U.S. cannabis legalization and use of vaping and edible products among youth

Clinician perspectives on adolescent cannabis-related beliefs and behaviors following recreational cannabis legalization

BACKGROUND

As more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them.

METHODS

This qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents' cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022-12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis.

RESULTS

The 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment.

CONCLUSIONS

Clinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work.

Dose of Product or Product Concentration: A Comparison of Change in Heart Rate by THC Concentration for Participants Using Cannabis Daily and Occasionally

Introduction: Studies show that acute cannabis use significantly increases heart rate (HR) and mildly raises blood pressure in the minutes following smoked or inhaled use of cannabis. However, less is known about how the THC concentration of the product or an individual's frequency of use (i.e., tolerance) may affect the magnitude of the change in HR. It is also relatively unexamined how the physical effects of increased HR after acute cannabis use relate to self-reported drug effects or blood THC levels. Aims: To describe the relationship between THC concentration of product used, self-reported subjective intoxication, THC blood levels, and frequency of cannabis use with the change in HR after acute cannabis use. Materials and Methods: Participants (n = 140) were given 15 min to smoke self-supplied cannabis ad libitum, HR was measured at baseline and an average of 2 min post-cannabis smoking. The ARCI-Marijuana scale and Visual Analog Scales (VAS) were administered, and blood samples were taken at both time points. Participants were asked about their frequency of use. Information about the product used was recorded from the package. Linear regression was used to analyze the relationship between changes in HR (post-pre cannabis use) and post-cannabis use HR, blood THC concentration, THC product concentration, frequency of use, and self-reported drug effect. Results: There was a significantly higher HR among those who smoked cannabis compared to the controls (p < 0.001), which did not significantly differ by frequency of use (p = 0.18). Higher concentration THC (extract) products did not produce a significantly different HR than lower concentration (flower) products (p = 0.096). VAS score was associated with an increase in HR (p < 0.05). Overall, blood THC levels were not significantly related to the change in HR (p = 0.69); however, when probed, there was a slight positive association among the occasional use group only. Discussion: Cardiovascular effects of cannabis consumption may not be as subject to tolerance with daily cannabis use and do not directly increase with THC concentration of the product. This is a departure from other effects (i.e., cognitive, subjective drug effects) where tolerance is well established. These findings also suggest that, at least among those with daily use, higher concentration THC products (>60%) do not necessarily produce cardiovascular physiological effects that are significantly more robust than lower concentration (<20%) products.

Cross-substance Effects of Adolescent Exposure to Alcohol Content in Popular Movies on Cannabis Initiation

Objective

Alcohol is the most frequently depicted substance in the media, and adolescent exposure to alcohol in the media predicts alcohol use. There is relatively little research on exposure to cannabis in the media, but exposure to alcohol content may exert cross-substance effects on cannabis use. Given the social and health risks associated with early cannabis use, the present study aims to assess the cross-substance effects of exposure to alcohol media content on age of cannabis initiation.

Method

A sample of 830 middle school students (53% female) reported on movie alcohol exposure and cannabis initiation longitudinally until high school completion. Discrete-time survival models examined whether movie alcohol exposure predicted subsequent initiation among students who were cannabis-naïve at baseline, controlling for demographic, social, and behavioral covariates. The interaction between sex and movie alcohol exposure was also explored.

Results

One third (33%) of participants reported cannabis initiation with a mean of 5.57 estimated hours (SD = 4.29) of movie alcohol exposure. A 1-hour increase in movie exposure predicted a significant 16% increased probability of cannabis initiation in models adjusted for demographic variables and a significant 14% increase in models adjusted for demographic, behavioral, and social variables. No differences were observed across sex.

Conclusions

Greater adolescent exposure to alcohol content in the media was associated with earlier cannabis initiation above and beyond other etiologically relevant demographic, behavioral, and social variables. The influence of cross-substance media exposures warrants further exploration and should be taken into consideration in the development of preventive interventions for youth substance use.

Recent Advanced Methods for Extracting and Analyzing Cannabinoids from Cannabis-Infused Edibles and Detecting Hemp-Derived Contaminants in Food (2013-2023): A Comprehensive Review

Cannabis-infused edibles are food products infused with a cannabis extract. These edibles include baked goods, candies, and beverages, offering an alternative way to consume cannabis instead of smoking or vaporizing it. Ensuring the accurate detection of cannabis-infused edibles and identification of any contaminants is crucial for public health and safety. This is particularly important for compliance with legal regulations as these substances can have significant psychoactive effects, especially on unsuspecting consumers such as children or individuals with certain medical conditions. Using efficient extraction methods can greatly improve detection accuracy, ensuring that the concentration of cannabinoids in edibles is measured correctly and adheres to dosage guidelines and legal limits. This review comprehensively examines the preparation and extraction techniques for cannabinoid edibles. It covers methods such as solid-phase extraction, enhanced matrix removal-lipid, QuEChERS, dissolution and dispersion techniques, liquid-phase extraction, and other emerging methodologies along with analytical techniques for cannabinoid analysis. The main analytical techniques employed for the determination of cannabinoids include liquid chromatography (LC), gas chromatography (GC), direct analysis in real time (DART), and mass spectrometry (MS). The application of these extraction and analytical techniques is further demonstrated through their use in analyzing specific edible samples, including oils, candies, beverages, solid coffee and tea, snacks, pet food, and contaminated products.

How have cannabis use and related indicators changed since legalization of cannabis for non-medical purposes? Results of the Canadian Cannabis Survey 2018-2022

BACKGROUND

Cannabis use for non-medical purposes was legalized and regulated in Canada through the Cannabis Act in October 2018. This paper examined trends in use of cannabis for non-medical purposes and related indicators from pre- to post-legalization in Canada (2018-2022).

METHODS

Data from 5 years of the Canadian Cannabis Survey, an annual web-based survey administered to Canadians 16 years of age or older, were used in the analysis (n2018=12,952; n2019=11,922; n2020=10,821; n2021=10,733; n2022=10,048). Cannabis measures include questions about use, types of products, sources, risk perceptions and beliefs, and exposure to public education campaigns and health warnings. Adjusted logistic regression models tested differences in outcomes over time.

RESULTS

Past 12-month cannabis consumption increased among Canadians from 22 % in 2018 to 27 % in 2022 (AOR=1.41;99 % CI:1.28-1.54). Similarly, daily/almost daily (DAD) consumption increased from 5 % in 2018 to 7 % in 2022 (AOR=1.36;99 % CI:1.16-1.59). Consumption of dried flower, hash/kief, and concentrates/extracts (e.g., wax, shatter, budder) decreased since 2018, whereas consumption of edibles, beverages and vape pens/cartridges increased (p < 0.001). Legal purchasing increased from 4 % in 2018 to 69 % in 2022, while accessing cannabis through social and illegal sources decreased over time (p < 0.001).

CONCLUSION

More Canadians are reporting cannabis consumption since legalization and regulation of cannabis for non-medical purposes, continuing a pre-existing trend despite an increase in awareness of the risks of consuming cannabis. Trends in product use indicate a transition from dried flower and concentrates/extracts towards consumption of cannabis foods, drinks and vape pens/cartridges. The legal market is increasingly displacing the illicit cannabis market in Canada.

Environmental influences on E-cigarette use among young people: A systematic review

E-cigarettes are a popular mode of delivery for nicotine, tobacco and cannabis. The prevalence of vaping among youth is increasing and this review aims to identify features of the neighbourhood environment, e.g., retailers, advertisements, and policies, that are associated with youth vaping. We included 48 studies. Of these, approximately 40% and 60% reported that presence of e-cigarette retailers, and advertisements, was associated with statistically higher odds of e-cigarette use in youth, respectively. Approximately 30% of studies reported that policies affecting e-cigarette availability were associated with statistically lower odds of vaping. Identifying these influential features of the neighbourhood environment will help formulate appropriate policies to reduce e-cigarette use among youth.

