Availability of tobacco products associated with use of marijuana cigars (blunts)

Cannabis policy liberalization is only associated with increased blunt use if states lack strong tobacco control

INTRODUCTION

Co-use of tobacco and cannabis has long been an issue for prevention and intervention efforts targeting these substances. Blunt use-cannabis inside a cigar wrapper-has been a consistent mode of cannabis consumption since the 1990s. Since then, both tobacco control and cannabis policies have changed considerably. This paper examines the influence of tobacco taxes and smoke-free policies as well as medical and recreational cannabis policies on blunt use among young people.

METHODS

Combining state-level tobacco control and cannabis policy data with the restricted-access youth cohort of the Population Assessment of Tobacco and Health (PATH) study, we use multilevel logistic regression models to examine the impact of these policies on past-year blunt use.

RESULTS

While we found a main effect whereby both legal medical and recreational cannabis policies are associated with higher odds of blunt use among youth, interaction effects demonstrate that this association only emerges in states lacking a comprehensive tobacco smoke-free policy. In states with smoke-free policies, we found no significant associations between cannabis policy and odds of blunt use.

CONCLUSIONS

Denormalization through smoke-free policies may mitigate the effects of recreational and medical cannabis policies on blunt use. Smoke-free policies represent a possible cost-effective mechanism to curb the co-use of tobacco and cannabis in the form of blunts. States with medical and recreational cannabis policies may benefit from greater prevention efforts for young people specifically focused on blunt use, especially in states that do not have strong tobacco control.

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

Accuracy Differences in Cannabis Retailer Information Ascertained from Webservices and Government-Maintained State Registries Across US States Legalizing the Sale of Cannabis in 2019

Cannabis retailer locations used to investigate geographic cannabis access are frequently ascertained from two sources: 1) webservices which provide locations of cannabis retailers (e.g., Yelp) or 2) government-maintained registries. Characterizing the operating status and location information accuracy of cannabis retailer data sources on a state-by-state level can inform research examining the health implications of cannabis legalization policies. This study ascertained cannabis retailer name and location from webservices and government-maintained registries for 26 states and the District of Columbia legalizing cannabis sales in 2019. Validation subsamples were created using state-level sequential sampling. Phone surveys were conducted by trained researchers for webservice samples (n=790, November 2019 - May 2020) and government-maintained registry (n=859, February - June 2020) to ascertain information about operating status and location. Accuracy was calculated as the percent agreement among subsample and phone survey data. For operating status and location, webservice derived data was 78% (614/790) and 79% (484/611) accurate, whereas government-maintained registry derived data was 76% (657/859) and 95% (622/655) accurate, respectively. Fifty-nine percent (15/27) of states and the District of Columbia had over 80% accuracy for operating status and 48% (13/27) states had over 80% accuracy for location information with both data sources. However, government-maintained registry derived information was more accurate in 33% (9/27) states for operating status and 41% (11/27) states for location information. Both data sources had similar operating status accuracy. Research using spatial analysis may prefer government-maintained registry derived data due to high location information accuracy, whereas studies looking at broad trends across states may prefer webservice derived. State level COVID-19 restrictions had minimal impact on ascertainment of cannabis retailer operating status and location information via phone survey derived from webservices and government-maintained registries.

Objective and perceived measures of tobacco marketing are uniquely associated with cigar use

BACKGROUND

Few studies have examined associations between perceived and objective exposure to tobacco marketing and cigar use, which is the second most commonly used tobacco product by youth.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from youth aged 16-20 years (n=83 participants, n=948 observations; 34% past month users of any tobacco product) in eight city areas in California. Tobacco outlets in study cities were visited by trained observers to record outlet Global Positioning System (GPS) point locations and outdoor tobacco marketing. We assessed daily perceived exposure to tobacco marketing within participants' activity spaces; daily objective exposure to tobacco outlets with outdoor marketing within 50 m of activity space polylines (number of outlets and time spent near outlets) and daily cigar use excluding and including blunts.

RESULTS

Controlling for demographics and baseline tobacco use, results from mixed logistic regression models showed that greater perceived exposure to tobacco marketing was positively associated with higher odds of cigar use each day, excluding blunts (adjusted odds ratios (aOR): 2.00; 95% CI 1.03 to 3.87) and including blunts (aOR: 1.87; 95% CI 1.26 to 2.77). Also, exposure to a greater number of tobacco outlets with outdoor marketing was associated with higher odds of cigar use each day, excluding blunts (aOR: 1.34; 95% CI 1.01 to 1.78), but not including blunts.

CONCLUSIONS

Tobacco control efforts should consider both perceived and objective exposure to tobacco marketing and unique associations with blunt use to prevent cigar use.

