Clearing the haze: the complexities and challenges of research on state marijuana laws

Cannabis Use Variations and Myocardial Infarction: A Systematic Review

Background: Cannabis use is associated with an increased risk of coronary heart disease (CHD), including angina pectoris (AP), and myocardial infarction (MI). However, it is not clear whether cannabis use is an independent risk factor of AP and/or MI, because cannabis is often smoked together with tobacco. We investigated whether cannabis is an independent risk factor of MI and whether this risk is similar in cannabis smokers, cannabis vapers, and those who use cannabis edibles. Methods: A systematic review was performed, according to the PRISMA guidelines and using Medline (PubMed), Embase, and Google Scholar as databases. Results: Twenty-two eligible papers were identified. After adjustment for concurrent tobacco use, cannabis smoking remained significantly associated with incidents of MI, with aORs ranging between 1.03 and 5.24, and particularly high aORs in the younger age group. In never-tobacco smokers, frequent cannabis smoking was also associated with a significant MI risk (aOR = 1.88). Frequent and current cannabis use in any form other than smoking (e.g., vaping, but mostly ingestion) was not associated with a significantly increased cardiovascular risk (frequent use: aOR = 1.00 ns; current use: aOR = 1.31 ns). Conclusions: Like tobacco smoking, cannabis smoking may independently provoke MI. Vaping and ingestion of cannabis might be less harmful, probably because absence of combustion prevents exposure to certain toxins in cannabis smoke, including carbon monoxide.

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

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

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.

Expectancies that Predict Cannabis Initiation in Response to Legalization

Background: Recent and prospective changes to nonmedical/recreational cannabis laws in the United States and abroad raise questions about how legalization may influence cannabis use behaviors. Objectives: In the current study, we examined links between legalization, context-specific likelihood of using cannabis, and cannabis expectancies using cross-sectional survey data from 121 college students who had never used or were abstaining from cannabis in a U.S. state where laws prohibit nonmedical cannabis. Results: We found that across scenarios, 61% of students reported they would be more likely to use cannabis if it were legal. Social/sexual facilitation expectancies predicted a higher likelihood of using cannabis after legalization in a social context. Relaxation/tension reduction expectancies predicted a higher likelihood of using in an anxiety relief context. Perceptual/cognitive enhancement expectancies predicted a higher likelihood of using in a pain relief context. Cognitive/behavioral impairment expectancies predicted a lower likelihood of using in social, pain relief, relaxation, and concert contexts. Global negative effects expectancies predicted a lower likelihood of using in relaxation and concert contexts. Conclusions: Our findings suggest that among college students who do not use cannabis, expectancies are linked to cannabis use likelihood in certain contexts if cannabis were legal. This work highlights cannabis expectancies and contexts as possible targets for evidence-based public health education and clinical prevention initiatives related to the potential increase in cannabis use associated with cannabis policy implementation. College students may benefit from initiatives that address cannabis expectancies and enhance harm reduction skills to help them effectively navigate contexts in which cannabis is available to them.

Deterrence effect of penalties upon adolescent cannabis use

OBJECTIVE

Penalties are used in an effort to curtail drug use by citizens in most societies. There are growing calls for a reduction or elimination of such penalties. Deterrence theory suggests that use should increase if penalties reduce and vice versa. We sought to examine the relationship between changes to penalties for drug possession and adolescent cannabis use.

METHOD

Ten instances of penalty change occurred in Europe between 2000 and 2014, seven of which involved penalty reduction and three involved penalty increase. We conducted a secondary analysis of a series of cross-sectional surveys of 15-16-year-old school children, the ESPAD surveys, which are conducted every four years. We focused on past month cannabis use. We anticipated that an eight-year time span before and after each penalty change would yield two data points either side of the change. A simple trend line was fitted to the data points for each country.

RESULTS

In eight cases, the trend slope in past month cannabis use was in the direction predicted by deterrence theory, the two exceptions being the UK policy changes. Using the principals of binomial distributions, the likelihood of this happening by chance is 56/1024 = 0.05. The median change in the baseline prevalence rate was by 21%.

CONCLUSIONS

The science seems far from settled on this issue. There remains a distinct possibility that reducing penalties could contribute to small increases in adolescent cannabis use and consequently increase cannabis-related harms. This possibility should be considered in any political decision-making influencing drug policy changes.