Typical Hits, Grams, or Joints: Evaluating Cannabis Survey Measurement Strategies for Quantifying Consumption

Aim: Standardized survey measures that capture diverse cannabis consumption patterns are needed to inform public health and policy. Our team is developing a flexible, personalized, low-burden survey item inventory to measure cannabis use patterns and estimate milligrams of THC (mgTHC) consumption in large samples. This study aimed to identify measurement gaps and analysis implications associated with an initial pool of candidate items that assessed use of cannabis flower and concentrate products (smoked and/or vaporized). Methods: Adult cannabis consumers (n=4247) completed an online survey assessing cannabis use frequency, quantity, product types, product potencies (%THC), and methods of administration. Participants chose to report their consumption quantities using one of three units: "hits per day," "grams per week," or "joints per week." Respondents also indicated whether their past 7-day consumption pattern represented their typical pattern. Results: Eighty-one percent had used cannabis daily in the past week. Thirty-two percent, 53%, and 15% chose to report flower and concentrate consumption quantity in hits, grams, and joints, respectively. Approximately 80-90% of responses for the number of hits, grams, and joints consumed were less than the maximum response option-suggesting that response options captured the full range of potential cannabis consumption behaviors. Those who chose grams or joints units were generally more likely to endorse higher risk cannabis use (e.g., morning use, high %THC products) in the past week than those who chose the hits unit (adjusted Odds Ratio range: 1.2-3.9). Among those who reported that the past week represented their typical behavior (83%), past 30-day and past 7-day frequencies were highly correlated (Spearman's Rho=0.77)-supporting the feasibility of using lower burden "typical week" items to extrapolate patterns beyond a 1-week time frame. Conclusion: Results from this online convenience sample of frequent cannabis consumers suggest that the current items yield coherent and expected response patterns. Although additional testing is required, a standardized, flexible survey instrument for large-scale assessment of cannabis patterns and calculation of mgTHC seems within reach.

Amyotrophic Lateral Sclerosis and Pain: A Narrative Review from Pain Assessment to Therapy

Amyotrophic lateral sclerosis (ALS) is the most frequent neurodegenerative disease of the motor system that affects upper and lower motor neurons, leading to progressive muscle weakness, spasticity, atrophy, and respiratory failure, with a life expectancy of 2-5 years after symptom onset. In addition to motor symptoms, patients with ALS have a multitude of nonmotor symptoms; in fact, it is currently considered a multisystem disease. The purpose of our narrative review is to evaluate the different types of pain, the correlation between pain and the disease's stages, the pain assessment tools in ALS patients, and the available therapies focusing above all on the benefits of cannabis use. Pain is an underestimated and undertreated symptom that, in the last few years, has received more attention from research because it has a strong impact on the quality of life of these patients. The prevalence of pain is between 15% and 85% of ALS patients, and the studies on the type and intensity of pain are controversial. The absence of pain assessment tools validated in the ALS population and the dissimilar study designs influence the knowledge of ALS pain and consequently the pharmacological therapy. Several studies suggest that ALS is associated with changes in the endocannabinoid system, and the use of cannabis could slow the disease progression due to its neuroprotective action and act on pain, spasticity, cramps, sialorrhea, and depression. Our research has shown high patients' satisfaction with the use of cannabis for the treatment of spasticity and related pain. However, especially due to the ethical problems and the lack of interest of pharmaceutical companies, further studies are needed to ensure the most appropriate care for ALS patients.

Countering online marketing and user endorsements with enhanced cannabis warning labels: An online experiment among at-risk youth and young adults

As cannabis legalization expands and online marketing intensifies, this study examines whether online social cues can amplify youth-targeted cannabis advertising and whether cannabis warning labels (CWLs) can counteract these influences. A U.S. online sample of 970 adolescents and 1776 young adults susceptible to cannabis use were recruited from Qualtrics in summer 2022. Each participant was randomly assigned to one of the 3 (CWLs: none vs. textual vs. pictorial) by 3 (comments: none vs. anti-cannabis vs. pro-cannabis) conditions in an online experiment. Participants were exposed to three online marketing posts promoting marijuana edibles (randomly selected from a large pool, N = 1260), each with either no warning label, a textual warning, or a pictorial warning (text and picture), and with either five comments (pro- or anti-cannabis in valence) or none. Results showed that among adolescents, pro-cannabis comments increased product appeal (vs. anti-cannabis comments: b = 0.18, p = .025; vs. no comments: b = 0.21, p = .021), and did so more than young adults. For adolescents, only pictorial warnings reduced product appeal (b = -0.20, p = .028). For young adults, both pictorial (b = -0.18, p = .002) and textual warnings (b = -0.12, p = .029) reduced product appeal. Furthermore, both textual (adolescents: b = -0.20, p = .004; young adults: b = -0.15, p = .005) and pictorial (adolescents: b = -0.30, p < .001; young adults: b = -0.18, p = .001) warnings reduced cannabis use intentions. Findings support requiring enhanced CWLs accompany online marketing ads.

The Moderating Role of Health Status on the Association Between Depressive Symptoms and Cannabis Vaping

Objective

Cannabis vaping is increasing among college students. There is little information on risk factors for vaping cannabis. Consistent with the self-medication hypothesis, experiencing depressive symptoms and having a chronic medical condition (CMC) are associated with cannabis use among young adults. Individuals who experience both risk factors may be at higher risk for cannabis vaping. This study examined cross-sectional associations between depressive symptoms, CMC status, and cannabis vaping, and identified the moderating role of CMC status on depressive symptoms and cannabis vaping.

Method

College students (N = 3,742) self-reported on depressive symptoms, CMC status, and lifetime and current cannabis vaping (i.e., cannabis vaporizers; electronic nicotine devices to use cannabis). Data were collected Fall 2017 until Spring 2021. The sample was predominantly female (70.9%) and White (75.4%). Regression analyses were used.

Results

Greater depressive symptoms were related to increased likelihood of cannabis vaping across outcomes. Having a CMC was related to lifetime history of cannabis vaporizing. CMC status moderated the associations between depressive symptoms and lifetime cannabis vaporizing. Depressive symptoms were only a risk factor for cannabis vaporizing among college students without a CMC, not those with a CMC.

Conclusions

Interventions that teach adaptive ways of coping with depressive symptoms and the potential demands of managing a CMC in college are needed. Comprehensive programs for college students, with and without CMCs, are needed to support those with comorbid depression and cannabis vaping use.

The Relationship between Vaping Cannabis and Frequency of Cannabis Use and Cannabis-Related Problems among Urban High School Students

Background: Vaping, including vaping cannabis, is increasing among adolescents. In this longitudinal study, we examined the relationship between vaping cannabis and frequency of cannabis use and related problems over 6 months among adolescents. Material and Methods: Data were from 233 participants (46.8% male, 93.1% African American, mean age = 16.4 years) reporting cannabis use. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) assessed frequency of past 30-day cannabis use and cannabis-related problems at baseline, 3- and 6-months post-baseline. We used latent growth curve modeling to compare vaping to non-vaping adolescents on trends in cannabis use frequency and ASSIST cannabis scores. Results: Adolescents who vaped cannabis (11.7%) had higher past 30-day frequency (mean = 17.89 days, SD = 10.49) of cannabis use at baseline compared to adolescents who had not vaped (mean = 12.1 days, SD = 10.93), but reported a significantly sharper decline in frequency of cannabis use (b = -0.34, p = 0.017). A significantly steeper decrease existed in the mean cannabis ASSIST scores for the vaping group than for the non-vaping group (b = -0.34, p = 0.014). Mean ASSIST scores on the cannabis subscale between the two groups were significantly different at 6-month follow-up (Vape mean = 6.00, SD = 8.12 vs. Non-vape mean = 9.6, SD = 9.39; p < 0.021). Conclusions: In a sample of cannabis-using adolescents, adolescents with experience vaping cannabis, compared to adolescents without vaping experience, on average reported sharper decreases in frequency of cannabis use and cannabis-related problems such as health or social problems.

Understanding and preventing the advertisement and sale of illicit drugs to young people through social media: A multidisciplinary scoping review

ISSUES

The sale of illicit drugs online has expanded to mainstream social media apps. These platforms provide access to a wide audience, especially children and adolescents. Research is in its infancy and scattered due to the multidisciplinary aspects of the phenomena.

APPROACH

We present a multidisciplinary systematic scoping review on the advertisement and sale of illicit drugs to young people. Peer-reviewed studies written in English, Spanish and French were searched for the period 2015 to 2022. We extracted data on users, drugs studied, rate of posts, terminology used and study methodology.

KEY FINDINGS

A total of 56 peer-reviewed papers were included. The analysis of these highlights the variety of drugs advertised and platforms used to do so. Various methodological designs were considered. Approaches to detecting illicit content were the focus of many studies as algorithms move from detecting drug-related keywords to drug selling behaviour. We found that on average, for the studies reviewed, 13 in 100 social media posts advertise illicit drugs. However, popular platforms used by adolescents are rarely studied.

IMPLICATIONS

Promotional content is increasing in sophistication to appeal to young people, shifting towards healthy, glamourous and seemingly legal depictions of drugs. Greater inter-disciplinary collaboration between computational and qualitative approaches are needed to comprehensively study the sale and advertisement of illegal drugs on social media across different platforms. This requires coordinated action from researchers, policy makers and service providers.