Cannabis use among adolescents and emerging adults who use e-cigarettes: Findings from an online, national U.S. Sample

Concurrent use of e-cigarettes and cannabis among adolescents and emerging adults is a growing public health concern. More research is needed describing cannabis use among adolescents and emerging adults who vape. The objective of this study was to characterize cannabis use among adolescents and emerging adults (age 14-20) who reported e-cigarette ever-use, particularly their use of blunts and liquid cannabis vape (LCV) products. Using cross-sectional data from a national online survey, we describe their patterns of cannabis use, detail their use of flavored cannabis and tobacco products, and estimate associations of demographic factors and other current substance use behaviors with levels of blunt and LCV use. Of the 2253 respondents in the sample, 1379 (61 %) reported some form of cannabis use in the past 30 days, among whom 80 % used flavored cannabis (including edibles). Significant associations with current cannabis use were observed on several demographic measures, with current cannabis blunt use more frequent among participants not in school, non-Hispanic Blacks, multiracial respondents, and those whose incomes do not meet their expenses. Other than income, demographic characteristics were generally not associated with LCV use frequency. Use of other substances was associated with more frequent use of both blunts and LCV in the past 30 days, and enrollment in college or the military seems somewhat protective for emerging adults. These findings suggest a need for tailored prevention efforts among high-risk adolescents and emerging adults, potential regulation of added flavors in commercialized cannabis products, and stronger enforcement of retail restrictions for individuals under age 21 more broadly.

Using Online Crowdsourced Data to Measure the Availability of Cannabis Home Delivery: A Pilot Study

OBJECTIVE

The growing availability of cannabis products through home delivery services may affect cannabis-related health outcomes. However, research is impeded by a lack of data measuring the scale of home delivery. Prior research demonstrated that crowdsourced websites can be used to validly enumerate brick-and-mortar cannabis outlets. We piloted an extension of this method to explore the feasibility of measuring availability of cannabis home delivery.

METHOD

We tested implementation of an automated algorithm designed to webscrape data from Weedmaps, the largest crowdsourced website for cannabis retail, to count the number of legal cannabis retailers offering home delivery to the geographic centroid of each Census block group in California. We compared these estimates to the number of brick-and-mortar outlets within each block group. To assess data quality, we conducted follow-up telephone interviews with a subsample of cannabis delivery retailers.

RESULTS

We successfully implemented the webscraping. Of the 23,212 block groups assessed, 22,542 (97%) were served by at least one cannabis delivery business. Only 461 block groups (2%) contained one or more brick-and-mortar outlets. In interviews, availability varied dynamically as a function of staffing levels, order sizes, time of day, competition, and demand.

CONCLUSIONS

Webscraping crowdsourced websites could be a viable method for quantifying rapidly evolving availability of cannabis home delivery. However, key practical and conceptual challenges must be overcome to conduct a full-scale validation and develop methodological standards. Acknowledging data limitations, cannabis home delivery appears to be nearly universal in California, whereas availability of brick-and-mortar outlets is limited, underscoring the need for research on home delivery.

A Spatiotemporal Analysis of the Association of California City and County Cannabis Policies with Cannabis Outlet Densities

BACKGROUND

Cannabis outlets may affect health and health disparities. Local governments can regulate outlets, but little is known about the effectiveness of local policies in limiting outlet densities and discouraging disproportionate placement of outlets in vulnerable neighborhoods.

METHODS

For 241 localities in California, we measured seven policies pertaining to density or location of recreational cannabis outlets. We geocoded outlets using web-scraped data from the online finder Weedmaps between 2018 and 2020. We applied Bayesian spatiotemporal models to evaluate associations of local cannabis policies with Census block group-level outlet counts, accounting for confounders and spatial autocorrelation. We assessed whether associations differed by block group median income or racial-ethnic composition.

RESULTS

Seventy-six percent of localities banned recreational cannabis outlets. Bans were associated with fewer outlets, particularly in block groups with higher median income, fewer Hispanic residents, and more White and Asian residents. Outlets were disproportionately located in block groups with lower median income [posterior RR (95% credible interval): 0.76 (0.70, 0.82) per $10,000], more Hispanic residents [1.05 (1.02, 1.09) per 5%], and fewer Black residents [0.91 (0.83, 0.98) per 5%]. For the six policies in jurisdictions permitting outlets, two policies were associated with fewer outlets and two with more; two policy associations were uninformative. For these policies, we observed no consistent heterogeneity in associations by median income or racial-ethnic composition.

CONCLUSIONS

Some local cannabis policies in California are associated with lower cannabis outlet densities, but are unlikely to deter disproportionate placement of outlets in racial-ethnic minority and low-income neighborhoods.

Concentration of Cannabis and Tobacco Retailers in Los Angeles County, California: A Spatial Analysis of Potential Effects on Youth and Ethnic Minorities

OBJECTIVE

Cannabis and tobacco retailers are believed to cluster in areas with more racial/ethnic minorities, which could account for the disproportionate use of blunts in Black and Hispanic communities. The current study examined the spatial relationship between cannabis and licensed tobacco retailers in Los Angeles County, California, and assessed whether various neighborhood and business factors influenced the spatial patterning.

