Perceived harms and benefits of tobacco, marijuana, and electronic vaporizers among young adults in Colorado: implications for health education and research

Assessment of Online Marketing and Sales Practices Among Recreational Cannabis Retailers in Five U.S. Cities

Background: With more states legalizing recreational cannabis, examining cannabis retail and marketing is crucial, as it may influence consumers' perceptions and behaviors. Particularly understudied is online cannabis retail. Methods: In Spring 2022, coders collected and analyzed data regarding retailer characteristics, age verification, and marketing strategies (e.g., product availability, health-related content, promotions, website imagery) among 195 cannabis retail websites in five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive analyses characterized the websites overall and across cities. Results: Overall, 80.5% verified age for website entry, and 92.8% offered online purchases (92.3% of retailers in Seattle, where prohibited). Of these, 82.9% required age verification for purchases, and 30.9% offered delivery. Almost all (>92%) offered flower/bud, concentrates, edibles, vaping devices, topicals, and tinctures. Health warnings were displayed on 38.3% of websites. Although all five states required health warnings regarding use during pregnancy, only 10.3% had these warnings. In addition, 59.0% posted some unsubstantiated health claims, most often indicating physical and mental health benefits (44.6%). Although Colorado, Washington, and Oregon prohibit health claims, 51.2-53.8% of these retailers posted them. Discounts, samples, or promotions were present on 90.8% of websites; 63.6% had subscription/membership programs. Subpopulations represented in website content included the following: 27.2% teens/young adults, 26.2% veterans, 7.2% sexual/gender minorities, and 5.6% racial/ethnic minorities. Imagery also targeted young people (e.g., 29.7% party/cool/popularity, 18.5% celebrity/influencer endorsement). Conclusions: Regulatory efforts are needed to better monitor promotional strategies and regulatory compliance (e.g., health claims, youth-oriented content, underage access) among online cannabis retailers.

Situations and roles of cannabis versus cigarette use: Integrating ecological momentary assessment with qualitative mapping interviews

Use of both cannabis and tobacco has surpassed use of tobacco alone among young adults in California. To better understand why, we collected data with 32 young adults ages 18-30 in Northern California who regularly used cigarettes and cannabis and had diverse sexual, gender, racial, and ethnic identities. Geographically-explicit ecological momentary assessment (EMA; 30 days) was integrated with qualitative mapping interviews. We found contrasting situations of use for cannabis (e.g., around other people) versus cigarettes (e.g., recent discrimination) and different reasons for why participants chose one substance over the other (e.g., enhancing experiences vs. stepping away). Understanding when and why diverse young adults choose cannabis versus cigarettes as they navigate everyday environments helps explain how cannabis and tobacco retail markets shape substance use disparities over time.

Young adult retail purchases of cannabis, product category preferences and sales trends in California 2018-21: Differences compared with older adults

AIMS

The aim of this study is to identify cannabis products according to their appeal among young adults and measure product sales trends.

DESIGN, SETTING AND PARTICIPANTS

This was a retrospective comparative study using point-of-sale data from licensed recreational cannabis retailers that include buyer age with birth year entered by retailers, set in California, USA. Cannabis purchases by young adults (aged 21-24, GenZ) were compared with older adults (age 25+) over 4 years (2018-21).

MEASUREMENTS

Sales for six cannabis product categories were analyzed using a commercial data set with imputations and a raw data set. Age-appeal metrics were dollar and unit sales to young adults, and dollar and unit share ratios (young adults/older adults), where a share ratio of 100 denotes age-appeal comparability. A product category was considered more young-adult appealing than others if its mean on a metric was at least one standard deviation above the grand mean across all product categories.

FINDINGS

Flower (cannabis plant material) and vapor pen appealed to young adults based on absolute dollar sales, dominating young-adult spending compared with other cannabis products (37.24 and 31.83%, respectively). Vapor pen and concentrate appealed to young adults based on dollar share ratios of 152, meaning these products comprised a 52% greater share of young-adult cannabis spending relative to older-adult spending (31.83/20.97% and 10.47/6.88%, respectively). Less appealing to young adults were pre-roll, edible/beverage and absorbable products (tincture/sublingual, capsule and topical). Flower showed the largest dollar sales growth (B = +$3.50 million/month), next to vapor pen (B = +$1.55 million/month). Vapor pen tied for highest growth in the percent of product dollars from the largest package size (B = +0.85%/month) and showed the steepest price decline (B = -0.53 price per gram/month).

CONCLUSIONS

In California, USA, from 2018 to 2021, relative to older adults, young adults spent a greater share of their cannabis dollars on vapor pen and concentrate (products with high potency of delta-9-tetrahydrocannabinol).

The Developmental Trajectory to Cannabis Use Disorder

The increase of cannabis use, particularly with the evolution of high potency products, and of cannabis use disorder (CUD) are a growing healthcare concern. While the harms of adult use and potential medicinal properties of cannabis continue to be debated, it is becoming evident that adolescent cannabis use is a critical window for CUD risk with potential lifelong mental health implications. Herein, we discuss mental health consequences of adolescent cannabis use, factors that contribute to the risk of developing CUD, and what remains unclear in the changing legal landscape of cannabis use. We also discuss the importance of preclinical models to provide translational insight about the causal relationship of cannabis to CUD-related phenotypes and conclude with highlighting opportunities for clinicians and allied professionals to engage in addressing adolescent cannabis use.

Marijuana Message Channels, Health Knowledge, Law Knowledge, and Confidence in Knowledge as Risk and Protective Factors of Marijuana Use among College Students

Marijuana use among U.S. college students is the highest since the mid-1980s. Because knowledge about marijuana and confidence in the knowledge are related to changing marijuana laws and marijuana-related messages ubiquitous in college students' information environment, we examined their relationships with use. The Structural Equation Modeling method was used to analyze the relationships using survey responses from 249 college students in an adult-use marijuana legal state. Marijuana health knowledge was related to less use, and law knowledge was related to more use. Both relationships were mediated by perceived risk. Confidence in knowledge was related to more use directly as well as indirectly via lower peer disapproval and lower perceived risk. Among various marijuana message channels, peers were the most influential, contributing to lower health knowledge and higher confidence in knowledge.

The impact of recreational cannabis legalization on youth: the Colorado experience

Over the past two decades, cannabis policies have liberalized in the United States, culminating in the legalization of recreational cannabis in Colorado and Washington state in 2012. This review will focus on the impact of recreational cannabis legalization in Colorado. While the prevalence of past-year and past-month cannabis use has remained relatively steady among adolescents post-legalization, the prevalence of young adult use has continued to rise. Cannabis products with increased potency have become more prevalent and widely used. There are concerns that the use of products with increased potency will increase risk for cannabis use and comorbid mental health disorders, particularly cannabis-induced psychosis and suicidal behavior, although more research is needed to fully understand the impact of high-potency products. Since the legalization of recreational cannabis, numerous additional public health concerns have emerged: unintentional overdoses requiring acute care visits, electronic vaping-associated lung injury, increased motor vehicle collisions related to cannabis consumption, and higher rates of cannabis use during pregnancy. Lessons learned from the first decade of cannabis legalization emphasize the need for research efforts to provide evidence-based guidelines, inform prevention strategies, and implement selective interventions for at-risk populations including youth, individuals with comorbid mental health disorders, and individuals who are pregnant.