Impact of Cannabis Legalization on Adolescent Cannabis Use

Because of substantial limitations in available national data, such as inconsistencies among surveys and small sample sizes, the increased prevalence of cannabis use among adolescents since recreational legalization has not been directly observed. Nevertheless, both usage frequency and product potency have significantly increased, alongside alternative routes of delivery to smoking, such as vaping cannabis. Moreover, certain populations may be especially vulnerable to the effects of legalization. Regardless of differing state-level cannabis legalization status, the adverse consequences of cannabis on youth have clear negative impacts on mental health, medical symptoms, educational outcomes, and increased risk of addiction to other substances.

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.

Parallel trajectories of vaping and smoking cannabis and their associations with mental and physical well-being among young adults

BACKGROUND

Vaping and smoking are common modes of using cannabis (THC) among young adults, but little is known about how patterns of cannabis vaping and smoking unfold over time or how using one or both types of products may differently affect mental and physical well-being. This study examines parallel processes of cannabis vaping and smoking over 5 years and mental and physical outcomes in a sample of young adults.

METHODS

Annual surveys were conducted between 2016 and 2022 with a mostly California-based cohort of 2428 young adults. Parallel process growth mixture models examined trajectories of past-month frequency of cannabis vaping and smoking from ages 20 - 25. Classes were extracted based on parallel trajectories of vaped and smoked product use. Models assessed differences in self-reported mental (anxiety, depression) and physical (ailments, subjective overall) well-being outcomes in young adulthood across classes, adjusting for demographic characteristics and mental and physical well-being at pre-baseline (average age 19).

RESULTS

Four cannabis vaping/smoking classes emerged: low use of cannabis (84.7%), decreasing smoking, low-moderate vaping (7.1%), stable moderate smoking, decreasing vaping (4.6%), and rapid increasing dual use (3.4%). Classes were similar on physical well-being indicators in young adulthood. The rapid increasing dual use class showed higher anxiety and depressive symptoms compared to other classes.

CONCLUSION

Progression to higher frequency of both vaping and smoking cannabis in young adulthood may contribute to poorer mental well-being compared to other use patterns. Targeted efforts to reduce dual vaping and smoking in young people who use cannabis may be needed.

Vaping, Environmental Toxicants Exposure, and Lung Cancer Risk

Lung cancer (LC) is the second-most prevalent tumor worldwide. According to the most recent GLOBOCAN data, over 2.2 million LC cases were reported in 2020, with an estimated new death incident of 1,796,144 lung cancer cases. Genetic, lifestyle, and environmental exposure play an important role as risk factors for LC. E-cigarette, or vaping, products (EVPs) use has been dramatically increasing world-wide. There is growing concern that EVPs consumption may increase the risk of LC because EVPs contain several proven carcinogenic compounds. However, the relationship between EVPs and LC is not well established. E-cigarette contains nicotine derivatives (e.g., nitrosnornicotine, nitrosamine ketone), heavy metals (including organometal compounds), polycyclic aromatic hydrocarbons, and flavorings (aldehydes and complex organics). Several environmental toxicants have been proven to contribute to LC. Proven and plausible environmental carcinogens could be physical (ionizing and non-ionizing radiation), chemicals (such as asbestos, formaldehyde, and dioxins), and heavy metals (such as cobalt, arsenic, cadmium, chromium, and nickel). Air pollution, especially particulate matter (PM) emitted from vehicles and industrial exhausts, is linked with LC. Although extensive environmental exposure prevention policies and smoking reduction strategies have been adopted globally, the dangers remain. Combined, both EVPs and toxic environmental exposures may demonstrate significant synergistic oncogenicity. This review aims to analyze the current publications on the importance of the relationship between EVPs consumption and environmental toxicants in the pathogenesis of LC.

Use of flavored cannabis vaping products in the US, Canada, Australia, and New Zealand: findings from the international cannabis policy study wave 4 (2021)

Background: Vaping is an increasingly popular mode of cannabis use. Few studies have characterized the role of flavors in cannabis e-liquids.Objectives: To explore the prevalence of flavored vaping liquids, including differences between countries and correlates of use.Methods: Data were from Wave 4 (2021) of the International Cannabis Policy Study with national samples aged 16-65 in Canada, the United States (US), Australia, and New Zealand. The sample comprised 52,938 respondents, including 6,265 who vaped cannabis e-liquids in the past 12-months (2,858 females, 3,407 males). Logistic regression models examined differences in the use of flavored e-liquids between countries and sociodemographic characteristics.Results: The prevalence of vaping cannabis e-liquids was highest in the US (15.3%) and Canada (10.7%) compared to Australia (4.0%) and New Zealand (3.7%). Among past 12-month cannabis consumers, 57.5% reported using flavored vaping liquids, 34.2% used unflavored vaping products and 8.3% did not know. People who vape in Australia were most likely to report using flavored liquids compared to New Zealand (OR = 2.29), Canada (OR = 3.14), and the US (OR = 3.14) (p < .05 for all). Fruit was the most reported vaping flavor (40.8%), followed by candy/dessert (20.4%) and vanilla (15.2%). Use of flavored vapes was greater among younger, ethnic minorities, female, higher education and income adequacy, and more frequent consumers (p < .05).Conclusion: Many cannabis consumers reported using flavored e-liquids, with highest levels among young people aged 16-35. Given the high prevalence of vaping in legal markets, regulators should consider the role of flavored vaping products in promoting cannabis use among this group.

Prevalence and hospital resource usage associated with substance use disorder among hospitalized adolescents in the United States

We sought to determine common characteristics of SUD-related hospitalizations and patterns of discharge diagnoses among adolescents in the United States. Using the 2016 KID, a cross-sectional study was conducted to identify discharge records associated with ICD-10-CM diagnostic codes for SUD. Adolescents between the ages of 13 and 19 were included. SUD and non-SUD groups were compared using the Student's t-test for continuous variables and the χ2 test for categorical variables. A total of 6.7 million hospital discharges were analyzed. A uniform and a standardized coding system were used to identify cases. Subgroup comparative analysis for length of stay, hospital charge, and common discharge diagnoses was performed. A weighted estimate of 94,732 adolescents associated with SUD was discharged from the U.S. hospitals during the study year. Teens with SUD accounted for 510,268 days of inpatient days in the U.S. community hospitals accounting for a total charge of $3,070,948,580. The average LOS for all SUD teens in the U.S. was 5.4 days with a mean charge per discharge of $32,754, indicating higher LOS but a significantly lower mean charge compared to non-SUD teens (4.1 days; $39,657). In 2016, more than 88% of SUD patients had ≥ 3 diagnoses compared to non-SUD patients (76%) (P < 0.0001 for all). The most frequently observed diagnosis associated with teens with SUD was psychoses, depressive neuroses, and alcohol use disorder. With one in ten teenagers found with an SUD, early substance initiation still appears to be an important public health issue. Unfortunately, the health and economic impact of substance use in adolescence on society are huge requiring effective strategies targeted to this population. The concerning data and literature identify a significant need to address prevention, treatment, and recovery services for adolescents throughout the United States.

Exploring Differences in Daily Vaping of Nicotine and Cannabis among People Who Use Drugs in New Zealand

Background: Little is known about daily vaping of different substances, particularly cannabis. Aim: To explore daily vaping of cannabis and nicotine products in a sample of people who use drugs in New Zealand. Method: The online New Zealand Drug Trends convenience survey (N = 23,500) was promoted to those aged 16+ via a targeted Facebook™ campaign, with 9,042 reporting vaping in the past six months. Multivariate logistic regression models were fitted to identify predictors of daily vaping of: (i) nicotine e-liquids, (ii) no-nicotine e-liquids, (iii) cannabis e-liquids/oils, (iv)cannabis herb. Results: Forty-two percent of past 6-month vapers used a vaporizing device "daily or near daily" (n = 3,508). Nicotine was most common substance used by daily vapers (96%), followed by dry herb cannabis (12%), no-nicotine e-liquids (10%) and cannabis e-liquid (6%). Daily vaping of no-nicotine e-liquids was associated with abstinence from tobacco use. Frequency of cannabis use was negatively correlated with daily vaping of nicotine liquids and positively correlated with daily vaping of no-nicotine and herbal cannabis. Younger age strongly predicted daily vaping of nicotine and no-nicotine liquids, but the reverse association was observed for daily vaping of herbal cannabis. Māori were less likely to daily vape cannabis herb than NZ Europeans. Daily vaping of both cannabis e-liquid and cannabis herb was associated with medicinal cannabis use. Conclusion: Daily vapers of nicotine and cannabis differed by several characteristics. Younger age group is at risk of daily vaping nicotine and non-nicotine, while herbal cannabis vaping is associated with older and medicinal use, suggesting a need for a nuanced vape policy response.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Cannabis smoking, tobacco cigarette smoking, and adenomyosis risk

OBJECTIVE

To investigate cannabis smoking and tobacco cigarette smoking in relation to adenomyosis risk.