Association of cannabis use disorder with cardiovascular diseases: A two-sample Mendelian randomization study

Background

The use of cannabis has increased globally due to more regions decriminalizing marijuana use for therapeutic and recreational aims. Several observational studies have revealed that cannabis use is associated with an increased risk of adverse cardiovascular pathologies and diseases. Nevertheless, the causal associations between cannabis use and cardiovascular diseases remain unclear. Hence, we performed single-variable and multivariable Mendelian randomization (MR) to evaluate the association between cannabis use disorder and various cardiovascular diseases.

Materials and methods

Summary statistics were collected from the largest-to-date genome-wide association studies (GWAS) of cannabis use disorder. The 12 SNPs for cannabis use disorder were used as instrumental variables in this study. MR estimates were pooled using a random-effects inverse-variance weighted (IVW) method. Simple median and weighted median methods were conducted as sensitivity analyses.

Results

The genetic liability to cannabis use disorder was associated with an augmented risk of coronary artery disease, myocardial infarction, atrial fibrillation, heart failure, deep venous thrombosis, pulmonary embolism, and stroke. Except for stroke, the results were inconsistent in the sensitivity analyses. The overall patterns for the associations of cannabis use disorder with atrial fibrillation, heart failure, pulmonary embolism and stroke remained in multivariable MR analyses adjusting for potential mediators, including smoking, alcohol, body mass index, blood lipid, type 2 diabetes, hypertension, and depression. However, the association with coronary artery disease, myocardial infarction, and deep venous thrombosis did not persist in multivariable MR analyses. Mediation analysis demonstrated that smoking, body mass index, low-density lipoprotein, hypertension, and depression have more significant mediation effects, which suggests that these factors partly mediate the link from cannabis use disorder to coronary artery disease, myocardial infarction, and deep venous thrombosis.

Conclusion

The genetic liability to cannabis use disorder was associated with a higher risk of atrial fibrillation, heart failure, pulmonary embolism, and stroke. The evidence for the association between cannabis use disorder, coronary artery disease, myocardial infarction, and deep venous thrombosis was weak. Hence, future use of cannabis for therapeutic and recreational aims should consider its potential impact on cardiovascular diseases.

Cannabis for Medical Use: Analysis of Recent Clinical Trials in View of Current Legislation

Cannabis has long been regarded as a recreational substance in the Western world. The recent marketing authorization of some medicinal products of industrial origin and the introduction onto the market of inflorescences for medical use mean that medical doctors can now prescribe Cannabis-based medicines in those countries which allow it. Nevertheless, there is still considerable controversy on this topic in the scientific community. In particular, this controversy concerns: the plant species to be used; the pathologies that can be treated and consequently the efficacy and safety of use; the routes of administration; the methods of preparation; the type and dosage of cannabinoids to be used; and, the active molecules of interest. As such, although medical Cannabis has been historically used, the results of currently completed and internationally published studies are inconclusive and often discordant. In light of these considerations, the aim of this work is to analyse the current legislation in countries that allow the use of medical Cannabis, in relation to the impact that this legislation has had on clinical trials. First of all, a literature search has been performed (PubMed and SciFinder) on clinical trials which involved the administration of Cannabis for medical use over the last 3 years. Of the numerous studies extrapolated from the literature, only about 43 reported data on clinical trials on medical Cannabis, with these mainly being performed in Australia, Brazil, Canada, Denmark, Germany, Israel, Netherlands, Switzerland, the United Kingdom and the United States of America. Once the reference countries were identified, an evaluation of the legislation in relation to Cannabis for medical use in each was carried out via the consultation of the pertinent scientific literature, but also of official government documentation and that of local regulatory authorities. This analysis provided us with an overview of the different legislation in these countries and, consequently, allowed us to analyse, with greater awareness, the results of the clinical trials published in the last 3 years in order to obtain general interest indications in the prosecution of scientific research in this area.

Facilitators and barriers to the regulation of medical cannabis: a scoping review of the peer-reviewed literature

Background

In recent decades, several political, legislative, judicial, consumer, and commercial processes around the world have advanced legalization efforts for the use of medical cannabis (MC). As the use of MC evolves through legislative reform, with an increase in public acceptance and therapeutic potential, a need exists to further investigate the facilitators and barriers to MC regulation.