METHOD

Generalized additive models were used to test the association between the location of cannabis retailers (N = 429) and their accessibility potential (AP) to tobacco retailers (N = 8,033). The covariates included cannabis licensure status, median household income, population density, percentages of racial/ ethnic minorities and young adults (18-34), unemployment status, families living in poverty, minimum completion of high school/General Educational Development (GED) credential, and industrial businesses by census tract.

RESULTS

The location of cannabis retailers was significantly associated with AP in all adjusted models (p < .005). The percentage of racial/ethnic minorities, age (18-34 years), and nonlicensure of cannabis retailers, which were positively correlated with AP (p < .05), confounded the association between AP and cannabis retailer location.

CONCLUSIONS

The concentration of unlicensed cannabis retailers and tobacco retailers in young and racially/ethnically diverse neighborhoods may increase access to and use of cigarillos for blunt smoking. Jurisdictions within Los Angeles County should consider passing ordinances requiring minimum distances between cannabis and tobacco retailers.

Concentration of Cannabis and Tobacco Retailers in Los Angeles County, California: A Spatial Analysis of Potential Effects on Youth and Ethnic Minorities

OBJECTIVE

Cannabis and tobacco retailers are believed to cluster in areas with more racial/ethnic minorities, which could account for the disproportionate use of blunts in Black and Hispanic communities. The current study examined the spatial relationship between cannabis and licensed tobacco retailers in Los Angeles County, California, and assessed whether various neighborhood and business factors influenced the spatial patterning.

METHOD

Generalized additive models were used to test the association between the location of cannabis retailers (N = 429) and their accessibility potential (AP) to tobacco retailers (N = 8,033). The covariates included cannabis licensure status, median household income, population density, percentages of racial/ ethnic minorities and young adults (18-34), unemployment status, families living in poverty, minimum completion of high school/General Educational Development (GED) credential, and industrial businesses by census tract.

RESULTS

The location of cannabis retailers was significantly associated with AP in all adjusted models (p < .005). The percentage of racial/ethnic minorities, age (18-34 years), and nonlicensure of cannabis retailers, which were positively correlated with AP (p < .05), confounded the association between AP and cannabis retailer location.

CONCLUSIONS

The concentration of unlicensed cannabis retailers and tobacco retailers in young and racially/ethnically diverse neighborhoods may increase access to and use of cigarillos for blunt smoking. Jurisdictions within Los Angeles County should consider passing ordinances requiring minimum distances between cannabis and tobacco retailers.

Co-administering cannabis with tobacco and persistent tobacco smoking after 4½ years in young adults who use stimulants: A prospective population-based study

Tobacco smoking remains highly prevalent in high-risk groups, including young adults who use cannabis and a variety of other drugs. We examine whether co-administering cannabis with tobacco is associated with heavier and more persistent tobacco smoking compared to separate use of these substances among young adults who use drugs recreationally. Data are from a prospective population-based study of young adults residing in Queensland, Australia, who recurrently used ecstasy or methamphetamine. The mean age was 20.8 years at baseline, and 47% were female. An ordinal regression model was developed (n = 277) with levels of tobacco smoking at 4½ years as the outcome. At baseline, just under half the sample (44.6%) had not co-administered cannabis with tobacco in the last month, 9.5% rarely co-administered, 7.7% sometimes co-administered, and 38.2% always co-administered. Always co-administering cannabis with tobacco was associated with more frequent and persistent tobacco smoking at 4½ years (Odds Ratio (OR): 1.98, 95% Confidence Interval (CI): 1.02, 3.83), independently of factors including baseline frequency of cannabis and tobacco use. Young adults who use cannabis should be advised not to co-administrate cannabis with tobacco, and comprise an important target group for tobacco smoking cessation interventions.

Associations of mode of administration on cannabis consumption and subjective intoxication in daily life

OBJECTIVE

As cannabis products are becoming increasingly available and young adults are increasingly using vaporizers to consume cannabis, there is a need to understand how this population is using different modes of administration and the extent to which specific modes are associated with differential cannabis use outcomes. Toward this end, the current study characterized predictors of cannabis mode of administration and examined how consumption levels and subjective intoxication vary as a function of mode of administration in daily life.

METHOD

Participants were 106 young adult cannabis and heavy alcohol users (51% female) who completed up to 14 daily diaries (n = 1,405 person days). Each day, participants reported whether they used any cannabis and, if any, which mode(s) were used, number of hits used per mode, overall subjective intoxication, and the socio-environmental context in which they used cannabis.

RESULTS

Across all cannabis use days, Bong-Only and Vape-Only days were the most common, followed by Multimode, Joint-, Pipe-, and Blunt-Only days. Participants reporting a greater proportion of cannabis use days were more likely to report Bong-Only and Multimode days than Vape-Only days. Compared to Vape-Only days, participants reported fewer hits on Bong-Only days and more hits on Blunt-Only, Pipe-Only, and Multimode days. Participants felt more intoxicated on Bong-Only days than Vape-Only days.