DESIGN

We used data from a case-control study of adenomyosis conducted among enrollees ages 18-59 years of an integrated health care system in Washington State. The case-control study used 2 control groups given the challenge of selecting noncases when cases are diagnosed by hysterectomy.

SUBJECTS

Cases (n = 386) were enrollees with incident, pathology-confirmed adenomyosis diagnosed between April 1, 2001, and March 31, 2006. The 2 control groups comprised hysterectomy controls (n = 233) with pathology-confirmed absence of adenomyosis and population controls (n = 323) with an intact uterus selected randomly from the health care system population and frequency matched to cases on age.

EXPOSURE

Detailed data on cannabis and tobacco cigarette smoking history were ascertained through in-person structured interviews, allowing estimation of joint-years of cannabis smoking and pack-years of tobacco cigarette smoking.

MAIN OUTCOME MEASURES

Odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between cannabis smoking, tobacco cigarette smoking, and adenomyosis were estimated using multivariable unconditional logistic regression. Analyses were adjusted for age, reference year, menarche age, education, and pack-years of cigarette smoking (or joint-years of cannabis smoking).

RESULTS

No association was observed between cannabis smoking history and adenomyosis risk. However, we did observe the suggestion of an association between ever tobacco cigarette smoking and adenomyosis risk, comparing cases to hysterectomy controls (OR, 1.3; 95% CI, 0.9-1.9) and population controls (OR, 1.2; 95% CI, 0.8-1.8). Our data suggested a 50% increased odds of adenomyosis with >15 pack-years of smoking (vs. never smoking), comparing cases to hysterectomy controls (OR, 1.5; 95% CI, 0.9-2.6; Ptrend=.135). The suggestion of a 40% increased adenomyosis odds was observed with smoking >5-15 pack-years (vs. never smoking), comparing cases to population controls (OR, 1.4; 95% CI, 0.8-2.4; Ptrend=0.136).

CONCLUSION

In the first study of cannabis smoking and adenomyosis risk, no association was observed. However, our data suggested an increased odds of adenomyosis with history of tobacco cigarette smoking. Further research is warranted to replicate our results given the substantial morbidity with adenomyosis and frequency of cigarette smoking and recreational and medical cannabis use.

The impact of legal cannabis availability on cannabis use and health outcomes: A systematic review

BACKGROUND

For alcohol, regulating availability is an effective way to reduce consumption and harm. Similarly, the higher availability of medical cannabis dispensaries has been linked to increased cannabis consumption and harm. For recreational cannabis markets, such a link is suspected but still poorly understood.

METHODS

A systematic literature review (PROSPERO registration number 342357) was conducted on 1 July 2022 in common libraries (Medline, Web of Science, PsycInfo, Psyndex, CINAHL, Embase, SCOPUS, Cochrane) for publications since 2012. Studies linking variations in the availability of legal cannabis products to behavioral outcomes (cannabis use or related health indicators) were included, while studies focusing solely on the legalization of medical cannabis were excluded. The risk of bias was assessed using an adapted version of the Newcastle-Ottawa-Scale.

RESULTS

After screening n = 6,253 studies, n = 136 were selected for full-text review, out of which n = 13 met the inclusion criteria, reporting on n = 333,550 study participants and n = 855,630 presentations to emergency departments. All studies were conducted in North America, with the majority from Western US states. Using longitudinal (n = 1), cross-sectional (n = 4), or repeated cross-sectional (n = 8) study designs, an increased availability of legal cannabis was linked to increased current cannabis use and health-related outcomes (vomiting, psychosis, or cannabis-involved pregnancies), regardless of the indicator employed to measure availability (proximity or density) among both adults and adolescents. The positive correlation between cannabis availability and consumption is most pronounced among those groups who have been less exposed to cannabis before legalization. The association between the availability of legal cannabis and risky use indicators was less consistent.

CONCLUSIONS

Groups who have been least exposed to cannabis before legalization may be most susceptible to increased availability. In jurisdictions with legal cannabis markets, restrictions on the number of legal cannabis retailers, especially in densely populated areas, appear warranted.

A cross-sectional survey on cannabis: Characterizing motives, opinions, and subjective experiences associated with the use of various oral cannabis products

BACKGROUND

Cannabis-infused products available for oral consumption include food and drink items (i.e., edibles) (e.g., baked goods, gummy-, chocolate-, and hard-candies, beverages/drinks) as well as non-food formulations (e.g., oils/tinctures, pills/capsules). This study characterized the motives, opinions, and subjective experiences associated with the use of these seven subtypes of oral cannabis products.

METHODS

This web-based survey collected cross-sectional, self-report data from a convenience sample of 370 adults regarding various use-motives, self-reported cannabinoid content, subjective experiences, and opinions related to ingesting oral cannabis products with alcohol and/or food. Advice participants had received about modifying oral cannabis product effects, in general, was also collected.

RESULTS

Participants reported consuming cannabis baked goods and gummy candies most frequently over the past year (68% and 63%, respectively). Participants were less likely to use oils/tinctures for enjoyment/desire relative to other product types and more likely to use oils/tinctures for therapeutic purposes (e.g., medication-replacement). Self-reported cannabinoid content was highly variable across participants and within product subtype. Participants reported feeling stronger and longer-lasting effects when consuming oral cannabis products on an empty stomach and 43% received advice to "eat a snack or meal" to mitigate effects that are too strong, which contrasts with controlled studies. Finally, 43% of participants reported modifying their experiences with alcohol at least some of time.

CONCLUSIONS

These findings underscore the need to further evaluate use-motives as well as the interaction between dietary factors, cannabinoid pharmacokinetics, and subjective drug effects and the interactive effects of oral cannabis products and alcohol in a controlled laboratory setting.

Effects of Cannabis Legalization on Adolescent Cannabis Use Across 3 Studies

INTRODUCTION

Canada, Uruguay, and 18 states in the U.S. have legalized the use of nonmedical (recreational) cannabis for adults, yet the impact of legalization on adolescent cannabis use remains unclear. This study examined whether cannabis legalization for adults predicted changes in the probability of cannabis use among adolescents aged 13-18 years.

METHODS

Data were drawn from 3 longitudinal studies of youth (spanning 1999-2020) centered in 3 U.S. states: Oregon, New York, and Washington. During this time, Oregon (2015) and Washington (2012) passed cannabis legalization; New York did not. In each study, youth average age was 15 years (total N=940; 49%-56% female, 11%-81% Black/African American and/or Latinx). Multilevel modeling (in 2021) of repeated measures tested whether legalization predicted within- or between-person change in past-year cannabis use or use frequency over time.

RESULTS

Change in legalization status across adolescence was not significantly related to within-person change in the probability or frequency of self-reported past-year cannabis use. At the between-person level, youth who spent more of their adolescence under legalization were no more or less likely to have used cannabis at age 15 years than adolescents who spent little or no time under legalization.

CONCLUSIONS

This study addresses several limitations of repeated cross-sectional studies of the impact of cannabis legalization on adolescent cannabis use. Findings are not consistent with changes in the prevalence or frequency of adolescent cannabis use after legalization. Ongoing surveillance and analyses of subpopulations are recommended.

Social Media Marketing Practices of Illinois Recreational Cannabis Dispensaries in the First Year of Legal Sales: Product Promotions, Branding, and Price Promotions

Research from tobacco suggests that the recreational cannabis industry will use aggressive tactics, including product innovation and mass-marketing and advertising, to increase demand for their products. The purpose of this study is to examine product promotions, branding, and promotional pricing on recreational dispensary social media pages in the state of Illinois in the first year of legal sales. Data were collected from all recreational cannabis dispensary Facebook and Twitter accounts and a quantitative content analysis was used to analyze the data. Differences in marketing practices were assessed by neighborhood race/ethnicity and income and dispensary type. Results of the study revealed that flower and edibles were the two most heavily promoted products; promotions for vaporizers and concentrates were also promoted frequently. Posts with branded promotions and price promotions increased substantially over the year. Research suggests that this trend in marketing practices will lead to greater initiation and intensity of cannabis use.