Methods

A scoping review was conducted to identify the facilitators and barriers associated with the implementation of MC regulations. MEDLINE, EMBASE, AMED and PsycINFO databases were systematically searched; no restrictions were placed on geographic location/jurisdiction. Eligible articles included those that evaluated the MC regulatory framework of one or more countries.

Results

Twenty-two articles were deemed eligible and included in this review. Themes identified include: (1) effects of conflicts, mindset, and ideology of state population, (2) the use of comparisons to analyze MC regulation, and (3) the need for more knowledge, advice, and empirical/clinical evidence to inform future MC policies.

Conclusion

Policymakers should be aware of facilitators to the MC regulation implementation process, such as the influence of state and federal congruence, increased transparency, and the incorporation of stakeholder concerns, in order to effectively respond to a growing societal acceptance of MC and its use among patients. Given a comprehensive understanding of these influential factors, policymakers may be better equipped to meet the consumer and commercial demands of a rapidly evolving MC regulatory environment.

How medical are states' medical cannabis policies?: Proposing a standardized scale

BACKGROUND

There are important differences in medical cannabis laws across the U.S.. However, prior studies investigating the effect of medical cannabis laws on outcomes disregard this heterogeneity. Findings from the body of literature using a simple dichotomous assessment of whether a particular state has enacted a medical cannabis law are equivocal or conflicting. To advance the science, a national advisory group of experts in medical cannabis developed and utilized a systematic methodology, the "medicalization of cannabis laws standardized scale" (MCLaSS), to characterize and quantify state laws' degree of medicalization, the extent to which medical cannabis is treated similarly to pharmaceutical medications.

METHODS

We conducted a systematic review of state-level medical cannabis laws in the U.S. Using the novel MCLaSS, we calculated seven domain scores (patient-clinician relationship, manufacturing and testing, product labeling, types of products, supply and dose limit, prescription drug monitoring program, and dispensing practices) and a summary score for each state which had enacted medical cannabis laws as of July 2019.

RESULTS

There is substantial heterogeneity in the degree of medicalization of states' medical cannabis laws, as demonstrated by the MCLaSS summary score, which ranged from 23 (least medicalized) to 86 (most medicalized).

CONCLUSION

This methodology will advance the evidence base about the impact of medical cannabis laws on patient and public health outcomes, which is urgently needed to ensure the development of policies that minimize the risks and maximize the benefits of medical cannabis.

Using the National Incident-Based Reporting System (NIBRS) to examine racial and ethnic disparities in cannabis incidents

Background: Reducing racial and ethnic arrest disparities is one driver of cannabis legalization in the US., but outcomes of cannabis policies and equity provisions remain unknown. Early research finds legalization reduces total cannabis incidents, but disparities persist. In response, novel research approaches are emerging, but a comprehensive assessment of their strengths and limitations is needed, particularly when using data sources developed for other purposes. Objectives: This perspective assesses the National Incident-Based Reporting System (NIBRS), originally developed for crime statistics, as a means to surveil cannabis incident disparities. Methods: Massachusetts NIBRS (2000-2013) illustrates discussion points, including around sample inclusion, data integrity, and missing data. Results: We find that NIBRS is a comprehensive source for state-level monitoring if used with knowledge of its limitations. However, drawing conclusions about disparities requires careful assessment of sample inclusion and any changes to participation rates, data integrity, reporting changes, and missing variables, before analysis and reporting. Conclusion: NIBRS utility would increase with greater or required jurisdiction participation, guidance for collection of racial and ethnic data, and required ethnicity reporting. Despite limitations, cannabis disparity analyses using NIBRS can provide key insights for increasing equity in states considering and enacting cannabis legalization.

Marijuana Use in Patients With Cardiovascular Disease: JACC Review Topic of the Week

Marijuana use is increasing as more states are legalizing cannabis for both medicinal and recreational purposes. National survey data estimate that >2 million Americans with established cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Cannabinoid receptors are distributed in multiple tissue beds and cells, including platelets, adipose tissue, and myocytes. Observational data suggest associations between marijuana and a broad range of adverse cardiovascular risks. Marijuana is becoming increasingly potent, and smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Synthetic cannabinoids have been linked to more sustained and deleterious pharmacodynamic effects. Marijuana is classified as a Schedule I substance, thus limiting its rigorous study for cardiovascular health effects. This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety. Screening for marijuana use is encouraged, especially in young patients presenting with cardiovascular disease.