CONCLUSIONS

Mode-specific associations with cannabis consumption and subjective intoxication levels suggest assessing modes of administration may be a meaningful way to guide individual and public health intervention efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Relationship between Cannabis and Tobacco Co-administration and Long-Term Patterns of Cannabis Use in Young Adults Who Use Stimulants: A Prospective Population-Based Study

BACKGROUND

Co-administering cannabis with tobacco (i.e. co-administration of the substances mixed together) is a common practice among cannabis users, but the consequences of this practice are not well understood. This study examines the relationship between co-administering cannabis with tobacco and the long-term frequency of cannabis use in a young adult population group with high rates of cannabis and tobacco use.

METHODS

The data are from an Australian prospective population-based study of young adults who recurrently used amphetamine-type stimulants (ATS). The mean age of participants was 20.8 years at baseline, sample size (n = 277), and 47% were female. We examined the frequency and quantity of cannabis consumption over 4 ½ years. Negative binomial regression analysis was conducted to examine the frequency of cannabis use at 12-month follow-up and at 4 ½ years, with co-administering practices as the predictor.

RESULTS

At every time interval, participants who always co-administered their cannabis with tobacco used cannabis on more days in the last month than those who only sometimes co-administered, rarely co-administered, or never co-administered these substances (p < 0.001). Sometimes co-administering cannabis with tobacco at baseline predicted more frequent cannabis use at 12-month follow-up (adjusted IRR: 2.25, 95% CI: 1.05, 4.78), independently of the baseline frequency of cannabis use. However, levels of co-administering cannabis with tobacco at 12-month follow-up (rarely, sometimes, and always) did not predict high levels of cannabis use at 4 ½ years follow-up after adjusting for cannabis use at 12-month follow-up.

CONCLUSIONS

Among people who use ATS and cannabis, frequent cannabis use may be a marker of the practice of co-administering cannabis with tobacco, and can be used to target tobacco cessation interventions in these populations.

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps

BACKGROUND

Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability.

METHODS

Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change).

RESULTS

Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction).

CONCLUSIONS

A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.

Locating Medical and Recreational Cannabis Outlets for Research Purposes: Online Methods and Observational Study

Background

An increasing number of states have laws for the legal sale of recreational and medical cannabis out of brick-and-mortar storefront locations. Given the proliferation of cannabis outlets and their potential for impact on local economies, neighborhood structures, and individual patterns of cannabis use, it is essential to create practical and thorough methods to capture the location of such outlets for research purposes. However, methods used by researchers vary greatly between studies and often do not include important information about the retailer’s license status and storefront signage.

Objective

The aim of this study was to find methods for locating and observing cannabis outlets in Los Angeles County after the period when recreational cannabis retailers were granted licenses and allowed to be open for business.

Methods

The procedures included searches of online cannabis outlet databases, followed by methods to verify each outlet’s name, address, license information, and open status. These procedures, conducted solely online, resulted in a database of 531 outlets. To further verify each outlet’s information and collect signage data, we conducted direct observations of the 531 identified outlets.

Results

We found that 80.9% (430/531) of these outlets were open for business, of which 37.6% (162/430) were licensed to sell cannabis. Unlicensed outlets were less likely to have signage indicating the store sold cannabis, such as a green cross, which was the most prevalent form of observed signage. Co-use of cannabis and tobacco/nicotine has been found to be a substantial health concern, and we observed that 40.6% (175/430) of cannabis outlets had a tobacco/nicotine outlet within sight of the cannabis outlet. Most (350/430, 81.4%) cannabis outlets were located within the City of Los Angeles, and these outlets were more likely to be licensed than outlets outside the city.

Conclusions

The findings of this study suggest that online searches and observational methods are both necessary to best capture accurate and detailed information about cannabis outlets. The methods described here can be applied to other metropolitan areas to more accurately capture the availability of cannabis in an area.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

Blunt Use among Adolescents and Young Adults: Informing Cigar Regulations

Objectives

We used focus groups to understand cigar product features that increase the appeal of blunts (hollowed out cigars filled with marijuana) among adolescents and young adults.

Methods

With a standardized focus group guide, we assessed cigar use behaviors and perceptions among lifetime cigar users (N = 47; 8 focus groups separated by sex and age group [adolescents, young adults]) in 2016. We analyzed data related to blunts.

Results

Overall, 85.5% of the participants had smoked a blunt in the past 30 days (38% used daily). Participants perceived that cheap cigar brands were used primarily for blunts. Cigar product features that made them useful for blunts included wide availability, easy accessibility (easy to bypass underage purchasing restrictions), attractive flavors, inexpensive cost, perforated wrappers that make cigars easy to open, and ability to remove the inner wrapper (also referred to as "cancer paper") to reduce the risk of harm.

Conclusions

Various product features of cigars make it easy for adolescents and young adults to manipulate them to create blunts. Tobacco regulations that include restrictions on product characteristics, as well as enforcement of prohibition of sales of cigars to underage minors are needed. Youth also need to be educated about harms of blunt use.