Cannabis Use and Its Impact on Mental Health in Youth in Australia and the United States: A Scoping Review

Cannabis is a widely used substance among the youth population, with an estimated 2.8% currently smoking cannabis. Its popularity is growing due to the perception of its harmless nature and lack of dependence. However, this increase in use has been linked to mental health issues, especially since its partial decriminalisation in some part of the United States and Australia. The objective of this scoping review was to investigate the mental health impact of cannabis use among young people in Australia and the United States. A scoping review was conducted according to the Joanna Briggs Institute (JBI) protocol, and articles were searched from ProQuest Central and EBSCO Host (MEDLINE and CINAHL databases). A total of 24 articles were analysed, including systematic reviews, meta-analyses, and cohort, longitudinal, and cross-sectional studies. The findings indicate that cannabis use is associated with depression, psychosis, suicide, cannabis use disorder, dependence, decline in cognitive function, and the development of externalising behaviour, particularly attention deficit hyperactivity disorder. However, the relationship between cannabis use and anxiety is equivocal. Mental health issues were more prevalent with increased frequency, duration, intensity, and type of use. Female, minority, LGBTQI, African American, Aboriginal, and Torres Strait Islander youth and the age of onset of cannabis use were significant factors for the development of mental health problems. The increasing prevalence of cannabis use among high school and college students suggests the need for intervention by teachers, parents, and community health professionals to make them aware of its potential negative mental health outcomes. Moreover, policy-level interventions by the government are required to discourage young people from using cannabis.

The Marketing and Perceptions of Non-Tobacco Blunt Wraps on Twitter

OBJECTIVE

Non-tobacco blunt wraps (N-TBWs), which entered the marketplace in 2017, are being promoted as an alternative to traditional TBWs (e.g., cigarillos) for blunt smoking. The lack of studies on these novel products warrants an investigation. This study was the first to explore blunt smokers' perceptions about N-TBWs and the extent of product marketing on Twitter.

METHODS

A corpus of tweets from Twitter, posted between January 2017 and November 2021, were identified by a Boolean search string (N = 149,343), where 48,695 tweets were classified as relevant by a machine learning algorithm. These relevant tweets were further screened and labeled as promotional or organic based on product URLs, usernames, keywords, or hashtags. Topic modeling using Dirichlet Allocation was then employed for identifying latent patterns of words among relevant tweets. The Social Networking Potential (SNP) score was employed for identifying influential accounts.

RESULTS

Most relevant tweets (89%) were organic, non-promotional expressions about N-TBWs. Account users who only posted non-promotional tweets had a significantly higher SNP than those who only posted promotional tweets. Yet, neither of the two groups of account users consisted of known celebrities. Topic modeling revealed three broad groups of topics (7 in total) denoting the attributes of hemp N-TBWs, interest in non-hemp N-TBWs, and product marketing.

CONCLUSIONS

The large proportion of organic tweets is indicative of the nascency of N-TBWs, which will need to be marketed more extensively if they are to replace cigar products used by blunt smokers.

"I think we can do without [tobacco]": support for policies to end the tobacco epidemic among California adolescents

INTRODUCTION

The tobacco endgame, policies aiming to end the commercial tobacco epidemic, requires sustained public support, including among youth. We assessed endgame support among California (USA) adolescents, including their reasons and associated participant and policy-specific factors.

METHODS

Teens, Nicotine and Tobacco Project online surveys (n=4827) and focus groups were conducted in 2021 and 2022 among California residents aged 12-17 years. Cross-sectional survey participants were asked their agreement level with eight policy statements related to tobacco and/or cannabis sales restrictions, use in public places and use in multiunit housing. Ordered logistic regression modelled level of agreement according to respondent characteristics, behaviours and statement content. Qualitative data were collected through focus groups (n=51 participants), which were analysed to provide insight into support for different policies.

RESULTS

Most survey participants agreed or strongly agreed with tobacco product sales restrictions (72%-75%, depending on the policy), bans on use in public spaces (76%-82%) and smoke-free (79%) and vape-free (74%) apartment buildings. Support was stronger among younger, female, Asian and tobacco non-using participants and for policies directed at 'tobacco' (vs 'vapes' or cannabis), at flavoured tobacco (compared with all tobacco), and when statements featured 'should end' (vs 'not allowed'). Focus group participants who were supportive viewed policies as protecting children from harmful products, while those less supportive cited concerns about limiting adults' freedoms and unintended consequences.

CONCLUSIONS

Most participants supported strong tobacco control policies. Public communication that promotes broader endgame benefits besides protecting youth and accelerates industry denormalisation may counter youth concerns and further bolster their support.

Young Adults' Perceptions of and Intentions to Use Nicotine and Cannabis Vaporizers in Response to e-Cigarette or Vaping-Associated Lung Injury Instagram Posts: Experimental Study

BACKGROUND

Inhaling aerosolized nicotine and cannabis (colloquially called "vaping") is prevalent among young adults. Instagram influencers often promote both nicotine and cannabis vaporizer products. However, Instagram posts discouraging the use of both products received national media attention during the 2019 outbreak of e-cigarette or vaping-associated lung injury (EVALI).

OBJECTIVE

This experiment tested the impact of viewing Instagram posts about EVALI, varying in image and text valence, on young adults' perceived harmfulness of nicotine and cannabis products, perceived risk of nicotine and cannabis vaporizer use, and intentions to use nicotine and cannabis vaporizers in the future.

METHODS

Participants (N=1229) aged 18-25 (mean 21.40, SD 2.22) years were recruited through Qualtrics Research Services, oversampling for ever-use of nicotine or cannabis vaporizers (618/1229, 50.3%). Participants were randomly assigned to view Instagram posts from young people portraying their experiences of EVALI in a 2 (image valence: positive or negative) × 2 (text valence: positive or negative) between-subjects experiment. Positive images were attractive and aesthetically pleasing selfies. The positive text was supportive and uplifting regarding quitting the use of vaporized products. Negative images and text were graphic and fear inducing. After viewing 3 posts, participants reported the perceived harmfulness of nicotine and cannabis products, the perceived risk of nicotine and cannabis vaporizer use, and intentions to use nicotine and cannabis vaporizers in the future. Ordinal logistic regression models assessed the main effects and interactions of image and text valence on perceived harmfulness and risk. Binary logistic regression models assessed the main effects and interactions of image and text valence on intentions to use nicotine and cannabis vaporizers. Analyses were adjusted for product use history.

RESULTS

Compared to viewing positive images, viewing negative images resulted in significantly greater perceived harm of nicotine (P=.02 for disposable pod-based vaporizers and P=.04 for other e-cigarette "mods" devices) and cannabis vaporized products (P=.01), greater perceived risk of nicotine vaporizers (P<.01), and lower odds of intentions to use nicotine (P=.02) but not cannabis (P=.43) vaporizers in the future. There were no significant main effects of text valence on perceived harm, perceived risk, and intentions to use nicotine and cannabis vaporized products. No significant interaction effects of image and text valence were found.

CONCLUSIONS

Negative imagery in Instagram posts about EVALI may convey the risks of vaporized product use and discourage young adults from this behavior, regardless of the valence of the post's text. Public health messaging regarding EVALI on Instagram should emphasize the risk of cannabis vaporizer use, as young adults may otherwise believe that only nicotine vaporizer use increases their risk for EVALI.

Changes in perceived harms of tobacco and cannabis and their correlations with use: A panel study of young adults 2014-2020

PURPOSE

Perceived harm is associated with substance use. Changes in product and policy landscapes may impact perceived harms of tobacco and cannabis. This study aimed to examine changes in young adults' perceived harms of tobacco and cannabis and their associations with use behavior during a period including both before and after legalization of cannabis.