Cannabis & ENT: State certification-An expanding yet unregulated system

OBJECTIVES

1) Ascertain the status of cannabis legalization by state, 2) Explore the process required to obtain cannabis credentials for both the patient and the physician, 3) Determine the level of interest of otolaryngologists in the medicinal cannabis, and 4) Explore possible research directions into efficacy and potential complications.

STUDY DESIGN

Descriptive study.

METHODS

Internet searches were conducted to identify each state's Medical Cannabis Program website. The qualifying conditions, list of approved-practitioners, process required for both practitioners and patients for approval were noted. Lists of approved practitioners were analyzed to determine the prevalence of board-certified otolaryngologists.

RESULTS

Of the 33 states that authorize medicinal cannabis, eight provide lists of approved-practitioners, six of which provide specialty information. A total of 24 Otolaryngologists can be found of the 5944 physicians on these six lists. All otolaryngologists were located in highly-populated metropolitan areas with a mean number of 29.9 years in practice. Significant variations exist between each state including legal definitions and qualifying conditions.

CONCLUSIONS

Lack of consistent regulation across the country drives uncertainty regarding the adoption of medicinal cannabis. Very few otolaryngologists in the country are registered to certify patients for medical cannabis. While the medicinal use of cannabis may currently have limited applications within otolaryngology, many areas that have yet to be explored.

The Impact of Marijuana on the Cardiovascular System: A Review of the Most Common Cardiovascular Events Associated with Marijuana Use

With the expanded legalization of marijuana, its medical and recreational use have sharply increased over the past decade. A wide array of new forms of cannabis is available on the market today, and the potencies are ten times those of forms previously tested, meaning that the true impact of marijuana on the cardiovascular system remains unclear. Cannabis mainly exerts its effects via the sympathetic and parasympathetic nervous systems, with different doses affecting different cannabinoids receptors. Studies have shown that marijuana plays a role in thrombosis, inflammation, and atherosclerosis. Case reports have linked marijuana use to myocardial infarction, cardiac arrythmias, cardiomyopathies, stroke, and arteritis. Most patients are young, healthy men with no cardiovascular risk factors; however, the patient population is expected to change to include older individuals in the future. The widespread public perception of safety accompanying marijuana use has contributed to its increased use among the elderly, who are the most at risk population for acute cardiovascular events. In this review, we aim to provide a basic understanding of the physiological effects of marijuana on the cardiovascular system and to review the current literature regarding cardiovascular diseases linked to marijuana use in adults.

Assessing the public health impacts of legalizing recreational cannabis use: the US experience

The sale of cannabis for adult recreational use has been made legal in nine US states since 2012, and nationally in Uruguay in 2013 and Canada in 2018. We review US research on the effects of legalization on cannabis use among adults and adolescents and on cannabis-related harms; the impact of legalizing adult recreational use on cannabis price, availability, potency and use; and regulatory policies that may increase or limit adverse effects of legalization. The legalization of recreational cannabis use in the US has substantially reduced the price of cannabis, increased its potency, and made cannabis more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth. It has also increased emergency department attendances and hospitalizations for some cannabis-related harms. The relatively modest effects on cannabis use to date probably reflect restrictions on the number and locations of retail cannabis outlets and the constraints on commercialization under a continued federal prohibition of cannabis. Future evaluations of legalization should monitor: cannabis sales volumes, prices and content of tetrahydrocannabinol; prevalence and frequency of cannabis use among adolescents and adults in household and high school surveys; car crash fatalities and injuries involving drivers who are cannabis-impaired; emergency department presentations related to cannabis; the demand for treatment of cannabis use disorders; and the prevalence of regular cannabis use among vulnerable young people in mental health services, schools and the criminal justice system. Governments that propose to legalize and regulate cannabis use need to fund research to monitor the impacts of these policy changes on public health, and take advantage of this research to develop ways of regulating can-nabis use that minimize adverse effects on public health.