Online Methods for Locating Medical Marijuana Dispensaries: Practical Considerations for Future Research

Knowing the names, locations, and signage of medical marijuana dispensaries is critical for assessing how marijuana availability affects neighborhood quality and marijuana use, yet no detailed methods for locating and coding dispensaries are published. Limitations regarding accuracy of official records, unregulated businesses, and the size of areas where dispensaries are located make it difficult to accurately capture all open dispensaries in any area. In this study, we test a practical and feasible method to collect a point-in-time portrayal of medical marijuana dispensaries in a large urban area lacking an official record of these businesses. Using publicly-available Internet sources alone, we collected the name, address, phone number, signage, and open/closed status of medical marijuana dispensaries in Los Angeles County between October 2016 and February 2017. Data were verified by calling a subset of dispensaries and comparing data against a list of licensed dispensaries. Our methods yielded 872 unique dispensaries in Los Angeles County, of which 470 were open. Most open stores were discernable by a green cross sign; however, few had names that clearly indicated the store sold marijuana. Data verification procedures showed that Internet sources were able to locate nearly all dispensaries in the county that were then verified with non-Internet methods, such as calling the businesses to confirm information. This study is significant as it provides methodology that can be replicated in other metropolitan areas, facilitating comparisons across databases in different locations and regulatory environments. However, caution should be taken when solely using Internet sources. Accurate information on dispensary names, locations, and signage can advance research and provide important information for policy decisions. Methods for enhancing the online methods described in this study are discussed.

Early Impacts of Marijuana Legalization: An Evaluation of Prices in Colorado and Washington

Following the legalization and regulation of marijuana for recreational purposes in states with medical markets, policymakers and researchers seek empirical evidence on how, and how fast, supply and demand changed over time. Prices are an indication of how suppliers and consumers respond to policy changes, so this study uses a difference-in-difference approach to exploit the timing of policy implementation and identify the impacts on marijuana prices 4-5 months after markets opened. This study uses unique longitudinal survey data of prices paid by consumers and a web-scraped dataset of dispensary prices advertised online for three U.S. medical marijuana states that all eventually legalized recreational marijuana. Results indicate there were no impacts on the prices paid for medical or recreational marijuana by state-representative residents within the short 4- to 5-months window following legalization. However, there were differences in how much people paid if they obtained marijuana for recreational purposes from a recreational store. Further analysis of advertised prices confirms this result, but further demonstrates heterogeneous responses in prices across types of commonly advertised strains; prices either did not change or increased depending on the strain type. A key implication of our findings is that there are both supply and demand responses at work in the opening of legalized markets, suggesting that evaluations of immediate effects may not accurately reflect the long run impact of legalization on consumption.

Cigarillo sales in legalized marijuana markets in the U.S

BACKGROUND

Nearly half of marijuana users in the United States also smoke cigarillos, with many using the products as marijuana "blunts." The relationship between marijuana legalization and tobacco retail has not yet been examined. This study uses tobacco sales data to compare the cigarillo marketplace in states with legalized recreational marijuana to the overall U.S. marketplace in 2016.

METHODS

Cigarillo sales data from 2016 were obtained from the Nielsen Research Company in the following market regions: Denver, CO; Seattle, WA; Portland, OR; and the overall U.S. Descriptive statistics highlighted differences in the market share of various product features (e.g., flavors, brand, pack size) across regions.

RESULTS

Characteristics such as fruit flavors, single sticks, and 2-3 packs were more popular in legal marijuana regions compared to the overall U.S. Black & Mild, a brand not traditionally used for blunts, was the top brand nationally (32.8% market share), but Swisher was the top brand in legal marijuana regions. In Seattle and Portland, for example, over half of cigarillo sales were for Swisher products (59.1% and 52.1%, respectively). Cigarillo wraps (i.e., no tobacco filler) were particularly popular in Denver, constituting 11.4% all cigarillo sales versus 2.8% nationally.

CONCLUSIONS

Cigarillo product characteristics traditionally associated with blunt use may shape the tobacco market in legal marijuana regions. As more states continue to legalize recreational marijuana, state and local governments should anticipate the potential impact on the tobacco marketplace and implement tobacco control policies (e.g., flavor bans, minimum pack sizes) that discourage product use.

Marijuana use among youths in Mississippi, United States

Background Increased use of marijuana among youths in Mississippi, United States is of great concern to Public Health in the 21st century. This study examined the prevalence of marijuana use according to gender, race and ethnicity. Method The data for this study was obtained from Youth Risk Behavior Surveillance System (YRBSS) for 2015, a cross-sectional survey of the Mississippi High School Students, which examined the prevalence and trends in the use of marijuana according to gender, race and ethnicity. The trends in the percentage of students that reported the use of marijuana and its product was examined by univariate t-test statistical analysis at p < 0.05. The frequency distribution was used to determine the percentage differences in the groups. Results The students that ever used marijuana was 39.4% in Blacks, 39.1% in Hispanics and 31.0% in Whites. A total of 13.7% male and female (4.8%) used marijuana before 13 years of age. In addition, the students currently using marijuana include Blacks (10.9%), Hispanic (13.7%) and Whites (7.2%). Approximately 9.7% of students ever used the synthetic product, which was higher in Hispanic (18.7%) when compared to Blacks (8.8%) and Whites (9.1%). Conclusion The use of marijuana is significantly higher among the male youth in Mississippi than females, which is a major public health concern. Furthermore, there was higher rates of smoking marijuana in Hispanics and Blacks when compared to White youth.