Cannabis vaping among high school seniors in adult-use, medical, and prohibited legal contexts

Background

Vaping cannabis among adolescents has been increasing. Monitoring the Future (MTF) indicated in 2019 that past-month cannabis vaping among 12th graders underwent the second-highest single-year jump ever tracked by MTF for any substance in its 45-year history. These increases in adolescents who vape cannabis do not parallel declining general adolescent cannabis use trends. Nevertheless, research on cannabis consumption via vaping, especially among adolescents, has been substantially limited.

Method

We examined associations between legal contexts (prohibited, medical, and adult use) and vaping cannabis in the past year among high school seniors. In addition, associations between vaping cannabis and factors such as availability and acceptability were examined using secondary data from MTF (2020), with a sub-sample size of 556 participants (overall sample size: n = 3,770), using multivariate logistic regression models.

Results

We found that high school seniors in medical states had higher odds of past-year vaping cannabis, but 12th graders in adult-use states were not significantly more likely to vape cannabis than those in prohibited states. Increased availability of vaping products and decreased risk perceptions in medical states may explain this relationship. Adolescents who perceived high risks associated with regular cannabis use had decreased odds of vaping cannabis. High school seniors reporting very easy access to cannabis cartridges had increased odds of vaping cannabis, regardless of legal context.

Conclusion

These results contribute knowledge about contextual factors related to adolescent cannabis vaping, a relatively new technique of cannabis consumption for which there is growing societal concern.

Trends in intentional abuse and misuse ingestions in school-aged children and adolescents reported to US poison centers from 2000-2020

CONTEXT

Childhood and adolescent misuse and abuse exposures remain a serious public health challenge in the United States. This study aimed to describe recent trends and patterns of intentional substance misuse and abuse exposures among school-aged children and adolescents in the United States.

METHODS

This study was a retrospective cohort study of intentional misuse and abuse exposures in children 6 through 18 years reported to the National Poison Data System (NPDS) from January 1, 2000, through December 31, 2020. Demographic trends, reported clinical effects, treatments, management sites, and health outcomes were assessed overall and within four age categories: 6-9, 10-12, 13-15, and 16-18.

RESULTS

Between 2000 and 2020, there were 338,727 cases regarding intentional misuse and abuse exposures for children ages 6 through 18 years old. Overall, misuse/abuse ingestions fluctuated over time, with a peak in 2011. The majority of intentional misuse/abuse ingestions occurred in males (58.3%), and more than 80% of all reported exposure cases occurred in youth aged 13 to 18. 32.6% of ingestions resulted in worse than minor clinical outcomes. Older age groups had a greater number of severe medical outcomes compared to younger age groups. Major or life-threatening exposures (including those resulting in death) were more common in males. Overall, deaths were rare (n = 450), 0.1%). Male sex, older age, abuse ingestions, exposure site of a public area or other residence, and multiple ingested substances were other factors associated with increased mortality. Marijuana exposure rates had the highest average monthly increase overall, with the most dramatic rise occurring from 2017 to 2020. Edible marijuana preparations accounted for the highest increase in call rates compared with all other forms of marijuana.

DISCUSSION AND CONCLUSION

With over 330,000 poison center cases reported during the 20-year study period, intentional substance misuse and abuse exposures substantially impact the pediatric population. The substances most commonly misused/abused are more widely available substances such as over-the-counter medications, household products and pharmaceuticals commonly prescribed to youth. Differences in age and sex were evident, with males and adolescents more likely to abuse and misuse substances. Our study describes an upward trend in marijuana misuse/abuse exposures among youth, especially those involving edible products. These findings highlight an ongoing concern about the impact of rapidly evolving cannabis legalization on this vulnerable population.

Impact of Cannabis Legalization on Adolescent Cannabis Use

Because of substantial limitations in available national data, such as inconsistencies among surveys and small sample sizes, the increased prevalence of cannabis use among adolescents since recreational legalization has not been directly observed. Nevertheless, both usage frequency and product potency have significantly increased, alongside alternative routes of delivery to smoking, such as vaping cannabis. Moreover, certain populations may be especially vulnerable to the effects of legalization. Regardless of differing state-level cannabis legalization status, the adverse consequences of cannabis on youth have clear negative impacts on mental health, medical symptoms, educational outcomes, and increased risk of addiction to other substances.

Trends and Socio-Demographic Differences of Cannabis Vaping in the USA and Canada

Given the rise in cannabis vaping, it is important to highlight the heterogeneity in vaping different cannabis product because of the potential differences in their health risks. This study aims to estimate the trends and socio-demographic correlates of the use of various cannabis vaping products across jurisdiction with different legal status. Data from the 2018 (n = 27,169) and 2019 (n = 47,747) waves of the International Cannabis Policy Study (ICPS) were used. Respondents aged 16-65 completed web-based surveys. In 2019, proportions of past year vaping of cannabis oil, dried flower and concentrates in the overall sample were highest in U.S. jurisdictions where cannabis was legalized for non-medical use (17.4%, 6.0%, 4.9%), followed by U.S. jurisdiction where non-medical cannabis use is illegal (13.7%, 5.8%, 2.9%), and lowest in Canada (8.1%, 4.4%, 2.1%). Vaping dried flower decreased from 2019 to 2018 in U.S. legal jurisdictions and Canada, while vaping cannabis oil and concentrates increased in all jurisdictions (p < 0.001). The odds of vaping all forms of products were higher among younger respondents (16-55 years), males, respondents with some college education, and persons with low-risk perceptions on daily cannabis vaping. In both ICPS surveys (2018 and 2019), cannabis oil was the most frequently vaped products, followed by dried flower, and concentrates. Detailed measures of product forms for cannabis vaping should be considered in future surveys.

Temporal trends in alcohol, cannabis, and simultaneous use among 12th-grade U.S. adolescents from 2000 to 2020: Differences by sex, parental education, and race and ethnicity

BACKGROUND

Simultaneous use of alcohol and cannabis to enhance each other's effect can cause potential harm. Time trends are diverging in adolescent use of alcohol, which is declining, and cannabis, which is increasing among certain subgroups. However, little is known about trends in their simultaneous and non-simultaneous use. Racial and socioeconomic disparities are emerging in cannabis use, which may portend consequences to public health.

METHODS

The 2000 to 2020 Monitoring the Future surveys included approximately 38,000 U.S. 12th-grade students with information on simultaneous use and pertinent demographic factors. A 5-level alcohol/cannabis measure included past-year simultaneous use (i.e., alcohol and cannabis use at the same time), non-simultaneous alcohol and cannabis use, alcohol-use-only, cannabis-use-only, and no use. Multinomial logistic regressions estimated associations (adjusted relative risk ratios; aRRR) with time period (2000 to 2004, 2005 to 2009, 2010 to 2014, 2015 to 2020). Models were adjusted and included interactions with sex, race/ethnicity, and parental education.

RESULTS

Between 2000 and 2020, simultaneous alcohol/cannabis use among 12th graders decreased from 24.4% to 18.7%. From 2015 to 2020 compared to 2000 to 2004, the odds of simultaneous use (adjusted relative risk ratio (aRRR) vs. no use = 0.57, 95% CI [0.50, 0.66]) and alcohol-use-only (aRRR = 0.55, 95% CI [0.49, 0.61]) decreased, while cannabis-use-only odds increased (aRRR = 2.59, 95% CI [1.87, 3.59]). Notably, the prevalence of cannabis-use-only more than doubled from 2011 to 2019. The odds of simultaneous use, alcohol-use-only, and non-simultaneous use of alcohol and cannabis declined more rapidly among males than females, whereas the odds for cannabis-use-only increased faster for females than males. Increases in cannabis-use-only were faster for non-white adolescents.

CONCLUSION

Simultaneous use of alcohol and cannabis is declining among U.S. adolescents, but the decline is slower among females than males. Declines in simultaneous use are largely concomitant with historical declines in alcohol use, indicating that a continued focus on reducing alcohol use among adolescents and young adults has extended benefits to other adolescent substance use. However, cannabis use without any reported past-year alcohol use more than doubled in the last decade, a concerning trend.

Adolescents' and young adults' perceptions of risks and benefits differ by type of cannabis products

INTRODUCTION

Cannabis use patterns among adolescents and young adults (AYAs) have changed recently, with increasing use of non-combustible cannabis products. Little is known about perceived risks or benefits related to non-combustible products (e.g., vaporized and edible cannabis). We examined whether AYAs' perceived risks and benefits differ across four cannabis products, and by use status.

METHODS

We conducted a survey of 433 California AYAs (M_age = 18.9 years old, 66.5% females) during 2017-2018. We compared a variety of perceived risks and benefits corresponding to short-term and long-term use of each product (combustible, blunt, vaporized, and edible cannabis), and between ever and never users.

