younger age. Relationships between recreational cannabis laws (RCLs) and changes in simultaneous cannabis/alcohol use prevalence remain untested.

OBJECTIVE

To examine trends in simultaneous cannabis/alcohol use from 2008 to 2019, and investigate associations between implementation of RCLs (i.e., presence of active legal dispensaries or legal home cultivation) and simultaneous cannabis/alcohol use in the United States (U.S.).

DESIGN

Repeated cross-sectional samples from the 2008-2019 U.S. National Survey on Drug Use and Health (NSDUH).

PARTICIPANTS

Respondents (51% female) aged 12 and older.

INTERVENTIONS

Changes in simultaneous cannabis/alcohol use before and after RCL implementation (controlling for medical cannabis law implementation) were compared in different age groups (12-20, 21-30, 31-40, 41-50, 51+), using adjusted multi-level logistic regression with state random intercepts and an RCL/age group interaction.

MEASUREMENTS

Self-reported simultaneous cannabis/alcohol use.

RESULTS

From 2008 to 2019, the overall prevalence of simultaneous cannabis/alcohol use declined among those aged 12-20 but increased in adults aged 21+. Model-based simultaneous cannabis/alcohol use prevalence increased after RCL implementation among respondents aged 21-30 years (+1.2%; aOR= 1.15 [95%CI = 1.04-1.27]), 31-40 years (+1.0; 1.15 [1.04-1.27]), and 41-50 years (+1.75; 1.63 [1.34-1.98]), but not in individuals aged <21 or 51+ years.

CONCLUSIONS

Implementation of recreational cannabis policies resulted in increased simultaneous use of cannabis and alcohol, supporting the complementarity hypothesis, but only among adults aged 21+. Efforts to minimize harms related to simultaneous cannabis/alcohol use are critical, especially in states with RCLs. Future studies should investigate cultural norms, perceived harm, and motives related to simultaneous use.

Adult use of highly-potent Δ9-THC cannabis concentrate products by U.S. state cannabis legalization status, 2021

BACKGROUND

Compared to plant/flower cannabis products, cannabis concentrates have higher average potency of delta-9-tetrahydrocannabinol (Δ9-THC), which may be associated with greater likelihood of cannabis-related harms. Information on factors associated with use of cannabis concentrates is needed.

METHODS

Respondents were 4,328 adult past-7-day cannabis users from all 50 U.S. states and Washington DC (DC) who participated in an online 2021 survey. Using logistic regression to generate adjusted odds ratios (aOR), we investigated whether participants in states that enacted recreational cannabis laws (RCL, 12 states plus DC [treated as a state], n = 1,236) or medical cannabis laws (MCL-only, 23 states, n = 2,030) by December 31, 2020 were more likely than those in states without cannabis laws (no-CL, 15 states, n = 1,062) to use cannabis concentrate products in the prior 7 days.

RESULTS

Most participants (92.4%) used plant material in the prior 7 days; 57.0% used cannabis concentrates. In RCL, MCL and no-CL states, concentrate use was reported by 61.5%, 56.6%, and 52.5%, respectively. Compared to participants in no-CL states, odds of using cannabis concentrate products were greater among those in RCL states (aOR = 1.47; CI = 1.17-1.84) and MCL-only states (aOR = 1.29; CI = 1.08-1.55). Whether states had legally-authorized dispensaries had little effect on results.

CONCLUSION

Results suggest that individuals in MCL-only and RCL states are more likely to use cannabis concentrate products. Determining mechanisms underlying these results, e.g., commercialization, could provide important information for prevention. Clinicians should be alert to patient use of concentrates, especially in MCL-only and RCL states. Continued monitoring is warranted as additional states legalize cannabis use.

Genetic influences on the interplay between obsessive-compulsive behavior symptoms and cannabis use during adolescence

INTRODUCTION

There are overlapping biological origins and behaviors associated with obsessive-compulsive symptoms (OCS) and cannabis use. There is also evidence that OCS and cannabis use are associated over time. Thus, we investigated polygenic predisposition for OCS as predictive of OCS and cannabis use from age 17 to 19. We hypothesized that greater genetic risk for OCS would predict both OCS and cannabis use.