Marijuana as a 'concept' flavour for cigar products: availability and price near California schools

OBJECTIVES

To assess the retail availability of cigar products that refer to marijuana and the largest package size of cigarillos available for ≤$1.

METHODS

Trained data collectors conducted marketing surveillance in a random sample of licensed tobacco retailers that sold little cigars/cigarillos (LCCs) (n=530) near a statewide sample of middle and high schools (n=132) in California. Multilevel models examined the presence of marijuana co-marketing and cigarillo pack size as a function of school/neighbourhood characteristics and adjusted for store type.

RESULTS

Of stores that sold LCCs, approximately 62% contained at least one form of marijuana co-marketing: 53.2% sold cigar wraps marketed as blunt wraps, 27.2% sold cigarillos marketed as blunts and 26.0% sold at least one LCC with a marijuana-related 'concept' flavour. Controlling for store type, marijuana co-marketing was more prevalent in school neighbourhoods with a higher proportion of young residents (ages 5-17 years) and with lower median household income. Nearly all stores that sold LCCs (87.9%) offered the products for ≤$1. However, significantly larger packs at similarly low prices were available near schools in lower-income neighbourhoods and with a lower percentage of Hispanic students.

CONCLUSIONS

Understanding how the tobacco industry manipulates cigar products and marketing to capitalise on the appeal of marijuana to youth and other priority populations is important to inform regulation, particularly for flavoured tobacco products. In addition, the retail availability of five and six packs of LCCs for ≤$1 near California schools underscores policy recommendations to establish minimum prices for multipacks.

Images of Little Cigars and Cigarillos on Instagram Identified by the Hashtag #swisher: Thematic Analysis

Background

Little cigar and cigarillo use is becoming more prevalent in the United States and elsewhere, with implications for public health. As little cigar and cigarillo use grows in popularity, big social media data (eg, Instagram, Google Web Search, Twitter) can be used to capture and document the context in which individuals use, and are marketed, these tobacco products. Big social media data may allow people to organically demonstrate how and why they use little cigars and cigarillos, unprimed by a researcher, without instrument bias and at low costs.

Objective

This study characterized Swisher (the most popular brand of cigars in the United States, controlling over 75% of the market share) little cigar- and cigarillo-related posts on Instagram to inform the design of tobacco education campaigns and the development of future tobacco control efforts, and to demonstrate the utility in using big social media data in understanding health behaviors.

Methods

We collected images from Instagram, an image-based social media app allowing users to capture, customize, and post photos on the Internet with over 400 million active users. Inclusion criteria for this study consisted of an Instagram post with the hashtag “#swisher”. We established rules for coding themes of images.

Results

Of 1967 images collected, 486 (24.71%) were marijuana related, 348 (17.69%) were of tobacco products or promotional material, 324 (16.47%) showed individuals smoking, 225 (11.44%) were memes, and 584 (29.69%) were classified as other (eg, selfies, food, sexually explicit images). Of the marijuana-related images, 157/486 (32.3%) contained a Swisher wrapper, indicating that a Swisher product was used in blunt making, which involves hollowing out a cigar and refilling it with marijuana.

Conclusions

Images from Instagram may be used to complement and extend the study of health behaviors including tobacco use. Images may be as valuable as, or more valuable than, words from other social media platforms alone. Posts on Instagram showing Swisher products, including blunt making, could add to the normalization of little cigar and cigarillo use and is an area of future research. Tobacco control researchers should design social media campaigns to combat smoking imagery found on popular sites such as Instagram.

Marijuana and tobacco co-administration in blunts, spliffs, and mulled cigarettes: A systematic literature review

BACKGROUND

Blunts and spliffs/mulled cigarettes combine marijuana and tobacco for co-administration (use at the same time, in the same product). Co-administration of marijuana and tobacco presents significant potential for nicotine exposure, and may lead to exclusive tobacco use patterns, nicotine addiction, and compounded health effects. No review articles have summarized the number and nature of studies published on these co-administered products.

METHODS

Keywords "(blunt* OR spliff OR mull* OR joint) AND (tobacco OR smok* OR cigarette) AND (cannabis OR marijuana OR hashish)" were searched in the published literature. A total of 220 articles were considered for inclusion, 49 were reviewed by two independent qualitative coders, and 45 were included in this review.

