The natural history of substance use as a guide to setting drug policy

Cannabis Use in Adolescence and Young Adulthood: A Review of Findings from the Victorian Adolescent Health Cohort Study

The Victorian Adolescent Health Cohort Study (VAHCS) is a long-term Australian cohort study that has documented cannabis use in young Australians from the mid-teens to the mid-30s. The study findings have described the natural history of early cannabis use, remission, and escalation and the social and mental health consequences of different patterns of use. The adverse consequences of cannabis use are most clear-cut in heavy early adolescent users. These consequences include educational failure, persisting mental health problems, and progression to other substance use. For later onset and occasional users, the risks are lower and appear to entail modest elevations in risk for other drug use compared with never users. With growing evidence of health consequences, there is a strong case for actions around early heavy adolescent users. Prevention of early use, identification and treatment of early heavy users, and harm reduction through diversion of early heavy users away from the custodial justice system into health care are all priority responses.

Transitions to regular smoking and to nicotine dependence in women using cannabis

BACKGROUND

While there is substantial support in the literature for an increased prevalence of cannabis use in cigarette smokers, emerging studies allude to the possibility that cannabis users may, in turn, be at significantly elevated risk for rapid transitions in their cigarette smoking trajectories. If there is evidence in its favor, the increased rates of cigarette smoking in cannabis users may prove to be the most significant public health problem associated with cannabis use.

METHODS

In a sample of 3787 female twins (age range 18-29 years), we examined, using discrete-time survival analyses, whether women who reported cannabis use were at increased risk for regular cigarette smoking and progression to nicotine dependence.

RESULTS

After controlling for a large number of potential covariates, we found that women who used cannabis were at 4.4 and 2.8 increased hazards for transitioning from initiation to regular smoking and from regular smoking to nicotine dependence, respectively.

CONCLUSIONS

Cannabis use is associated with transitions to more involved stages of cigarette smoking in women. This is a source of public health concern, first due to the high mortality associated with cigarette smoking and second, due to the high prevalence of cannabis use in the general population.

Trajectories of adolescent alcohol and cannabis use into young adulthood

BACKGROUND

Both alcohol and cannabis use carry health risks. Both are commonly initiated in adolescence. To date little research has described trajectories of adolescent cannabis or alcohol use or compared their respective consequences in young adulthood.

METHODS

The design was a 10-year eight-wave cohort study of a state-wide community sample of 1943 Victorians initially aged 14-15 years. Moderate- and high-risk alcohol use was defined according to total weekly alcohol consumption. Moderate- and high-risk cannabis use were defined as weekly and daily use, respectively.

RESULTS

Around 90% of young adults used either alcohol or cannabis. Although an association existed between alcohol and cannabis use, there was a tendency for heavy users to use one substance predominantly at any one time. Weekly or more frequent cannabis use in the absence of moderate-risk alcohol use in teenagers predicted a sevenfold higher rate of daily cannabis use in young adults but only a twofold increase in high-risk alcohol use. Conversely, moderate-risk adolescent alcohol use in the absence of weekly cannabis predicted an approximately threefold increased rate of both high-risk drinking and daily cannabis use in young adulthood. Selective heavy cannabis use in both adolescence and young adulthood was associated with greater illicit substance use and poorer social outcomes in young adulthood than selective alcohol use.

CONCLUSIONS

Heavier teenage cannabis users tend to continue selectively with cannabis use. Considering their poor young adult outcomes, regular adolescent cannabis users appear to be on a problematic trajectory.

Duration of cannabis use--a novel phenotype?

Although cannabis is the most commonly used illicit drug, duration of cannabis use is typically short, with many of those who initiate cannabis use ceasing use by their late twenties. In this paper we analyze data from a volunteer Australian cohort of 6265 male and female twins to examine whether the duration of cannabis use is an informative phenotype for future genetic analyses. Genetic modeling indicated: (a) moderate genetic influences on duration of cannabis use in both males (41%; 95% CI=31-51) and females (55%; 95% CI=46-63); (b) strong genetic influences on cannabis dependence in both males (72%, 95% CI=61-81) and females (62%, 95% CI=48-74); (c) no evidence of shared environmental influences on duration of cannabis use or on cannabis dependence in either males or females. Importantly, this model fitting indicated that a substantial component of genetic influences (rg=.90, 95% CI=.77-.99 (males); .70, 95% CI=.57-.83 (females)) on duration of cannabis use was shared with those influencing liability to cannabis dependence. While there were high genetic correlations in both women and men, lifetime duration of cannabis may be uniquely informative in assessing components of liability to cannabis use.

Reverse gateways? Frequent cannabis use as a predictor of tobacco initiation and nicotine dependence

AIMS

To examine the risk posed by cannabis use in young people for tobacco use disorders. Specifically we examined whether cannabis use in non-smokers predicted later initiation of tobacco use and whether cannabis use predicted later nicotine dependence in tobacco users.

DESIGN

A 10-year eight-wave cohort study.

SETTING

State of Victoria, Australia.

PARTICIPANTS

A community sample of 1943 participants initially aged 14-15 years.

MEASUREMENTS

Self-report of tobacco and cannabis use was assessed in the teens using a computerized interview assessment and in young adulthood with a CATI assessment. The Fagerström Test for Nicotine Dependence was used to define nicotine dependence.

FINDINGS

For teen non-smokers, at least one report of weekly cannabis use in the teens predicted a more than eightfold increase in the odds of later initiation of tobacco use (OR 8.3; 95% CI 1.9-36). For 21-year-old smokers, not yet nicotine-dependent, daily cannabis use raised the odds of nicotine dependence at the age of 24 years more than threefold (OR 3.6, 1.2, 10) after controlling for possible confounders, including level of tobacco use and subsyndromal signs of nicotine dependence.

CONCLUSIONS

Weekly or more cannabis use during the teens and young adulthood is associated with an increased risk of late initiation of tobacco use and progression to nicotine dependence. If this effect is causal, it may be that a heightened risk of nicotine dependence is the most important health consequence of early frequent cannabis use.

Harm reduction and decriminalization in the United States: a personal perspective

Harm reduction, an alternative to both drug legalization and drug prohibition, seeks to preserve prohibition by keeping the supply of drugs illegal while softening some of the harsh consequences of prohibition. Typical harm reduction proposals are needle exchanges for intravenous drug users to reduce the spread of HIV infection and the medical use of marijuana for a variety of illnesses including AIDS, glaucoma, multiple sclerosis, and cancer chemotherapy-induced nausea and vomiting. While attractive as a reasonable-sounding compromise, harm reduction carries a high price because it undermines the social signal of prohibition. This signal is a vital public health strategy, especially when it comes to primary prevention of use of alcohol and other drugs by youth. A personal experience with harm reduction, leading to rejection of this approach, is described. Harm reduction, enjoying a minor comeback in the United States, is a favored policy in much of Europe today. Harm reduction is not new, and it is a failure as a public health policy.