METHODS

We conducted a panel survey of California Bay Area young adults (mean age = 23.5 years old, 64.4% female) in 2014 and 2019-2020. Participants (N = 306) reported past 30-day use and perceived harms of tobacco and cannabis at both waves. Perceived harms to health of cannabis and tobacco (cigarettes, e-cigarettes, hookah, smokeless tobacco, and secondhand tobacco smoke) were measured from 1-"Not at all harmful" to 7-"Extremely harmful." Mixed-effects logistic regressions examined associations between perceived harms and use of tobacco and cannabis, controlling for demographics.

RESULTS

Participants perceived lower harm for cannabis than for tobacco products. Perceived harms of e-cigarettes, hookah, and smokeless tobacco significantly increased over time; while perceived harms of cigarettes, secondhand tobacco smoke, and cannabis did not change. Increased perceived harm of e-cigarettes was associated with lower odds of any tobacco use (OR = 0.72, 95%CI = 0.56, 0.92), and increased perceived harm of cannabis was associated with lower odds of any cannabis use (OR = 0.51, 95%CI = 0.42, 0.62).

CONCLUSIONS

Findings suggest that perceived harms of e-cigarettes and cannabis play important roles in driving young adult use behaviors. Risk communication efforts that increase perceptions of health harms related to e-cigarettes and cannabis may decrease use of tobacco and cannabis among young people.

Short-Term Effects of Recreational Cannabis Legalization on Youth Cannabis Initiation

PURPOSE

As recreational cannabis is legalized, it is critical to know the impacts of legalization on youth cannabis use. Existing research generates conflicting results and does not shed light on channels of effects. This study investigates the impacts of legalization on youth cannabis initiation and overall cannabis use prevalence.

METHODS

We used Interrupted Time Series design and data from nationally-representative repeated cross-sectional Canadian surveys spanning 16 years. The primary outcomes were cannabis initiation rates and cannabis use prevalence among youths. The secondary outcomes were self-reported age of first cannabis use, ease of cannabis access, and perception of cannabis harm among youths.

RESULTS

After legalization, cannabis initiation rate among youths was 2.7 percentage points (95% confidence interval: 1.7-3.7; p < .01) or 69% higher, although there was no significant increase in the overall prevalence of cannabis use. Furthermore, there was a 4-month delay in the average age of first cannabis use among youths aged 17-18 years (95% confidence interval: 2.6-5.5 months; p < .01). The legalization was associated with greater perception of cannabis harm but also easier access to cannabis.

DISCUSSION

The impacts of legalization on youth cannabis use after 1 year are mixed. Although we observed an increase in cannabis initiation among youths who had never used cannabis, there was no change in the overall prevalence of cannabis use, implying a possible offsetting increase in cannabis cessation among existing users. To achieve legalization's goal of reducing youth cannabis use, policy measures are needed to curb youth cannabis access and initiation.

Qualitative Research on Cannabis Use Among Youth: A Methodological Review

Recreational cannabis legalization has encouraged research regarding cannabis use among youth, especially the use of qualitative approaches. In fact, alcohol and drug use journals have recently encouraged qualitative submissions and provided criteria to ensure “high-quality” research. This study provides an objective account of the qualitative approaches used by researchers in this field and discusses implications for future research. A methodological review was conducted for studies published between January 2010 and November 2019. Targeted keyword searches in four research databases returned 1956 unique records. Pairs of reviewers independently screened records against eligibility criteria and charted data for study philosophical positioning, methodology, study aims, sampling, sample, data collection, and data analysis. 23 studies met the inclusion criteria. Several gaps in study quality criteria are observed: less than half of the studies specified the overarching methodology and just two stated philosophical positioning, with some methods unjustified. Implications for future research are discussed.

'It brings light to what you really put into your body': a focus group study of reactions to messages about nicotine reduction in cigarettes

OBJECTIVE

In 2017, the US Food and Drug Administration (FDA) announced a proposed regulation to lower nicotine in cigarettes to minimally addictive levels to help smokers quit. We sought to explore effective message strategies communicating about nicotine reduction in cigarettes across the different key audiences that the regulation is most likely to influence.

METHODS

We designed four types of messages: efficacy messages, risk messages, a message about alternative sources of nicotine and a compensation message. Sixteen virtual focus groups were conducted in Atlanta and San Francisco in April-May 2020. Data were analysed in NVivo 12.0 using a thematic analysis approach.

FINDINGS

Exclusive smokers were receptive to both efficacy messages and risk messages. Dual users were the only group that was open to resorting to alternative sources of nicotine. Former smokers were critical of these messages as promoting the new kinds of cigarettes and potentially encouraging initiation and relapse of smoking. Non-smokers felt that efficacy messages downplayed the risks of smoking and did not scare people away from smoking. Presenting information that very low nicotine cigarettes (VLNCs) still contain harmful chemicals made smokers question continued smoking in the absence of nicotine and view VLNCs as harmful.

CONCLUSIONS

Messages communicating about nicotine reduction in cigarettes might help to motivate smokers to quit and can correct the misperceptions that VLNCs are less harmful. The FDA should consider specific target audiences and use different messages that complement each other in communicating about this regulation.

Trends in Alcohol, Cigarette, E-Cigarette, and Nonprescribed Pain Reliever Use Among Young Adults in Washington State After Legalization of Nonmedical Cannabis

PURPOSE

Liberalization of cannabis laws may be accompanied by changes in the use of substances other than cannabis and changes in associations of cannabis use with other types of substance use. This study assessed (1) trends in alcohol, nicotine, and nonprescribed pain reliever use and (2) changes in associations of cannabis use with these other substances among young adults in Washington State after nonmedical cannabis legalization.

METHODS

Regression models stratified by age (18-20 vs. 21-25) were used to analyze six annual waves of cross-sectional survey data from a statewide sample from 2014 through 2019 (N = 12,694).

RESULTS

Prevalence of past-month alcohol use, heavy episodic drinking (HED), and cigarette use and prevalence of past-year pain reliever misuse decreased, while the prevalence of past-month e-cigarette use increased since 2016 (the first year assessed). Across years and age groups, the prevalence of substance use other than cannabis was higher among occasional and frequent cannabis users compared to cannabis nonusers. However, associations between both occasional (1-19 days in the prior month) and frequent (20+ days) cannabis use and pain reliever misuse and between frequent cannabis use and HED weakened over time among individuals ages 21-25.

DISCUSSION

Contrary to concerns about spillover effects, implementation of legalized nonmedical cannabis coincided with decreases in alcohol and cigarette use and pain reliever misuse. The weakening association of cannabis use with the use of other substances among individuals ages 21-25 requires further research but may suggest increased importance of cannabis-specific prevention and treatment efforts.

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.

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.

Wonder or evil?: Multifaceted health hazards and health benefits of Cannabis sativa and its phytochemicals

Cannabis sativa, widely known as 'Marijuana' poses a dilemma for being a blend of both good and bad medicinal effects. The historical use of Cannabis for both medicinal and recreational purposes suggests it to be a friendly plant. However, whether the misuse of Cannabis and the cannabinoids derived from it can hamper normal body physiology is a focus of ongoing research. On the one hand, there is enough evidence to suggest that misuse of marijuana can cause deleterious effects on various organs like the lungs, immune system, cardiovascular system, etc. and also influence fertility and cause teratogenic effects. However, on the other hand, marijuana has been found to offer a magical cure for anorexia, chronic pain, muscle spasticity, nausea, and disturbed sleep. Indeed, most recently, the United Nations has given its verdict in favour of Cannabis declaring it as a non-dangerous narcotic. This review provides insights into the various health effects of Cannabis and its specialized metabolites and indicates how wise steps can be taken to promote good use and prevent misuse of the metabolites derived from this plant.