METHODS

The current study used participants from the Project Alliance 1 study, a US-based sample, for whom genomic, OCS, and cannabis use data were available (n = 547). Polygenic risk scores (PRS) were formed via a meta-genome-wide association study on OCS and examined as a predictor of OCS and cannabis use at age 17 and 19. The sample was diverse (52.4% male; 45% European American, 30% African American, 14% multiracial, 5% Hispanic/Latino, 4% Asian American, and 2% other groups). Sensitivity analysis was performed by gender for European American and African American subsamples.

RESULTS

Across the whole sample, the greater polygenic risk for OCS was negatively associated with cannabis use at age 17 and positively associated with OCS at 19. Cannabis use at age 17 was positively associated with OCS at age 19. The association between polygenic risk for OCS and cannabis use at age 17 was replicated in European American males, whereas the association between cannabis use at age 17 and OCS at age 19 was replicated in African American males.

CONCLUSIONS

Cannabis use may exacerbate OCS through adolescence, and genetic predisposition for OCS may be associated with lower cannabis use in efforts to avoid exacerbation of OCS.

Revisiting the effect of recreational marijuana on traffic fatalities

BACKGROUND

This study examines the effect of retail recreational marijuana legalization on traffic fatalities using the most current data available and recent advancements in difference-in-difference estimation methods proposed by Callaway and Sant'Anna, (2021).

METHOD

A modified difference-in-difference (CS-DID) is used to estimate the effect of recreational marijuana legalization on traffic fatalities reported in the Fatality Analysis Reporting System (FARS). Difference-in-difference regression models are run at the state-year level, using data from 2007 through 2020, and compared to estimates using traditional two-way-fixed-effects (TWFE) models.

RESULTS

Consistent with past studies, results from conventional TWFE suggest traffic fatalities increase at a rate of 1.2 per billion vehicle miles traveled (BVMT) after retail of recreational marijuana begins. However, using the CS-DID model, we find slightly larger average total treatment effects (∼2.2 fatalities per BVMT). Moreover, the size of the effect changes across time, where cohorts "treated" earlier have substantially higher increases than those who more recently legalized.

CONCLUSION

Traffic fatalities increase by 2.2 per billion miles driven after retail legalization, which may account for as many as 1400 traffic fatalities annually. States who legalized earlier experienced larger traffic fatality increases. TWFE methods are inadequate for policy evaluation and do not capture heterogeneous effects across time.

Alcohol use in the older adult US population: Trends, causes, and consequences

Alcohol use, binge drinking, and alcohol use disorders have been increasing among older adults in the US population, including adults over 50 as well as adults over 65. Increases in consumption are sharper among women, and among those who use additional substances such as cannabis, and those who are relatively healthy in older adulthood (i.e. those without multimorbidites). This commentary describes these trends as well as provides hypotheses, and the data underlying them, for both supply-side (alcohol marketing and messaging) and demand-side (healthier aging, increased financial stress) potential drivers of these increases. The need for additional resources and focus on older adult drinking is increasingly urgent, as alcohol-attributable deaths escalate among older adults in the United States.

Long-Term Impact of Medical Marijuana Laws on the Burden of Cannabis Use Disorders in US Male and Female Adolescents and Young Adults

Deregulation of cannabis use has raised concerns regarding its potential effects on health, particularly in adolescents and young adults. Here, we extracted data from the Global Burden of Disease database to estimate the long-term effect (> 5 years) of medical marijuana laws (MML) on 2019 cannabis use disorders Disability Adjusted Life Years (2019 CUD DALYs) in US male and female adolescents (15-19 years old) and young adults (20-24 years old). Socio-cultural, demographic and economic characteristics were used as baseline covariates. To improve the robustness of estimation, we took advantage of machine learning techniques. We found no significant effect of MML on 2019 CUD DALYS in each of our four age/sex groups. Estimates from a marginal structural model taking into account age and sex strata in the same model were also non-significant. Our findings suggest that MML may have a negligible effect (if any) on cannabis use disorders in this population group.