Marijuana Use and Achievement Motives: An Exploratory Analysis of Self-Reported Health Among Adult Cannabis Consumers

The purpose of this study was to explore self-reported physical health and achievement motives in a sample of adult cannabis consumers. An online target sample ( n = 181) of adult cannabis consumers ( M = 38 yoa) was obtained from a cannabis tourism company in Colorado. Physical health and the primary benefit of cannabis use were self-reported and achievement motives were measured using the revised 10-item version of the Achievement Motives Scale (AMS). Results revealed five categories of benefit from cannabis consumption: stress/anxiety reduction (40%), pain/disease management (38.5%), thinking/introspection (11%), alternative drug (7.1%), and enhanced sociability (3%). t test results revealed no significant differences between the stress/anxiety and pain/disease groups in self-reported health (SRH), AMS dimensions, or cannabis consumption preferences. Regression results revealed that AMS factor fear of failure ( b = −0.224, p = .003), followed by cannabis spending per week ( b = −0.217, p = .024) best predicted SRH.

Guidelines for public health and safety metrics to evaluate the potential harms and benefits of cannabis regulation in Canada

ISSUES

Canada recently introduced a public health-based regulatory framework for non-medical cannabis. This review sought to identify a comprehensive set of indicators to evaluate the public health and safety impact of cannabis regulation in Canada, and to explore the ways in which these indicators may be expected to change in the era of legal non-medical cannabis.

APPROACH

Five scientific databases were searched to compile a list of cannabis-related issues of interest to public health and safety. A set of indicators was developed based on topics and themes that emerged. Preliminary evidence from other jurisdictions in the USA and Canada that have legalised medical and/or non-medical cannabis (e.g. Colorado, Washington) was summarised for each indicator, wherever possible.

KEY FINDINGS

In total, 28 indicators were identified under five broad themes: public safety; cannabis use trends; other substance use trends; cardiovascular and respiratory health; and mental health and cognition. Preliminary trends from other legalised jurisdictions reveal little consensus regarding the effect of cannabis legalisation on public health and safety harms and an emerging body of evidence to support potential benefits (e.g. reductions in opioid use and overdose).

IMPLICATIONS

In addition to indicators of commonly discussed challenges (e.g. cannabis-related hospitalisations, cannabis-impaired driving), this review led to the recommendation of several indicators to monitor for possible public health and safety improvements.

CONCLUSION

In preparing a comprehensive public health and safety monitoring and evaluation system for cannabis regulation, this review underscores the importance of not only measuring the possible risks but also the potential benefits.

Cannabis legalization, tobacco prevention policies, and Cannabis use in E-cigarettes among youth

BACKGROUND

E-cigarettes are the most popular tobacco product among youth. As more states adopt cannabis legalization policies, youth cannabis use in e-cigarettes is a mounting concern.

METHODS

Data were from the 2016 and 2017 National Youth Tobacco Survey, a nationally-representative repeated cross-sectional survey administered to US middle and high school students. Ever use groups were categorized into e-cigarette ever users, cannabis in e-cigarette ever users, other tobacco ever users, and never users. Weighted multinomial logistic regression compared ever use groups, while controlling for state-level cannabis legalization and tobacco prevention polices, tobacco perceptions and exposures, and sociodemographic variables. Weighted prevalence of ever and current, or past 30 day, tobacco product use was determined by ever use groups.

RESULTS

Compared to e-cigarette ever users, cannabis in e-cigarette ever users increased (Adjusted Relative Risk Ratio (ARRR) = 1.65; p < 0.01) from 2016 to 2017. Medical-only and medical and recreational cannabis laws, and no e-cigarette minimum legal sales age (MLSA) and increased e-cigarette MLSA at 19 or 21 were positively associated with cannabis in e-cigarette ever users (ARRR = 1.34-1.85; p < 0.01, each). Ever and current use of all individual tobacco products was highest among cannabis in e-cigarette ever users compared to e-cigarette and other tobacco ever users.

CONCLUSIONS

Cannabis use in e-cigarettes has increased among youth, and these trends will likely continue as e-cigarettes continue to gain popularity and cannabis legalization policies proliferate. Targeted tobacco and cannabis prevention strategies are needed for youth, especially in states that have implemented cannabis 'medical and recreational laws.