Cannabis Vaping: Existing and Emerging Modalities, Chemistry, and Pulmonary Toxicology

The outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) has been cause for concern to the medical community, particularly given that this novel illness has coincided with the COVID-19 pandemic, another cause of severe pulmonary illness. Though cannabis e-cigarettes tainted with vitamin E acetate were primarily associated with EVALI, acute lung injuries stemming from cannabis inhalation were reported in the literature prior to 2019, and it has been suggested that cannabis components or additives other than vitamin E acetate may be responsible. Despite these concerning issues, novel cannabis vaporizer ingredients continue to arise, such as Δ8-tetrahydrocannabinol, Δ10-tetrahydrocannabinol, hexahydrocannabinol, and cannabichromene. In order to address cannabis e-cigarette safety and vaping in an effective manner, we provide a comprehensive knowledge of the latest products, delivery modes, and ingredients. This perspective highlights the types of cannabis vaping modalities common to the United States cannabis market, with special attention to cartridge-type cannabis e-cigarette toxicology and their involvement in the EVALI outbreak, in particular, acute lung injurious responses. Novel ingredient chemistry, origins, and legal statuses are reviewed, as well as the toxicology of known cannabis e-cigarette aerosol components.

Exploring Impact of Marijuana (Cannabis) Abuse on Adults Using Machine Learning

Marijuana is the most common illicit substance globally. The rate of marijuana use is increasing in young adults in the US. The current environment of legalizing marijuana use is further contributing to an increase of users. The purpose of this study was to explore the characteristics of adults who abuse marijuana (20-49 years old) and analyze behavior and social relation variables related to depression and suicide risk using machine-learning algorithms. A total of 698 participants were identified from the 2019 National Survey on Drug Use and Health survey as marijuana dependent in the previous year. Principal Component Analysis and Chi-square were used to select features (variables) and mean imputation method was applied for missing data. Logistic regression, Random Forest, and K-Nearest Neighbor machine-learning algorithms were used to build depression and suicide risk prediction models. The results showed unique characteristics of the group and well-performing prediction models with influential risk variables. Identified risk variables were aligned with previous studies and suggested the development of marijuana abuse prevention programs targeting 20-29 year olds with a regular depression and suicide screening. Further study is suggested for identifying specific barriers to receiving timely treatment for depression and suicide risk.

Reasons for individual and concurrent use of vaped nicotine and cannabis: their similarities, differences, and association with product use

BACKGROUND

Understanding similarities, differences, and associations between reasons people vape nicotine and cannabis may be important for identifying underlying contributors to their co-use.

METHODS

A cross-sectional survey of 112 co-users of vaped nicotine and cannabis was conducted in 2020. A convenience sample of participants was recruited for the survey using Amazon Mechanical Turk. Participants responded to questions about their reasons for individual nicotine and cannabis product use and co-use and rated their level of agreement using numerical scales. Mean ratings for each reason for use subscale were examined across all participants and compared using paired samples t tests. Associations between reasons for use ratings and product consumption behaviors were examined using linear and logistic regression analyses.

RESULTS

Cannabis vaping and smoking exhibited similar mean ratings for user experience and product/substance-related reasons for use. Mean ratings for reasons related to product utility were similar for cannabis vaping and nicotine vaping. Mean ratings for utility-related reasons for use were higher for cannabis vaping than cannabis smoking (mean (SD), 3.6 (± 1.0) vs. 2.6 (± 1.2), p < 0.0001). On average, harm reduction-related reasons for use were rated higher for nicotine vaping than cannabis vaping (2.4 (± 1.6) vs. 1.8 (± 1.4), p < 0.0001). Regression models showed higher average ratings for utility-related (b = 0.32; 95% CI, 0.03-0.60) and harm reduction-related (b = 0.21; 95% CI, 0.04-0.37) reasons for nicotine vaping were associated with more frequent nicotine vaping (both p < 0.05). Higher average ratings for instrumentality-related reasons for co-use corresponded with more frequent monthly nicotine vaping (b = 0.26; 95% CI, 0.08-0.44) and higher odds of ever chasing cannabis with nicotine (aOR, 3.06; 95% CI, 1.29-7.30).

CONCLUSIONS

Vaping serves purposes that differ by substance; nicotine vaping was more closely related to reducing tobacco smoking-related harms, and cannabis vaping was more closely related to circumventing social problems posed by cannabis smoking. Lifetime sequential co-use practices and more frequent nicotine vaping were associated with enhancing the intoxicating effects of cannabis. While replication of these findings using non convenience-based sampling approaches is warranted, results underscore the need to consider shared and unique aspects of nicotine and cannabis vaping, as well as cross-substance interactions between nicotine and cannabis.

Theoretical understanding of contextual motivations for sustained adolescent marijuana use in South Africa

Background

Although various reasons for adolescent marijuana use have extensively been explored, contextual factors that sustain the practice in settings where the plant is illegally cultivated, especially in South Africa, remain a grey area.

Aim

We aimed to explore the contextual factors of sustained adolescent marijuana use in two illicit marijuana-growing settings of the Ingquza Hill Local Municipality of South Africa, based on the differential opportunity theory (DOT) and subcultural theory (SCT).

Setting

The study was conducted in two illicit marijuana-growing communities in the Ingquza Hill Local Municipality of the Eastern Cape Province of South Africa.

Methods

Exploratory qualitative research, using focus group discussions approach, was conducted amongst 37 participants, four focus groups and in two communities in the Ingquza Hill Municipality of the Eastern Cape Province of South Africa. Purposive and snowball sampling techniques were used to select the communities and participants, respectively. The data were analysed using a thematic content analysis approach and presented under various themes.

Results

Nine themes, grouped under two broad factors, DOT influences (availability and affordability of marijuana, idleness and means of dealing with personal problems) and SCT influences (peer conformity, the pleasure derived from marijuana smoking, manipulation of appetite, health reasons, for higher cognitive function and addiction), emerged from the analysis.

Conclusion

As marijuana has been identified to be a gateway drug for the use of other illicit drugs, its sustained usage amongst adolescents poses a health challenge to the user, community and the country’s healthcare system at large. Hence, there is the need to intensify adolescent marijuana use prevention campaigns in illicit marijuana-growing contexts of South Africa, focussing on the differential opportunities and subcultural inclinations that promote the behaviour in those contexts.

A mixed-methods study to inform the clarity and accuracy of cannabis-use and cannabis-tobacco co-use survey measures

BACKGROUND

Legalization of medical and recreational cannabis in US states has been accompanied by increases in availability, acceptability, and diversity in methods of cannabis use, as well as an increase in devices and methods for cannabis-tobacco co-use. Updated and specific survey measures of cannabis and cannabis-tobacco co-use are needed.

METHODS

We employed a mixed-methods approach to identify sources of specification and measurement error in cannabis and cannabis-tobacco co-use measures. We surveyed and interviewed 36 young adult (age 18-29) cannabis and tobacco co-users in California (2017-2018), triangulated with document analysis of online cannabis websites and forums. We investigated how survey reports of cannabis use and cannabis-tobacco co-use compared to narrative descriptions provided during in-depth interviews. We identify key strategies for researchers collecting self-reported survey data to enhance accuracy and comprehensiveness of measures.

FINDINGS

Potential sources of survey error included: broad variation in cannabinoid content and concentration, inconsistent interpretation of questions between participants and researchers (e.g. blunts were not considered co-use), and substantial variation in dosage within and between products. No evidence of survey recall bias or response editing was detected.

CONCLUSION

To enhance survey accuracy, we recommend surveys specify which cannabis delivery methods and forms are included and excluded in each measure, differentiate between cannabis products, and explicitly include or exclude CBD product use.