RESULTS

Of the 45 articles, most (n=27) of studies were observational or descriptive; ten were qualitative, five employed causal designs, and three were mixed methods. A majority of the studies assessed blunts; only 11 studies assessed spliffs/mulled cigarettes. Many studies focused on sub-populations of youth, males, and African Americans. Use of co-administered marijuana and tobacco products was associated with several indicators of problematic use patterns, including perceptions of less risk, dependence on nicotine and marijuana, and greater subjective effects related to marijuana.

CONCLUSIONS

Literature on marijuana and tobacco co-administration comes largely from qualitative and observational/descriptive studies. In addition to continued surveillance, experimental research that directly assesses the smoking patterns of co-administered marijuana and tobacco products as compared with to those of marijuana and tobacco only products is needed to determine the potential long-term health consequences of using blunts, spliffs, or other co-administered products.

The availability of medical marijuana dispensary and adolescent marijuana use

PURPOSE

To examine the association between medical marijuana dispensary (MMD) availability and adolescent marijuana use.

METHODS

The study sample was comprised of 8th, 10th, and 12th graders (N=14,953) from 141 schools in the 2014 Monitoring the Future study, who resided in the 18 states that had legalized medical marijuana as of January 1, 2014. Multilevel logistic regressions with random effects were conducted to quantify the cross-sectional associations of the availability of MMD within 5- and 25-mile buffers from the centroid of school zip codes with self-reported recent use (past-year) and current use (past-month) of marijuana, controlling for individual characteristics and school, zip code, and state contextual factors.

RESULTS

In the combined sample, the availability of MMD was not associated with recent or current use of marijuana. Subsample analyses suggested that the availability within a 5-mile buffer was associated with a higher likelihood of recent use in 8th graders (OR=1.93, 95% CI=1.11-3.33) and the availability within a 5- to 25-mile buffer was associated with a higher likelihood of recent use in 10th graders (OR=1.33, 95% CI=1.00-1.77). The availability of MMD was not associated with recent use in 12th graders or current use in any grades.

CONCLUSIONS

The availability of MMD was not associated with current use of marijuana among adolescents. There was some evidence suggesting that the availability of MMD within short to medium traveling distance may be associated with a higher level of recent use in middle schoolers who are also at a high risk of experimenting with marijuana.

Trends in cannabis use disorders among racial/ethnic population groups in the United States

BACKGROUND

Minority groups generally experience more disparities than whites in behavioral healthcare use. The population of racial/ethnic groups is growing faster than whites. Given increased concerns of cannabis use (CU) and its associations with health conditions, we examined national trends in cannabis use disorder (CUD) among adults aged ≥18 by race/ethnicity.

METHODS

Data were from the 2005-2013 National Surveys on Drug Use and Health (N=340,456). We compared CU patterns and the conditional prevalence of CUD among cannabis users by race/ethnicity to understand racial/ethnic variations in CUD.

RESULTS

Approximately 1.5% of adults met criteria for a CUD in the past year. Regardless of survey year, cannabis dependence was more common than cannabis abuse, representing 66% of adults with a CUD. Across racial/ethnic groups, the prevalence of cannabis abuse and dependence remained stable during 2005-2013. In the total adult sample, the odds of weekly CU, monthly CU, and cannabis dependence were greater among blacks, native-Americans, and mixed-race adults than whites. Among cannabis users, the odds of cannabis abuse and dependence were greater among blacks, native-Americans, and Hispanics than whites. Logistic regression controlling for age, sex, education, and survey year indicated an increased trend in monthly CU and weekly CU in the total sample and among past-year cannabis users. Younger age, male sex, and low education were associated with increased odds of cannabis dependence.

CONCLUSIONS

The large sample provides robust information that indicates a need for research to monitor CUD and identify culturally appropriate interventions especially for targeting minority populations.

"I just use it for weed": The modification of little cigars and cigarillos by young adult African American male users

Little cigar and cigarillo (LCC) use has received increased attention, but research on their modification is limited. Qualitative interviews with 17 young adult African American male LCC users investigated tobacco use behaviors and patterns, including LCC modification. The modification of LCCs for use as blunts emerged as a very prominent aspect of LCC users' tobacco use. Four subthemes regarding marijuana and blunt use are explored in this article, including participants' explanations of how blunts are made and used, concurrent use of marijuana and tobacco, perceptions and reasons for smoking marijuana and blunts, and perceptions of the risks of blunt use.

Cannabis use and other predictors of the onset of daily cigarette use in young men: what matters most? Results from a longitudinal study

Background

According to the gateway hypothesis, tobacco use is a gateway of cannabis use. However, there is increasing evidence that cannabis use also predicts the progression of tobacco use (reverse gateway hypothesis). Unfortunately, the importance of cannabis use compared to other predictors of tobacco use is less clear. The aim of this study was to examine which variables, in addition to cannabis use, best predict the onset of daily cigarette smoking in young men.

Methods

A total of 5,590 young Swiss men (mean age = 19.4 years, SD = 1.2) provided data on their substance use, socio-demographic background, religion, health, social context, and personality at baseline and after 18 months. We modelled the predictors of progression to daily cigarette smoking using logistic regression analyses (n = 4,230).