RESULTS

Participants perceived combustible cannabis and blunts conferred the greatest risk for short-term (bad cough, trouble catching breath) and long-term (lung disease, oral and lung cancer, and heart attack) health outcomes and short-term social risks (friends upset, getting into trouble). These products were also perceived to have greater short-term and long-term benefits (i.e., reducing mental health problems) than vaporized and edible cannabis. The most common perceived risks were "get into trouble" and "become addicted." The most common benefits were "feel high or buzzed" and "feel less anxious." Ever cannabis users perceived less risks and greater benefits related to cannabis use than never users.

CONCLUSIONS

AYAs differentially perceived risks and benefits related to use of four cannabis products. Public health and education efforts should address both perceived and real risks and benefits of specific cannabis products to prevent cannabis use among AYAs.

Frequency of adolescent cannabis smoking and vaping in the United States: Trends, disparities and concurrent substance use, 2017-19

AIM

To quantify the trends in frequent and occasional cannabis vaping, demographic differences and concurrent nicotine and alcohol use.

DESIGN

Observational study. Survey-weighted multinomial logistic regression models assessed trends and disparities in past 30-day cannabis use. Trends were assessed overall and by sex, race/ethnicity, parental education and urbanicity. Multinomial logistic regression models also estimated associations of cannabis use (none, use without vaping, use with vaping) with past 2-week binge drinking and past 30-day nicotine/tobacco use.

SETTING

United States, 2017-19.

PARTICIPANTS

Participants in the national Monitoring the Future (n = 51 052) survey.

MEASUREMENTS

Past 30-day frequent cannabis use (six or more times/30 days) and past 30-day occasional use (one to five times/30 days), with and without vaping.

FINDINGS

Past 30-day frequent cannabis use with vaping and occasional use with vaping rose from 2017 to 2019. Past 30-day frequent and occasional cannabis use without vaping declined. Certain groups, such as Hispanic/Latino or lower socio-economic status adolescents, experienced particularly notable increases in frequent cannabis use with vaping (e.g. prevalence among Hispanic/Latino adolescents). Adolescents who reported smoking and vaping nicotine, and 10+ occasions of binge drinking, were 42.28 [95% confidence interval (CI) = 33.14-53.93] and 10.09 (95% CI = 4.51-22.53) times more likely to report past 30-day cannabis use with vaping, respectively, compared with no use.

DISCUSSION

Cannabis use without vaping appears to be declining among adolescents in the United States, while cannabis use with vaping is accelerating; frequent cannabis vaping is especially increasing, with consistent increases across almost all adolescent demographic groups. Cannabis use among US adolescents remains highly associated with other substance use.

Evaluating the relationship between industry sponsorship and conflicts of interest among systematic review authors on treatments for cannabis use disorder

Background: Cannabis is the most commonly used illicit drug worldwide. In addition to potential adverse effects, an estimated 9% consistent cannabis users are likely to become dependent and may develop a cannabis use disorder (CUD). Methods: This cross-sectional study developed a search strategy using Ovid, MEDLINE, and Ovid Embase for systematic reviews and meta-analyses focused on CUD treatment in June 2020. These reviews were evaluated for conflicts of interest (COIs) per previously developed classification scheme. Our primary objectives were to (1) evaluate the presence of disclosed or undisclosed COI of systematic review authors, regarding treatment of CUD; and (2) determine whether overall summary effect estimates, narrative results and conclusions were influenced by the presence of disclosed or undisclosed COIs among systematic review authors. Results: Our systematic search returned 560 articles which 9 systematic reviews were eligible for data extraction. We found 77.8% (7/9) contained at least one author with a COI. From the 51 authors included, 29.4% (15/51) were found to have a COI. Forty-four percent (4/9) were funded, 22.2% (2/9) were not funded, and 33.3% (3/9) had no funding statements. Out of the 7 systematic reviews with one or more authors containing COI, 14.2% (1/7) included results favoring the treatment group and 28.6% (2/7) included conclusions favoring the treatment group. Our results showed no significance between funding source and results (p = 0.429) or conclusions. Additionally, we found no significance between the presence of COIs with the favorability of results (p = 0.56) or conclusions. Conclusion: Multiple studies favored the treatment of cannabis-containing products, even though COIs were found in the majority of the systematic reviews. COIs have the ability to sway results of a study, which can affect clinical decision-making. Stricter guidelines should be enforced among authors displaying COIs in systematic reviews studying CUD treatment.

A Longitudinal Study of E-Cigarette, Cigarette, and Marijuana Use Sequence in Youth

Objective

There is evidence linking youth use of electronic (e-) cigarettes to subsequent cigarette and marijuana use, raising public health concerns. We examined the sequence of use of e-cigarettes, conventional cigarettes, and marijuana in a longitudinal sample of adolescents, to determine if use of e-cigarettes often preceded use of other substances.

Methods

We collected self-reports from 1123 Oregon adolescents (52% female; 37% Hispanic) longitudinally from 8th to 11th grade (8 total surveys) regarding their lifetime (ever use) and current use (last 30 days) of e-cigarettes, cigarettes, and marijuana. If applicable, students also reported the delivery method of their current marijuana use.

Results

Almost 10% of adolescents reported using e-cigarettes prior to use of cigarettes or marijuana, and the majority of these youth initiated use of marijuana, cigarettes, or both by 11th grade. More youth transitioned from e-cigarette use to marijuana use then from e-cigarettes to use of conventional cigarettes. Participants who were co-using e-cigarettes and marijuana in 11th grade had an increased likelihood of consuming marijuana via vaping, dabbing, and edibles, compared to those who were only using marijuana.

Discussion

E-cigarettes were often the first substance used in this longitudinal sample, and more of these youth subsequently used marijuana compared to cigarettes. While research has focused on the progression from e-cigarettes to cigarettes in youth, these findings indicate that more attention should be focused on the subsequent initiation of marijuana.

Associations of cannabis product source and subsequent cannabis use among adolescents

BACKGROUND

Cannabis is obtained from a variety retail and illicit sources, with unknown implications for youth cannabis use. This study assessed whether source of obtaining cannabis was associated with future cannabis use among adolescents.

METHODS

High-schoolers (N = 835) completed 3 semiannual surveys, reporting use of 7 cannabis sources (i.e., free, bought from someone, from an online dispensary, with a [valid/invalid] medical card, self-grown, or other; separate dichotomous exposure variables) at wave 1 (n = 621; M[SD] age=17.14[.40]) or wave 2 (n = 622; M[SD] age=17.51[.39]). Past-6-month (yes/no) and number of past-30-day (0-30) non-medical use of any cannabis product, combustible, edible, and vaporized cannabis, blunts, and concentrates (i.e., dabs) were reported at waves 2-3. Random-effect time-lagged repeated-measures regression was used to test longitudinal associations of youth's cannabis source (waves 1-2; time-varying exposure) with cannabis use outcomes 6 months later (waves 2-3).

RESULTS

Most youth (72.1%) received cannabis for free; 50.9% bought cannabis from someone, 15.9% used a valid medical card at a brick-and-mortar dispensary, and 3.9% grew cannabis. Buying cannabis from someone (OR=1.46, 95% CI: 1.07-1.99, p = .02) or using a valid medical card (OR=1.99, 95% CI: 1.20-3.31, p = .008) conferred greater odds of any cannabis product use 6 months later. Buying from someone predicted subsequent past-30-day use frequency (RR=1.25, 95% CI:1.05-1.48, p = .01). Some associations between particular cannabis sources and products were observed.

CONCLUSIONS

Adolescents may access cannabis from several sources. Those who purchase cannabis illicitly from someone or from a brick-and-mortar dispensary using a valid medical card may be at increased risk for more persistent and frequent patterns of non-medical cannabis use.

Municipal regulation of cannabis and public health in Canada: A comparison of Alberta, Ontario, and Québec

Canada legalized nonmedical cannabis in October 2018, but significant variations in municipal regulations exist. This study explored the variations that exist and pondered their potential public health consequences. A comparative analysis was completed on the regulations and guidelines that addressed retailers' location and public consumption in the municipalities of Alberta, Ontario, and Québec. Municipal regulations that addressed the location of retailers were more numerous and extensive in Alberta and Ontario (in the context of provincial private retail models) than in Québec (government-based model). Municipalities in Alberta added more restrictions to public consumption laws as compared to municipalities in Ontario and in Québec. These additions were made to Alberta's and Ontario's provincial-level smoking and vaping bans which used tobacco-inspired frameworks, and to Québec's ban on smoking and vaping in all public spaces. The comparative analysis showed the importance of considering municipal cannabis regulations when studying the impact of legalization, given the significant variations that exist. Policy makers should be made aware of these variations in the regulation of cannabis in order to limit health harms and further social inequalities.