The importance of psychology for shaping legal cannabis regulation

Different patterns of cannabis use can be traced directly back to different interactions between 2 types of variables: pharmacological and environmental. As legal cannabis expands in the U.S. and around the world, state and national regulatory agencies are gaining control over these variables. Specifically, regulatory agencies are increasingly capable of altering (a) the pharmacological properties of cannabis products and (b) the way these products are distributed to the population. Consequently, cannabis regulatory agencies are in a unique position to use evidence from psychological science to alter cannabis consumption patterns in ways that mitigate potential harm to public health. However, most state-level legal cannabis regulatory systems in the U.S. are not yet evidence-based or public health-oriented. This applied review and commentary draws on evidence from the psychological science literature to help regulators better understand the types of behaviors they must address and guide empirically supported regulation of THC-laden cannabis, whether used putatively for medical or recreational reasons. This review is organized into 3 parts that correspond to the 3 primary agents within the cannabis regulation ecosystem: (a) the cannabis consumer, (b) the cannabis industry, and (c) the cannabis regulatory agency. Within this structure, the review addresses critical psychological variables that drive cannabis consumer and industry behaviors and discusses how regulatory agencies can use this information to protect public health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mode of Marijuana Use among Young Adults: Perceptions, Use Profiles, and Future Use

BACKGROUND

Given changes in marijuana regulations, retail, and products and potential impact on use, we examined young-adult perceptions of different modes of use, the proportion using via different modes (e.g. smoking, vaping, ingesting), and associations with the use levels and stability of use over time.

METHODS

We analyzed baseline and one-year follow-up survey data (Fall 2018-2019) among 3,006 young adults (ages 18-34) across six metropolitan areas (Atlanta, Boston, Minneapolis-St. Paul, Oklahoma City, San Diego, Seattle). Measures included marijuana use frequency and mode, sociodemographics, other substance use, and social influences.

RESULTS

Participants' rated the following modes of use as: least harmful/addictive: topicals, oral pills, joint/bowl; most socially acceptable: joint/bowl, edibles/beverages, vaporized; and most harmful/addictive and least acceptable: wrapped, vaped, or waterpipe/bong with tobacco. Baseline past-month use prevalence was 39.2% (n = 1,178). Most frequent use mode was smoking (joints/bowls/cigar papers; 54.0%), vaping (21.8%), via pipe/bong (15.1%), and ingesting (9.1%). Multinomial logistic regression indicated that participants in states with legalized marijuana retail were at greater odds for using via modes other than smoking; participants more frequently using were at greater odds for using via pipe/bong (vs. smoking) (ps < .001). Regarding most frequent mode across time, most consistent was pipe/bong (53.3%), followed by smoking (49.3%), vaping (44.5%), and ingesting (32.9%). Past-month abstinence at follow-up was most common among those originally ingesting (34.3% abstinent), followed by smoking (23.6%), vaping (18.8%), and pipe/bong (14.8%).

CONCLUSIONS

Ongoing surveillance is needed to understand marijuana use patterns over time across different user groups (particularly by mode) and to inform interventions promoting abstinence.

"Don't do vape, bro!" A qualitative study of youth's and parents' reactions to e-cigarette prevention advertisements

INTRODUCTION

Growing rates of e-cigarette use among youth have reached epidemic proportions. Media messages have been deployed to counteract this trend, but their evaluations are lacking. We assessed youth's and parents' reactions to various existing e-cigarette prevention messages.

METHODS

In 2019, 12 focus groups were conducted with youth (n = 63) and parents (n = 27). Participants discussed their reactions to 9 existing messages with various topics.

RESULTS

Information on chemicals in e-cigarettes was seen as new and scary, but unknown chemical names created confusion. Youth appreciated novel ways to visualize health effects of e-cigarettes (parasites in the body) and nicotine's effect on behavior (mood swings), but they cautioned that some of these effects (irritability) are not always caused by nicotine. Some participants did not know if e-cigarette companies were "Big Tobacco." Some found it hard to argue with the financial costs of vaping, but others did not think they were too great. Participants recommended messages featuring testimonials from diverse adolescents and messages aimed at youth who are struggling with addiction to e-cigarettes.

CONCLUSION

Messages would be particularly effective if they featured real youth and did not look like adults created them for youth. Another area that is currently not covered in media messages is talking to youth who are using e-cigarettes and might be already addicted but do not know where to turn for help. These adolescents need to be referred to resources for cessation.

A qualitative study of e-cigarette use among young people in Ireland: Incentives, disincentives, and putative cessation

BACKGROUND

Smoking prevalence in Ireland is falling in all age groups, but e-cigarette use is rising among young people. This qualitative study explores young people's accounts of e-cigarette use in Ireland.

METHODS

Semi-structured individual (22) and focus group (8) interviews were conducted with 62 young people aged 18-22 years, recruited from a higher-education institution and youth organisations working with early school-leavers across Dublin. All were smokers or ex-smokers; 41 had tried e-cigarettes, 11 continued as dual users. We identified themes using thematic data analysis.

RESULTS

Three broad themes were identified: incentivising features, disincentivising features, and ambivalent and unsuccessful cessation, named putative smoking cessation. Incentivising features included price, pleasing taste/ flavours, and the possibility of indoor use. Disincentivising features related to adverse health effects (pain, discomfort, sore throat, coughing, headache) and unpleasant physical effects (bad taste, problems resulting from device faults). Other disincentives were over-consumption arising from inability to control intake, "greater addictiveness", product taste, and device faults. Putative cessation refers to the conflict between participants' expected use of e-cigarettes as a smoking cessation/reduction aid and their observed reality of e-cigarettes' failure in this regard, with reported outcomes including: failure to quit or reduce; continued or resumed cigarette and/or roll-your-own smoking; dual use of e-cigarettes and other tobacco products; and inability to quit e-cigarettes.

CONCLUSIONS

Participants were sceptical about e-cigarettes' "purported relative healthiness", concerned about addictiveness and potential long-term health consequences, and critically aware of advertising and industry strategies. E-cigarettes were viewed as being less denormalised, in part because they could be used in indoor spaces where smoking is banned in Ireland. Although price, taste, and perceived renormalisation were important motivators for young people's use of e-cigarettes, they wanted to quit smoking. The regulation of e-cigarettes through age restriction of access, licensing of outlets, pricing, point of sale and advertising restrictions as well as through the banning of indoor use should be considered by legislators and tobacco control policymakers.

Seeking safety: a focus group study of young adults' cannabis-related attitudes, and behavior in a state with legalized recreational cannabis

BACKGROUND

Only July 1, 2017, Nevada became the fifth US state to allow the legal sale of recreational cannabis products for adults ages of 21 and over. This study investigates young adults' cannabis-related attitudes, perceptions, and behaviors in a state where recreational and medical cannabis use was recently legalized.

METHODS

We conducted 8 focus groups stratified by cannabis use (regular users, occasional users, and nonusers) with 32 college students ages 18 to 24. Data were analyzed using the inductive qualitative thematic analysis method.

RESULTS

Four themes emerged during analyses: "sort of legal," "mitigating harm through legalization," "Increasing acceptance," and "seeking safety when purchasing cannabis." Despite their limited knowledge of cannabis regulation, the majority of the participants supported recreational cannabis legalization from a harm reduction perspective. Most participants did not believe that cannabis legalization had affected their use behavior. However, participants, especially cannabis users, perceived that recreational cannabis legalization created a context where cannabis use was legally, socially, and behaviorally "safer" than in an illegal context, even for those below the legal age of sale.

CONCLUSIONS

Most studies focus on the role of perceived health risk on cannabis use. If there are population-level long-term effects of recreational cannabis legalization on use behavior, findings suggest that they will be mediated by the perceived legal, social, and behavioral risk of using cannabis.