Recurrent Severe Burns Due to Cannabinoid Hyperemesis Syndrome

Cannabinoid hyperemesis syndrome (CHS) is one of the health outcomes of cannabis use that is showing an increase in the number of reported cases since it first emerged in the medical literature. It is a condition that is now frequently seen by many specialists, including consultation-liaison psychiatrists. CHS is a diagnosis of exclusion that is characterized by the presence of a prolonged history of daily cannabis use, cyclic episodes of nausea and vomiting, and frequent compulsive hot baths. It will be fairly argued that with the surge in the number of marijuana users and frequency of use since the legalization of marijuana in the United States, a proportionate rise in CHS cases is expected over time. In this case report, we present a unique case of a 36-year-old female diagnosed with CHS, and the compensatory behavior of compulsive hot baths led to repeated episodes of severe burns, sepsis, and intensive care unit (ICU) hospitalizations. To the authors' knowledge, this is the first published case of severe burns and sepsis as complications of cannabinoid hyperemesis syndrome.

Content Analysis of the Corporate Social Responsibility Practices of 9 Major Cannabis Companies in Canada and the US

IMPORTANCE

The cannabis industry has sought to normalize itself and expand its markets in the 21st century. One strategy used by companies to generate positive public relations is corporate social responsibility (CSR). It is critical to understand these efforts to influence the public and politicians given the risks of increased cannabis use.

OBJECTIVES

To analyze cannabis industry CSR behaviors, determine their characteristics, and compare their practices with those of the tobacco industry.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study of CSR activities conducted between January 1, 2012, and December 31, 2021, evaluated 9 of the 10 largest publicly traded cannabis companies in the US and Canada. Data were collected from August 1 to December 31, 2021. The 10th company was excluded because it engaged in cannabis-based pharmaceutical sales but not CSR. A systematic review of corporate websites and Nexis Uni was performed, resulting in collection of 153 news articles, press releases, and Web pages. Charitable and philanthropic actions were included. Themes were identified and interpreted using modified grounded theory.

MAIN OUTCOMES AND MEASURES

CSR activities and spending.

RESULTS

Nine major cannabis companies in the US and Canada engaged in CSR activities that encouraged increased consumption and targeted marginalized communities. Companies claimed these activities would mitigate the harms of cannabis prohibition, promote diversity, expand access to medical cannabis, and support charitable causes. They developed educational programs, sustainability initiatives, and voluntary marketing codes and used strategies similar to those used by tobacco companies to recruit public interest organizations as allies.

CONCLUSIONS AND RELEVANCE

These findings suggest that cannabis companies developed CSR strategies comparable to those used by the tobacco industry to influence regulation, suggesting that cannabis companies should be included when addressing commercial determinants of health.

Daily cannabis use, cannabis use disorder, and any medical cannabis use among US adults: Associations within racial, ethnic, and sexual minoritized identities in a changing policy context

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Daily cannabis use, disorder, and medical use were higher among sexual minoritized adults.

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Magnitudes of association were comparable across racial and ethnic subgroups.

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Associations with cross-sectional MCL status differed by racial, ethnic, and sexual minoritized subgroup.

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Cannabis outcome prevalences were generally higher in states with MCLs.

Differences in cannabis use patterns among racial, ethnic and sexual minoritized identity subgroups have been attributed to marginalized identity stressors. However, associations at the intersection of these minoritized identities remain underexplored in a changing medical cannabis law (MCL) context. We estimated medical cannabis and daily cannabis use, and cannabis use disorder (CUD) by intersecting racial, ethnic and sexual minoritized identity subgroups. We included 189,800 adults in the 2015–2019 National Survey on Drug Use and Health identifying as non-Hispanic white, non-Hispanic Black, or Hispanic and self-reported heterosexual, gay/lesbian, or bisexual sexual identity. We estimated the adjusted odds of past-year: (a) any medical cannabis, (b) daily cannabis use (i.e., 300 + days/year), and (c) DSM-5-proxy CUD by sexual identity, stratified by race and ethnicity. Cannabis measures were higher among sexual minoritized groups than heterosexual adults across racial and ethnic subgroups. Bisexual adults had higher odds of any medical cannabis use than their heterosexual counterparts: non-Hispanic white (6.4% vs. 1.8%; aOR = 2.6, 95% CI = [2.5–3.5]), non-Hispanic Black (4.1% vs. 1.7%; aOR = 2.7, 95% CI = [1.6–4.5]), and Hispanic adults (5.3% vs. 1.8 %; aOR = 2.6, 95% CI = [1.9–3.3]). We found heterogeneous associations with state MCL status across subgroups stratified by race and ethnicity. Bisexual adults in MCL states had higher odds of any medical cannabis use among non-Hispanic white (aOR = 2.0, 95% CI = [1.4–2.9]) and Hispanic (aOR = 3.6, 95% CI = [1.2–10.2]) adults compared to their non-MCL counterparts, but this was marginal among non-Hispanic Black bisexual adults (aOR = 1.6, 95% CI = [1.0–2.6]). Studies should assess intended and unintended cannabis policy effects among racial, ethnic, and sexual identity subgroups.