Geographical variation in hospitalization for psychosis associated with cannabis use and cannabis legalization in the United States: Submit to: Psychiatry Research

The 2017 National Inpatient Sample database was utilized to investigate the association between cannabis legalization in the United States and hospitalizations for psychosis associated with cannabis use. We compared the odds of hospital discharges for psychosis associated with cannabis use in adults between the Pacific census division (where most states legalized recreational cannabis use) and other divisions using multivariable logistic regression, adjusting for confounders. We calculated a score for each census division representing cannabis legality as the population-weighted sum of state scores: 1=illegal or cannabidiol/low potency cannabis; 2= medical marijuana; and 3=recreational and medical marijuana legalized. Pearson's correlation coefficients (r) quantified the relationship between scores and the proportion of hospitalizations with psychosis associated with cannabis. In 2017, there were an estimated 129,070 hospital discharges for psychosis associated with cannabis use. The Pacific census division had significantly higher odds of discharges than other divisions (adjusted odds ratio 1.55; 95% confidence interval 1.25 - 1.93). There was a significant correlation between the cannabis legality score and proportion of hospital discharges for psychosis associated with cannabis use (r = 0.67, p<0.05). In conclusion, we observed a higher proportion of hospital discharges for psychosis associated with cannabis use in areas with more liberal cannabis legalization laws.

A Clinical Framework for Evaluating Cannabis Product Quality and Safety

Increase in medical cannabis use, along with available products, warrants the need for clinicians to be knowledgeable in evaluating the quality of any cannabis product presented in clinical practice. Determining whether a product is regulated within the region is key in assessing overall quality and safety. Regulated products are held to a higher standard including independent testing, contamination mitigation, and concentration limits. Here, we present a clinical framework in evaluating cannabis products to ascertain the quality and regulation level of the product. Evaluation includes assessing the source company, reviewing product details (e.g., type, cannabinoid content, and labeling), and assessing quality control variables such as manufacturing and decontamination processes. The quality of products patients use is an important part of mitigating cannabis-related harms, especially in medically vulnerable patients. Currently, there is a great need to implement widespread standardization and regulations to ensure product quality and safety.

Perceived Parental Knowledge Reduces Risk for Initiation of Nicotine and Cannabis Vaping: A Longitudinal Study of Adolescents

PURPOSE

This study examines the role of perceived parental knowledge on initiation of nicotine and cannabis vaping among youth.

DESIGN

Longitudinal study from a self-administered online survey. Three waves of data collected in 6-month intervals.

SETTING

79 public and private schools in Texas.

PARTICIPANTS

Adolescents who self-reported never using e-cigarette to vape nicotine (n=1907; weighted sample [N] = 304371) or vape cannabis (n=2212; N=351955) at baseline. Participants were in 8^th, 10^th, and 12^th grade at baseline.

MEASURES

Self-reported measures of nicotine and cannabis vaping.

ANALYSES

Weighted multivariate logistic regression models examined role of perceived parental knowledge at baseline (Spring 2016) as a predictor of nicotine and cannabis vaping initiation at 6-month (Fall 2016) and 12 month (Spring 2017) follow-up. Covariates were age, sex, race/ethnicity, and other tobacco use.

RESULTS

Initiation rates were 5.9% for nicotine vaping and 8.6% for cannabis vaping, at 12-month follow-up overall. Higher perceived parental knowledge was associated with lower odds of nicotine vaping initiation at 6 months (adj OR: .69; 95% CI: .50-.93) and 12 months (adj OR: .68; 95% CI: .50-.92). Similarly, higher perceived parental knowledge was associated with lower odds of cannabis vaping initiation at 6 months (adj OR: .58; 95% CI: .38-.87) and 12 months (adj OR: .53; 95% CI: .38-.74).

CONCLUSION

E-cigarette prevention efforts directed at adolescents should incorporate parent engagement strategies as a method of increasing actual and perceived parental knowledge of their child's location, activities and peer groups.

The impact of cannabis legalization for recreational purposes on youth: A narrative review of the Canadian experience

Cannabis legalization for non-medical purposes (subsequently referred to as "cannabis legalization" or "legalization") took place in Canada in October 2018. One of the federal government's stated goals with cannabis legalization was to protect Canadian youth from cannabis-related harms. The main objective of this narrative review is to describe the impact of cannabis legalization on Canadian youth. To that end, we discuss the regulation of the Canadian cannabis market, outline changes in the epidemiology and parameters of cannabis use (modes of use, potency of cannabis) among youth, and discuss prevention and education initiatives related to cannabis. The Canadian model differs from other jurisdictions that legalized recreational cannabis use, especially with regard to a higher degree of government regulation of the cannabis market. Another difference is the development and endorsement of lower-risk cannabis use guidelines to educate the public and health professionals. The results available for this review cover only 3 years post-legalization. Cannabis legalization in Canada brought an apparent increase in use among Canadian older than 25. However, results for youth are mixed, with the majority of studies showing no pronounced increase. Notably, the trend of a decrease in adolescents' cannabis use seen pre-legalization may have reversed. Emerging evidence also suggests that cannabis-related hospitalizations and emergency department visits among Canadian youth may have increased due to cannabis legalization. Data about changes in the age of initiation, the influence of legalization on sex and gender, and race/ethnicity are limited, with evidence suggesting that the age of initiation slightly increased. So far, there is limited data about the impact of cannabis legalization on Canadian youth. Further long-term monitoring and research to assess the effects of cannabis legalization on Canadian youth.

Presence of Content Appealing to Youth on Cannabis-Infused Edibles Packaging

BACKGROUND

There is a lack of consistent regulation of cannabis edibles packaging to restrict youth-appealing content in the United States.

OBJECTIVE

To describe content appealing to youth on U.S. cannabis-infused edibles packaging.

METHODS

We analyzed 256 photos of cannabis-infused edibles packaging collected from U.S. adults from 25 states, District of Columbia, and Puerto Rico between May 2020 to August 2021. We coded the presence of product knockoffs, human and non-human creatures, images indicating flavor, text indicating flavor, and the number of colors. We compared these codes across states' legalization status (medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization).

RESULTS

Overall, 15% of packages resembled product knockoffs, 23% contained human/non-human creatures, 35% contained flavor images, 91% contained flavor text, and median number of colors was 5 (range from 1 to 10+). Packages purchased in states with medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization differed significantly on product knockoffs (11%, 26%, 38%, p = 0.007), human/non-human creatures (19%, 33%, 63%, p = 0.002), flavor text (93%, 81%, 100%, p = 0.046), and number of colors (median of 5, 5, and 10, p = 0.022).

CONCLUSIONS

Existing laws have not adequately limited content appealing to youth on U.S. cannabis-infused edibles packaging. Robust and consistent regulations in the U.S. are needed to ensure that the packaging of such products does not contain content that appeal to youth and lead to initiation or inadvertent ingestion.

Cannabis Vaping Among Youth and Young Adults: a Scoping Review

Purpose of Review

The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults.

Recent Findings

Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same.

Summary

Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vaping for young people, along with risk factors and reasons for the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-022-00413-y.

Use of highly-potent cannabis concentrate products: More common in U.S. states with recreational or medical cannabis laws

BACKGROUND

Highly-potent cannabis products, e.g., concentrates, entail greater risks of cannabis-related harms than lower-potency products such as plant or flower material. However, little information is available on whether individuals in U.S. states with recreational cannabis laws (RCL) or medical cannabis laws (MCL) are more likely than individuals in U.S. states without cannabis legalization (no-CL) to use highly-potent forms of cannabis.

METHODS

Cannabis-using adults in a 2017 online survey (N = 4064) provided information on state of residence and past-month cannabis use, including types of products used, categorized as low-potency (smoked or vaped plant cannabis) or high-potency (vaping or dabbing concentrates). Multivariable logistic regression models generated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for use of high-potency cannabis products by state cannabis legalization status (RCL, MCL, no-CL).

RESULTS

Compared to participants in no-CL states, participants in RCL states had greater odds of using high-potency concentrate products (aOR=2.61;CI=1.77-3.86), as did participants in MCL-only states (aOR=1.55;CI=1.21-1.97). When participants in RCL states and MCL states were directly compared, those in RCL states had greater odds of using high-potency concentrate products (aOR=1.69;CI=1.27-2.42).