U.S. College Students' Marijuana Information Sources, Confidence in Knowledge, and Objective Knowledge

In recent years, marijuana use on U.S. college campuses reached the highest point while the perceptions of risk and social disapproval registered the lowest since the early 1980s. However, little attention has been paid to the sources of the marijuana-related messages and their relationships with marijuana knowledge and confidence in knowledge, proximate protective/risk factors. To fill this gap, a convenience sample of students (N = 249) on a campus located in a U.S. recreational marijuana legal state were surveyed to identify their marijuana information sources and explore the relationships among the sources, confidence in marijuana knowledge, and objective knowledge. Peers/media were the most important sources and they were used more than other sources. Use of peers/media sources was related to lower health knowledge and higher confidence in knowledge. Although students named parents and education/science sources as important, these were less frequently used than siblings, the sources they named as the least important. This study advanced our understanding of the various sources of marijuana information used by U.S. college students and the relationships between the information sources and confidence in knowledge and objective knowledge, two emerging risk/protective factors in the era of marijuana deregulation.

A Practice Theory Approach to Understanding Poly-Tobacco Use in the United States

This paper uses practice theory to explore a poorly understood phenomenon with important health implications: How and why an increasing number of young Americans regularly use multiple tobacco products. Practice theory is a promising alternative to traditional public health frameworks for understanding everyday activities related to health. It broadens the analytic focus from characteristics of individuals to viewing practices as having lives of their own in competing for, winning, and losing practitioners. We drew from in-depth interviews with 21 young adults (ages 18-29; California) who regularly use cigarettes, electronic nicotine delivery systems (ENDS), and/or smokeless tobacco. Participants described their everyday routines. We examined the characterizing elements of each tobacco product use practice and the roles of each within participants' routines. We found that each product comprises a distinct substance use practice with different roles to play in different situations and contexts. Notably, many participants rotated between or modulated use of different products as a strategy for reducing perceived tobacco-related harms. Cigarettes are uniquely capable of aiding in the space-time organization of everyday activities and coping with crisis, while ENDS and smokeless tobacco open up times and spaces for nicotine consumption. This kind of approach aids our understanding and anticipation of the evolution of tobacco use practices as new products and regulations are introduced.

Psychiatric comorbidity in adolescent use and poly-use of combustible, vaporized, and edible cannabis products

Cannabis legalization and commercialization has resulted in novel alternative cannabis products on the market, including edible and vaporized cannabis, which may appeal to youth with psychiatric problems. Psychiatric comorbidity in adolescent use and poly-use (i.e., use of >2 products) of combustible, edible, and vaporized cannabis products has largely gone uninvestigated. This 2015 cross-sectional survey of Los Angeles, California area adolescents (Mage = 16.1, N = 3177) characterized associations of various psychiatric problems with use and poly-use of combustible, edible, and vaporized cannabis. Exposure variables included past 30-day non-cannabis substance use (alcohol, e-cigarettes, combustible cigarettes, and nonmedical prescription opioid and stimulant use; yes/no), and psychiatric problems including past-week depressive symptom frequency, past 6-month ADHD symptom and conduct problem frequency, anhedonia, and five dimensions of impulsivity (sensation seeking, perseverance, lack of premeditation, positive urgency, and negative urgency). Outcome variables included past 30-day use (yes/no) of combustible, edible, and vaporized cannabis, independently, and number of cannabis products used (single, dual-use, poly-use). Results showed that all forms of non-cannabis substance use (ORs range: 13.7-36.1) and all psychiatric symptoms and traits (ORs in SD units range: 1.1-2.1) were positively associated with combustible, edible, and vaporized cannabis product use. The magnitude of comorbidity did not significantly differ by cannabis product type used in most cases. Psychiatric comorbidity was typically stronger in poly-product than single-product cannabis use and greater for externalizing-type than internalizing-type psychiatric problems. Practitioners, policy makers, and scientists should be aware that pervasive psychiatric comorbidity may be observed across the spectrum of cannabis product use among adolescents, particularly poly-product users.

International differences in patterns of cannabis use among adult cigarette smokers: Findings from the 2018 ITC Four Country Smoking and Vaping Survey

BACKGROUND

Although evidence shows that co-use of cigarettes and cannabis is common, there is little research examining if co-use patterns vary depending on the regulatory environment for cannabis. This study examined patterns of co-use and perceptions of relative harm among cigarette smokers in four countries with different histories, and at different stages of cannabis legalization.

METHODS

Data are from the 2018 International Tobacco Control 4CV Survey and included 10035 adult cigarette smokers from Canada, United States (US), Australia, and England. At the time of the survey, Canada and the US had relatively more permissive cannabis regulations compared to Australia and England.

RESULTS

Among this sample of 10035 cigarette smokers, Canada had the highest rate of cannabis co-use in the last 12 months (36.3%), followed by the US (29.1%), England (21.6%), and Australia (21.4%). Among past 12 month co-users (n = 3134), the US (40.2%) and Canada (35.2%) had the highest rates of daily cannabis use, followed by smokers in England (26.3%) and Australia (21.7%); Australian co-users had the highest rate of infrequent (

CONCLUSION

Patterns of tobacco and cannabis co-use differed between countries. Smokers in Canada and the US had higher rates of co-use, daily cannabis use, dual-daily use of both cannabis and cigarettes, and were more likely to perceive smoked cannabis as less harmful than cigarettes compared to England and Australia. Further attention as to how varying cannabis regulations may impact co-use patterns is warranted.

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Key Words

• Cannabis
• Co-use
• Harm Perceptions
• Policy
• Regulation
• Tobacco cigarettes

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MESH Headings Collapse

Grants

• P01 CA200512 NCI NIH HHS

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Affiliation(s)

Shannon Gravely Department of Psychology, University of Waterloo, Waterloo, Canada.
Pete Driezen Department of Psychology, University of Waterloo, Waterloo, Canada; School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
Danielle M Smith Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, United States
Ron Borland School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia; Cancer Council Victoria, Melbourne, VIC, Australia
Eric N Lindblom O'Neill Institute for National & Global Health Law, Georgetown University Law Center, Washington, DC United States
David Hammond School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
Ann McNeill King's College London, Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom; UK Centre for Tobacco & Alcohol Studies, Nottingham, United Kingdom
Andrew Hyland Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, United States
K Michael Cummings Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, United States; Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States
Gary Chan Centre for Youth Substance Abuse Research, The University of Queensland, Brisbane, QLD, Australia
Mary E Thompson Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
Christian Boudreau Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
Nadia Martin Department of Psychology, University of Waterloo, Waterloo, Canada
Janine Ouimet Department of Psychology, University of Waterloo, Waterloo, Canada
Ruth Loewen Department of Psychology, University of Waterloo, Waterloo, Canada
Anne C K Quah Department of Psychology, University of Waterloo, Waterloo, Canada
Maciej L Goniewicz Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, United States
James F Thrasher Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, United States; Tobacco Research Department, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
Geoffrey T Fong Department of Psychology, University of Waterloo, Waterloo, Canada; School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada; Ontario Institute for Cancer Research, Toronto, Canada

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Vaporization of Marijuana Among Recreational Users: A Qualitative Study

OBJECTIVE

Vaporization of marijuana products, or "vaping," has become a prevalent mode of administration and is typically perceived to hold unique benefits compared to combustible administration methods. Such positive beliefs regarding marijuana vaporization may contribute to its abuse liability. This qualitative study examined cognitions pertaining to vaping among recreational marijuana users.