Results

In the multivariate overall model, use of cannabis remained among the strongest predictors for the onset of daily cigarette use. Daily cigarette use was also predicted by a lifetime use of at least 50 cigarettes, occasional cigarette use, educational level, religious affiliation, parental situation, peers with psychiatric problems, and sociability.

Conclusions

Our results highlight the relevance of cannabis use compared to other potential predictors of the progression of tobacco use and thereby support the reverse gateway hypothesis.

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity). Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities. There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.

The Most Natural Tobacco Used: A Qualitative Investigation of Young Adult Smokers' Risk Perceptions of Flavored Little Cigars and Cigarillos

INTRODUCTION

Flavored little cigar and cigarillo (LCC) smoking prevalence rate is increasing among young adults; little is known about their comprehension of its risks. To inform tobacco control regulatory policy and prevention methods, we explored young adult smokers' risk perceptions of flavored LCC products and its use.

METHODS

Purposive samples (n = 90) of African American, Hispanic, and white young adults who self-identified as dual (smoked ≥ 1 LCC and cigarette in past 30 days) and cigarette-only (≥1 cigarette in past 30 days) smokers participated in 12 audiotaped focus groups and a semi-structured interview conducted in the Southeastern United States. Participants discussed their experiences smoking flavored LCCs and perceived health risks of smoking flavored LCCs. A brief survey was administered to characterize participants.

RESULTS

The participants had a mean age of 25.1 years (SD = 4.5), were majority male (53.1%), and were 60.0% African American, 29.5% white, and 17.5% Hispanic. Along with health risks and addiction, three major themes emerged as underlying contributors of risk perceptions: affect, participants' smoking practices (amount smoked and inhalation), and beliefs about the components of LCCs (including flavoring and filters). Participants' reported intention to smoke flavored LCCs with its tobacco or as blunts (filled with marijuana) also influenced perceptions. Flavored LCCs were viewed along a continuum of risks compared to cigarettes and blunt smoking.

CONCLUSIONS

Our study revealed dimensions that were important for the formation of risk perceptions about flavored LCCs. A multidimensional conceptual model and a measure of risk perceptions that is inclusive of these dimensions should be developed and examined for LCC use patterns.

Cannabis problem experiences among users of the tobacco-cannabis combination known as blunts

BACKGROUND

In most of the world, cannabis smokers mix loose tobacco inside a joint, pipe, spliff, or cone. More recently, a 'blunt' formulation combines these two drugs by inserting cannabis into a hollowed-out cigar. Epidemiological research linking simultaneous use of these two drugs and the development of cannabis use disorders (CUD) remains unclear. This study estimates associations linking blunt smoking with levels and subtypes of cannabis problems.

METHODS

Cross-sectional data on 27,767 past-year cannabis users were analyzed from the US National Survey on Drug Use and Health (NSDUH) conducted from 2009 to 2012. Ten self-reported items of DSM-IV CUD features elicited a single latent trait of cannabis problem (CP) severity, which was then regressed on past-year blunt smoking and past-month blunt frequency measures within the context of a conceptual model. Differential item functioning (DIF) analysis evaluated potential bias in CP feature response by blunt smoking history.

RESULTS

Past-year blunt smoking was associated with higher CP severity compared to cannabis users who did not smoke blunts. Days of blunt smoking in the past month also predicted higher CP severity than less frequent blunt use. Those smoking blunts experienced more subjectively felt tolerance and having spent more time obtaining or using cannabis, but were less likely to experience other problems, even at the same level of CP severity.

CONCLUSIONS

These findings suggest smoking blunts might promote the development of problematic cannabis use. Responses to cannabis problems differed by history of blunt smoking, possibly implicating an influence of tobacco on measurement of cannabis use disorders.

Examining the relationship between the physical availability of medical marijuana and marijuana use across fifty California cities

BACKGROUND

The purpose of the current study is to assess statistical associations between individual demographic and personality characteristics, the city-level physical availability of medical marijuana (as measured through densities per roadway mile of storefront dispensaries and delivery services), and the incidence and prevalence of marijuana use.

METHOD

Individual level data on marijuana use were collected during a telephone survey of 8853 respondents living in 50 mid-size cities in California. Data on medical marijuana dispensaries and delivery services were obtained via six different websites and official city lists. Three outcome variables pertaining to lifetime, past year use, and frequency of past year use were analyzed using random effects logistic models (for lifetime and past year use) and random effects tobit models (for frequency of past 365-day use).

RESULTS

The current study finds that the total physical availability of medical marijuana through dispensaries and delivery services per roadway mile at the city-level is positively related to current marijuana use and greater frequency of use, controlling for a variety of demographic and personality characteristics. As expected, current physical availability of medical marijuana was unrelated to lifetime use.

CONCLUSIONS

Regulations on the number and densities of marijuana outlets may be a sufficient means to restrain overall levels of marijuana use within cities. However, alternative use of delivery services may also provide easy access to marijuana and mitigate these effects.