Estimating the effects of legalizing recreational cannabis on newly incident cannabis use

Liberalized state-level recreational cannabis policies in the United States (US) fostered important policy evaluations with a focus on epidemiological parameters such as proportions [e.g., active cannabis use prevalence; cannabis use disorder (CUD) prevalence]. This cannabis policy evaluation project adds novel evidence on a neglected parameter–namely, estimated occurrence of newly incident cannabis use for underage (<21 years) versus older adults. The project’s study populations were specified to yield nationally representative estimates for all 51 major US jurisdictions, with probability sample totals of 819,543 non-institutionalized US civilian residents between 2008 and 2019. Standardized items to measure cannabis onsets are from audio computer-assisted self-interviews. Policy effect estimates are from event study difference-in-difference (DiD) models that allow for causal inference when policy implementation is staggered. The evidence indicates no policy-associated changes in the occurrence of newly incident cannabis onsets for underage persons, but an increased occurrence of newly onset cannabis use among older adults (i.e., >21 years). We offer a tentative conclusion of public health importance: Legalized cannabis retail sales might be followed by the increased occurrence of cannabis onsets for older adults, but not for underage persons who cannot buy cannabis products in a retail outlet. Cannabis policy research does not yet qualify as a mature science. We argue that modeling newly incident cannabis use might be more informative than the modeling of prevalences when evaluating policy effects and provide evidence of the advantages of the event study model over regression methods that seek to adjust for confounding factors.

Factors that shape pregnant women's perceptions regarding the safety of cannabis use during pregnancy

Background

Cannabis use among pregnant women has increased. We surveyed pregnant women in rural Pennsylvania to examine cannabis use and opinions regarding its safety during pregnancy. We examined associations between challenges of pregnancy (e.g., exhaustion, pain, nausea) and cannabis use.

Methods

A cross-sectional survey was administered to a convenience sample of English-speaking pregnant women receiving prenatal care at Geisinger, May–June 2019. Principal component analysis (PCA) was used to construct three scores (overwhelmed/exhausted, happy/optimistic, and health worries) based on 10 questions regarding common experiences during pregnancy (e.g., nausea/vomiting, pain, exhaustion, mood). A score based on four questions regarding cannabis safety during pregnancy was also constructed.

Results

From a maximum of 300 surveys distributed, 284 were completed (95%). Most participants were white (87%), married (49%) or living with a partner (38%), and had private health insurance (62%). Most women indicated it was unsafe to use alcohol and tobacco products during pregnancy (> 90%), but that proportion dropped to 82% and 63% regarding recreational cannabis and medical cannabis, respectively. Only women with prior cannabis use (23% of sample) continued to do so during pregnancy: 57% of women reporting daily cannabis use prior to pregnancy continued to use cannabis during pregnancy with 33% reporting daily use. Two thirds of users during pregnancy indicated they were self-medicating for: nausea (90%), anxiety (70%), insomnia (30%), and pain management (30%). Many (56%) of the women who used cannabis during pregnancy believed it is safe. Younger women and women who were overwhelmed/exhausted or less happy/optimistic were more likely to believe cannabis use is safe. Women valued healthcare provider advice more than advice from family and friends. Study strengths include a high response rate. Weaknesses include self-report and that is was a convenience sample; however, the demographics of the sample were similar to past studies.

Conclusion

Women with a history of cannabis use, especially daily use, are at risk of continuing during pregnancy and should receive counseling. Younger women and women with greater stressors during pregnancy also are at greater risk. Screening for prior use and for stressors may identify patients that would benefit from enhanced counseling.