METHOD

Focus groups were conducted with frequent marijuana users (N = 31; five groups; six to seven per group; M = 5.0 days/week marijuana use). Three topic areas were queried during discussions with the goal of revealing factors that may contribute to the abuse liability of vaporization. These comprised differences between smoking and vaporizing marijuana products, perceived advantages of vaporization, and perceived disadvantages of vaporization. Focus groups lasted approximately 60 minutes and followed a semistructured agenda; the sessions were audio recorded and transcribed for an applied thematic analysis. An executive summary of each group was made and key themes pertaining to vaporization were summarized.

RESULTS

Several themes emerged, including differences between smoking and vaporizing marijuana, convenience, discretion, and efficiency of vaping, perceived health benefits, the absence of traditional smoking rituals, and the high cost of vaporization devices.

CONCLUSIONS

Several factors appear to promote marijuana vaporization, including device aspects (e.g., discreet, convenient), the subjective high, economical efficiency, and perceived harm-reducing and health-promoting effects. These qualitative data highlight unique cognitions about marijuana vaping that may substantially increase its abuse liability. Quantitative research is needed to examine the extent to which cognitions about marijuana vaporization contribute to actual use patterns and problematic behaviors.

Modes of delivery in concurrent nicotine and cannabis use ("co-use") among youth: Findings from the International Tobacco Control (ITC) Survey

BACKGROUND

Cannabis use is more common among nicotine users than non-users. This study characterized concurrent use of nicotine and cannabis ("co-use") among 12,064 youth aged 16-19 years residing in Canada, the United States, and England in 2017. Methods: Data were from the ITC Youth Tobacco & Vaping Survey (Wave 1). Seven modes of cannabis delivery (MOD) were characterized by country of residence and past 30-day use of combusted tobacco and electronic cigarettes. Weighted multivariable regression models were fitted to assess the correlates of co-use and each cannabis MOD. Results: Seventy percent of cannabis users reported nicotine use. Co-users exhibited behavioral and demographic differences compared to exclusive users of either substance. "Smoking cannabis without tobacco" was the most popular form of use (78%). Use of nicotine-containing e-cigarettes was associated with "using an e-cigarette to vape cannabis oil/liquid" (aOR: 4.96, 95%CI: 2.23-11.06). Combustible tobacco use was associated with "smoking cannabis with tobacco in a joint/blunt" (aOR: 2.93, 95%CI: 1.89-4.56). Country-level differences were detected. Conclusions: Nicotine use is substantial among cannabis users, and associations exist between modes of delivery for both drugs. Results underscore the importance of studying cannabis and nicotine use concurrently, and the need to address the use of both substances in developing interventions for youth users.

Arkansas community's attitudes toward the regulation of medical cannabis and the pharmacist's involvement in Arkansas medical cannabis

OBJECTIVES

This study explored the attitudes of the Arkansas community toward medical cannabis (MC) regulation and the role of pharmacists in dispensing MC before the product became available and examined whether participants' demographics (e.g., age, gender) and characteristics (e.g., history of cannabis use) were associated with these attitudes.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Using social media, a university research registry, and posted flyers, we invited residents of Arkansas to participate in the self-administered online survey study during a 3-month period, February to April, in 2018.

OUTCOME MEASURES

Five questions that inquired about participants' attitudes toward MC regulation and pharmacists' roles regarding MC use.

RESULTS

Participants (n = 1343) who completed at least 1 of the 5 questions were included. The majority were aged 40-64 years (52.2%), female (69.1%), and white (88.7%). Most participants reported a history of cannabis use (81.8%) and possession or intention to apply for an MC card (52.9%). Among the conditions approved for MC use, pain (20.3%), arthritis (15.4%), and posttraumatic stress disorder (14.5%) were reported frequently. Likewise, prescription use for mood disorders (46.1%) and pain (37.4%) were also reported. In multivariable regression analyses, participants' history of cannabis use was associated with a preference for lesser oversight of MC, disagreement with MC being available through a pharmacy only, and disagreement on whether MC should be regulated before it is legalized for recreational use (all P < 0.001). It was also associated with a decrease in agreement that pharmacists are well-trained to improve patient safety (P < 0.001) and counsel patients regarding appropriate MC use (P = 0.032).

CONCLUSION

Participants who had previously used cannabis were in favor of fewer restrictions and negatively perceived pharmacists' involvement in ensuring appropriate dispensing and MC use. The findings may highlight the need for Arkansas pharmacists to explore alternative ways to promote the safe and proper MC use.

Correlates of smoker identity among intermittent and light daily young adult smokers: Findings from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study

Identifying as a 'smoker' has been associated with many cigarette smoking-related behaviors, including less frequent and intense cigarette use. Additional smoking behaviors (e.g., use of cannabis or cigars) also may contribute to self-identification as a 'smoker'. This study compared correlates of identifying as a 'smoker' and measurement strategies for non-daily cigarette consumption among young-adult intermittent and light daily smokers. Using data from Wave 1 of the PATH Study, different measurements of past 30-day non-daily cigarette use were evaluated. Weighted logistic regression models were used to compare associations with self-identification as a smoker among 18-24 year-old intermittent and light daily smokers (n = 1531). Use of other smoked products (combustible tobacco, cannabis) and other documented correlates of smoker identity were evaluated. As frequency of monthly smoking increased, self-identification as a smoker increased (1-5 days = 24%, 6-19 days = 48%, 20-29 days = 78%, light daily smokers = 93%, daily smokers using >5 cigarettes per day = 99%). Self-reported smoking status 12 months ago significantly contributed to current identification as a smoker. Smoking cigars daily or using cannabis in the past 30 days were each positively associated with smoker identity. Different measurement approaches to non-daily cigarette use offer different advantages in terms of interpretability and granularity of information. Compared to daily smokers, non-daily smokers exhibit significant variability in identifying as a smoker, and systematic correlates of smoker identification are apparent. These findings may serve to enhance understanding of non-daily smokers and potential targets for intervention among this growing subpopulation of tobacco users.

Aerosol Gas-Phase Components from Cannabis E-Cigarettes and Dabbing: Mechanistic Insight and Quantitative Risk Analysis

Consumption of cannabis by nontraditional methods has surged since the advent of legalization in North America and worldwide. Inhaling cannabis extracts using vaporizers and via dabbing has risen in popularity, while concerns over product safety have not hindered their proliferation. The work herein is the first step toward assessing the safety of vaporizing and dabbing concentrated cannabis extracts as a function of gas-phase reaction products. The gas-phase thermal degradants of Δ⁹-tetrahydrocannabinol (THC) have not been previously investigated. It was found that users may be exposed to concerning degradants such as methacrolein, benzene, and methyl vinyl ketone when using cartridge vaporizers and dabbing. It was shown that THC alone and mixed with terpenes generated similar degradation products and, most notably, elevated levels of isoprene. Importantly, it was shown that added terpenes led to higher levels of gas-phase products compared to THC alone. To estimate cancer and noncancer risks associated with exposure to these and other degradants, quantitative risk assessment was applied to experimentally determined values for dabbing and vaping and literature-sourced levels of hazardous components in cannabis smoke. Overall, gas-phase aerosol products had significantly lower values in dabbing and vaporizing compared to cannabis smoking, although these results should be interpreted in light of potential variations in degradant levels due to disparate usage patterns and the dangers of the higher aerosol concentration of THC.

Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study

OBJECTIVE

Electronic cigarettes (e-cigarettes) which utilise prefilled 'pods' (pod devices) entered the US market in 2015. One brand, JUUL, captured more than half the e-cigarette market in early 2018, and the US Food and Drug Administration recently warned its manufacturer about adolescent uptake. This is the first qualitative study to describe distinct features of pod devices that appear to contribute to their popularity among young people.