DISCUSSION

Although the sample was not nationally representative and the cross-sectional data precluded determining the direction of effect, results suggest that use of high-potency cannabis concentrates is more likely among those in RCL states. Clinicians in RCL states should screen cannabis users for harmful patterns of use. Policymakers in states that do not yet have RCL should consider these findings when drafting new cannabis laws, including the specific products permitted and how best to regulate them.

Changes in cannabis use modes among Canadian youth across recreational cannabis legalization: Data from the COMPASS prospective cohort study

INTRODUCTION

Canadian youth consume cannabis in multiple ways, including by smoking, vaping, and eating or drinking. Existing evidence suggests that these behaviours may change after law liberalization, though data regarding youth are scarce. We investigated changes in cannabis modes of use and associated factors across the federal legalization of recreational cannabis use for adults in Canada, among a large sample of underage youth before alternative products were made legally available.

METHODS

Data were available from 2953 longitudinally linked Canadian high school students who reported on their cannabis use during the 2017/2018 and 2018/2019 school years. We explored whether students maintained a single or multiple cannabis use mode(s), contracted, or expanded the number of modes used. We then used generalized estimating equations to analyse associations of baseline characteristics with use mode trajectory.

RESULTS

Expansion of cannabis use modes (42.3%) was more common than maintenance of a single mode (31.3%), maintenance of multiple modes (14.3%), or reduction (12.1%). Students who maintained multiple modes were significantly more likely to have high amounts of weekly spending money (AOR 1.68), to binge drink (AOR 2.25) or vape (AOR 1.99), to use cannabis regularly (AOR 2.67), and to endorse more symptoms of depression (AOR 1.06). School support for quitting tobacco, drug, or alcohol use appeared to have no effect.

CONCLUSIONS

Multi-modal cannabis use increased among Canadian youth in our sample. Its association with other substance use and depressive symptoms may indicate clustering of additional harms. Screening for this use pattern may assist in identifying high-risk substance use and should be considered in the design of harm reduction programming.

Longitudinal trajectories of E-cigarette use among adolescents: A 5-year, multiple cohort study of vaping with and without marijuana

E-cigarette use harms adolescent health, yet it continues to escalate rapidly among teens nationwide. This longitudinal study sought to identify and differentiate between developmental trajectories of past 30-day e-cigarette use with and without marijuana (i.e., liquid THC) across adolescence (11-19 years old). Three population-based cohorts of adolescents (n = 3907; N = 461,069) living in major metropolitan areas of Texas (Houston, Dallas-Ft. Worth, San Antonio, Austin) completed up to 9 Waves of an e-cigarette use survey, from 2014 to 2019. Growth curve models (GCMs) were used to identify average trajectories of past 30-day e-cigarette use, by cohort. Growth mixture models (GMMs) were used to investigate developmental patterns in these trajectories, by cohort. Sociodemographic differences in trajectories were also investigated. Stable trajectories of e-cigarette use with and without marijuana were identified, from 11 through 19 years of age. Trajectories varied by age of onset; frequency and escalation in use; and substance used. With one exception, all trajectories of e-cigarette use escalated with age. Moreover, age of onset and progression in use were positively related. The most problematic trajectories, corresponding to more frequent use, were observed among the younger cohorts compared to the oldest. Primary prevention is critical. Interventions to prevent the onset and progression in e-cigarette use among teens must begin early (e.g., in middle school) and be sustained throughout adolescence.

The Potential Impact of Legalization of Recreational Cannabis among Current Users: A Qualitative Inquiry

Given legislative initiatives in Rhode Island pertaining to consideration of cannabis legalization for recreational purpose, a qualitative inquiry was conducted regarding anticipated changes in use among recreational cannabis users in Rhode Island. Five focus groups were conducted with recreational cannabis users (N = 31; 6-7 per group). Participants were queried about anticipated impact of legalization on their use patterns. Themes were identified using applied thematic analysis. Participants discussed (1) a desire to maintain the status quo due to satisfaction with local cannabis regulations and their current use behaviors, (2) how and why cannabis use may change, including pros and cons of legalization, and (3) anticipated changes in purchasing behavior given display and legitimacy of legal dispensaries. While participants anticipate use levels and prevalence may remain relatively stable following legislation changes, findings suggest possible changes related to mode of administration and location of use. Public health concerns exist related to high-risk potencies and use of cannabis in edible form; therefore, trialing of new cannabis products has important clinical implications should legalization occur in Rhode Island.

Form and content of Jamaican cannabis edibles

BACKGROUND

In 2017, the Jamaican government banned the sale of cannabis-infused edibles after reports of over-intoxication in adults and children. There is a general lack of public awareness regarding the risk involved with edible dosage. Vandrey et al. in 2015 reported that random cannabis edibles sampled from dispensaries in California and Washington in the USA failed to meet the basic labeling standards for pharmaceuticals (Vandrey et al.; JAMA 2015). This study aims to measure the levels of THC and CBD in a variety of edibles available locally in order to establish current cannabinoid content and to report on safety and packaging. This study is deemed necessary as no such study has been done to measure the potency levels of edibles and to raise awareness of the potential risk to children.

METHODS

Forty-five cannabis-infused edible items were collected as convenience samples over a 4-year period (2014-2018) and analyzed. The QuEChERS technique (modified) was used to extract cannabinoids from each item. The extracts were then derivatized with MSTFA prior to analysis by gas chromatography-mass spectrometry (GC-MS). The descriptive statistics were calculated using the Statistical Package for Social Sciences-SPSS Software. Descriptive statistics presented include the mean, median, standard deviation, and range for each product category. The distribution of data with a box and whisker plot and frequency of THC to CBD ratios with a histogram was also presented.

RESULTS

Edibles on the Jamaican market comprise baked goods, candies, frozen foods, and beverages. Eighty-six percent of samples were poorly labeled and failed to meet basic labeling requirements. None of the packages were observed to be child-proof. THC levels ranged from 0.01 to 99.9 mg per product while CBD levels ranged from 0.001 to 69.2 mg per product. The highest THC and CBD levels were detected in cookies and brownies. Thirty percent of the samples had THC levels greater than the recommended 10 mg THC per serving.

CONCLUSION

The lack of proper labeling and the wide range of THC levels in cannabis edibles raises public health concerns for all consumers including inexperienced persons who may be at a greater risk of overdosing. Concern must also be raised over the possibility that the attractive and tasty ways in which the drug is being presented might tempt young children and teens to take cannabis. Impact statement It is hoped that this information will raise public awareness of the current potential danger these edibles pose to children and inexperienced users and that policymakers will see the need for the imposition of suitable regulations.

Correlates of the use of electronic devices to vape cannabis in a cohort of young Swiss male reporting current cannabis use

BACKGROUND

Information about correlates of cannabis vaping in Europe is scarce.

METHODS

In a cohort of 1613 Swiss young males currently using cannabis, we used logistic regression, adjusting for age, linguistic region and education to assess the association between sensation seeking, substance use and sociodemographic variables with cannabis vaping.

RESULTS

Mean age was 25.38 years, 60.4% had post-secondary education and 57.3% lived in French-speaking cantons; 26.3% met criteria for nicotine dependence, 16.0% met criteria for alcohol use disorder and 34.9% used illicit drugs other than cannabis; 27.4% used cannabis at least twice a week and 27.8% met criteria for cannabis use disorder (CUD). Ninety-four participants (5.8%) reported cannabis vaping (of them 87.4% reported infrequent cannabis vaping). In the adjusted analysis, using joints with no tobacco {adjusted odds ratio (aOR) [95% confidence interval (CI)] = 1.45 (1.02-1.76)}, water pipe with [aOR (95% CI) = 1.70 (1.29-2.24)] and without tobacco [aOR (95% CI) = 2.15 (1.60-2.87)], cannabis mixed with food [aOR (95% CI) = 1.61 (1.29-2.02)], using cannabis >2 times a week [aOR (95% CI) = 3.73 (2.40-5.81)], meeting criteria for CUD [aOR (95% CI) = 4.19 (2.70-6.50)], using illicit drugs other than cannabis [aOR (95% CI) = 1.88 (1.23-2.87)], weekly number of alcohol drinks [aOR (95% CI) = 1.01 (1.00-1.03)] and living in the German-speaking area of Switzerland [aOR (95% CI) = 2.70 (1.71-4.25)] were associated with higher odds of cannabis vaping; post-secondary schooling [aOR (95% CI) = 0.37 (0.16-0.86)] and vocational training [aOR (95% CI) = 0.41 (0.17-0.99)] (as opposed to primary schooling) were associated with lower odds of cannabis vaping.

CONCLUSION

Cannabis vaping might be a marker of riskier behaviours among cannabis users.