DESIGN

Qualitative interview study of young adults who had used pod devices. Participants were recruited from Facebook, other social media, street recruitment and via snowball sampling.

SETTING

Participants were from California, with most from the San Francisco Bay Area.

PARTICIPANTS

Young adults (aged 18-29 years) using multiple tobacco products (cigarettes, e-cigarettes and/or smokeless tobacco) were recruited. Of the sample of 60 participants, 24 were included in this analysis: 10 who reported experience with pod devices and 14 who used other non-pod e-cigarette devices.

RESULTS

Ten participants had used a pod device in the past year. Of the pod device users, seven still used a pod device at the time of the interview and five did so daily. Nearly all (n=9) pod device users smoked cigarettes in the past month; none were daily smokers. The 14 participants who used non-pod devices provided a point of comparison. Participants highlighted some distinct aspects of pod devices that facilitated use, including their aesthetic similarity to personal electronics, high levels of nicotine delivery with distinct psychoactive effects, more discreet and shorter duration use sessions, and greater social acceptability than more ostentatious non-pod e-cigarettes.

CONCLUSIONS

Pod devices' unique characteristics likely encourage pod device uptake among young people. Limitations on advertising in youth channels, flavours and distribution, and education about nicotine addiction may decrease initiation among young people and non-smokers.

Cannabis use among a nationally representative cross-sectional sample of smokers and non-smokers in the Netherlands: results from the 2015 ITC Netherlands Gold Magic Survey

OBJECTIVES

Existing evidence shows that co-occurring use of tobacco and cannabis is widespread. Patterns of co-use of tobacco and cannabis may change as more jurisdictions legalise medicinal and/or recreational cannabis sales. This analysis examined predictors of current cannabis use and characterised methods of consumption among smokers and non-smokers in a context where cannabis use is legal.

SETTING

The 2015 International Tobacco Control Netherlands-Gold Magic Survey conducted between July and August 2015.

PARTICIPANTS

Participants (n=1599; 1003 current smokers, 283 former smokers and 390 non-smokers) were asked to report their current (past 30-day) use of cigarettes and cannabis. Cigarette smokers reported whether they primarily used factory made of roll-your-own cigarettes. Those who reported any cannabis use in the last 30 days were asked about forms of cannabis used. X2and logistic regression analyses were used to assess relationships among combustible tobacco and cannabis use.

RESULTS

Past 30-day cannabis use was somewhat higher among current tobacco (or cigarette) smokers (n=57/987=5.8%) than among former or never smokers (n=10/288=3.5% and n=6/316=1.9%, respectively). Joints were the most commonly used form of cannabis use for both current cigarette smokers (96.9%) and non-smokers (76.5%). Among those who smoked cannabis joints, 95% current smokers and 67% of non-smokers reported that they 'always' roll cannabis with tobacco.

CONCLUSIONS

In this Netherlands-based sample, most cannabis was reported to be consumed via smoking joints, most often mixed with tobacco. This behaviour may present unique health concerns for non-cigarette smoking cannabis users, since tobacco use could lead to nicotine dependence. Moreover, many non-cigarette smoking cannabis users appear to be misclassified as to their actual tobacco/nicotine exposure.

Perceptions of plain packaging and health warning labels for cannabis among young adults: findings from an experimental study

BACKGROUND

There is strong evidence that plain cigarette packaging and health warning labels (HWLs) reduce brand appeal and increase health knowledge. There is limited evidence examining this population-level public health approach for cannabis packaging. This issue is of particular importance in light of the recent legalization of recreational cannabis in Canada. The current study examined perceptions of plain packaging and HWLs for cannabis packages among young adults.

METHODS

An online experimental study was conducted with a sample of university students in Alberta, Canada (n = 656). Respondents were randomly assigned to view cannabis packages in one of four conditions: Condition 1: branded pack, Condition 2: plain pack (uniform color, brand imagery removed, standardized font), Condition 3: branded pack with a HWL, and Condition 4: plain pack with a HWL. Respondents in Conditions 3 and 4 viewed five text-based HWLs, each corresponding to a health effect associated with cannabis use: (1) brain development, (2) mental health issues, (3) impaired driving, (4) nonlethal overdose, and (5) addiction. After viewing packs, respondents rated packs and health warnings on various measures.

RESULTS

Branded packages without HWLs were rated as most appealing compared to all other packs (p < 0.001 for all contrasts). No differences were found in ratings of appeal when comparing branded and plain packs with HWLs. Warning messages for cognitive development and impaired driving were rated highest on levels of perceived effectiveness, believability, and fear, whereas the addiction warning was rated among the lowest. In general, there were gaps in health knowledge related to cannabis use, however after viewing packs with warnings (compared to viewing packs without warnings) levels of health knowledge increased across all health effects (p < 0.01 for all). Lastly, a significant majority of young adults reported they would purchase the branded pack without a HWL (39.5%), compared to all other pack types (p < 0.05 for all contrasts). The lowest proportion of young adults reported they would purchase a plain pack with a HWL (1.1%).

CONCLUSIONS

Plain packaging and health warnings may reduce brand appeal and increase health knowledge among young adults.

Who are the smokers who never plan to quit and what do they think about the risks of using tobacco products?

INTRODUCTION

Smoking cigarettes is the most harmful way to use tobacco. Smokers who do not plan to quit present a particular challenge in reducing the morbidity and mortality from tobacco use. Switching to a lower harm product might encourage them to end their use of combusted cigarettes. This study aimed to better understand smokers who do not intend to quit (including their demographic and worldviews as indicators of their social, cultural, and political dispositions) and their perceived risks of cigarettes and possible lower-risk products such as e-cigarettes.

METHODS

Participants were 2572 current smokers. Data were pooled from 2015 and 2016 cross-sectional surveys of national probability samples of U.S. adults and analyzed with multivariable logistic regressions.

RESULTS

Smokers who never plan to quit comprise 14.3% of current U.S. smokers and are more likely to be older (24.2% among 65+ years old vs. 9.8% among 18-24) and less likely to have ever used e-cigarettes. A one-unit increase in hierarchical worldview (measured on a 1-6 scale) was associated with a 20% increase in the odds of never planning to quit. Those who denied that cigarettes cause disease or death (aORs between 1.6 and 2.0) or were uncertain (aORs: 2.5-2.7) were more likely to never plan to quit compared to those who agreed. They did not view risks of e-cigarettes substantially different compared to smokers who plan to quit.

CONCLUSION

One in seven U.S. smokers never plans to quit and might benefit from interventions which reflect their hierarchical worldviews and increase their risk perceptions of combustible cigarettes.

Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control

State legalization and regulation of cannabis, despite continued federal illegality, is a massive shift in regulatory approach. Manufactured cannabis, including concentrates, extracts, edibles, tinctures, topicals and other products, has received less attention than more commonly used dried flower, but represents emerging regulatory challenges due to additives, potency, consumption methods, and abuse and misuse potential. In November 2017, the California Department of Public Health (CDPH) released initial cannabis manufacturing regulations as part of a new state regulatory structure. As the largest U.S. medical cannabis market (and largest legal adult use market in the world beginning in 2018), California's regulatory approach will potentially influence national and global policy. Comparing CDPH's initial regulations to tobacco control best practices reveals that, while the regulations recognize the need to protect public health, prioritizing public health over business interests requires stronger approaches to labeling, packaging, and product formulations. Based on tobacco best practices, we recommend that cannabis regulations incorporate large and proportionately sized informational labels, a prominent universal cannabis symbol, rotating and pictorial health warnings, mandatory plain packaging, a comprehensive ban on characterizing flavors and addictive additives, and strict limits on the potency of inhalable products and those easily confused with non-cannabis products.