Early evidence of the impact of cannabis legalization on cannabis use, cannabis use disorder, and the use of other substances: Findings from state policy evaluations

Background: The past decade has seen unprecedented shifts in the cannabis policy environment, and the public health impacts of these changes will hinge on how they affect patterns of cannabis use and the use and harms associated with other substances.Objectives: To review existing research on how state cannabis policy impacts substance use, emphasizing studies using methods for causal inference and highlighting gaps in our understanding of policy impacts on evolving cannabis markets.Methods: Narrative review of quasi-experimental studies for how medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) affect cannabis use and use disorders, as well as the use of or harms from alcohol, opioids, and tobacco.Results: Research suggests MCLs increase adult but not adolescent cannabis use, and provisions of the laws associated with less regulated supply may increase adult cannabis use disorders. These laws may reduce some opioid-related harms, while their impacts on alcohol and tobacco use remain uncertain. Research on RCLs is just emerging, but findings suggest little impact on the prevalence of adolescent cannabis use, potential increases in college student use, and unknown effects on other substance use.Conclusions: Research on how MCLs influence cannabis use has advanced our understanding of the importance of heterogeneity in policies, populations, and market dynamics, but studies of how MCLs relate to other substance use often ignore these factors. Understanding effects of cannabis laws requires greater attention to differences in short- versus long-term effects of the laws, nuances of policies and patterns of consumption, and careful consideration of appropriate control groups.

Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis

RATIONALE

Certifications for medical cannabis are generally restricted to a small number of specific medical conditions, yet patients frequently report symptoms of pain, anxiety, and depression as reasons for use. This is a critical concern for researchers, healthcare providers, and policymakers, yet research in this area is currently obstructed by the lack of a focused review or empirical synthesis on patient-reported reasons for medical cannabis use.

OBJECTIVES

AND METHOD: The first aim of this project was to conduct the first systematic review and meta-analysis of empirical studies of patient-reported symptoms of pain, anxiety, and depression as reasons for medical cannabis use. The second aim was to conduct an empirical assessment of the methodological quality of extant research, test for publication bias, and test sex composition and quality scores of individual studies as possible sources of observed heterogeneity.

RESULTS

Meta-analytic results indicated that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons for medical cannabis use. No evidence for publication bias was detected, despite heterogeneity in prevalence rates. A comprehensive assessment of study quality identified a number of specific methodological limitations of the existing research, including challenges in patient recruitment, use of restrictive sampling frames, and a lack of randomized recruitment methods and validated assessment measures.

CONCLUSION

Findings are discussed with regard to possible explanations for current results, clinical considerations, and areas of future research that are needed to move the field forward.

Parental views on state cannabis laws and marijuana use for their medically vulnerable children

BACKGROUND

Given a rapidly changing policy landscape, we sought to characterize the effects of state marijuana laws on parents' views of marijuana use by their teenage children.

METHODS

Data are from 595 respondents to a nationally administered, web-based survey of parents of adolescents (ages 13-18 years) with any of three chronic conditions (type 1 diabetes, rheumatic disease, attention-deficit/hyperactivity disorder). Multivariate ordinal logistic regression was used to model the effects of parents' reports of state cannabis laws on their views toward marijuana use by their child.

RESULTS

While 89.9% said any marijuana use was risky for their child, 27.9% would approve of its use if prescribed as medicine. Parents reporting marijuana decriminalization (11.1%) were more amenable to teenage use, less concerned about how marijuana might impact their child's condition, more accepting of the safety of marijuana as medicine, and approved its use with a prescription. Parents reporting legal medical (35.6%) or recreational (5.7%) use were more likely to report that their child has tried or used marijuana regularly. Parents reporting legal recreational use were less likely to agree that marijuana has medical benefits for their child.

CONCLUSIONS

Among parents of medically vulnerable children, perceiving state marijuana policies as more permissive is strongly associated with lower perceived riskiness of marijuana use for their children. State marijuana policies are changing with implications for how parents of medically vulnerable youth view and potentially govern marijuana use by their medically vulnerable children.

Examining cannabis protective behavioral strategy use using multiple methods

Purpose –

Cannabis use among young adults is increasing, despite being associated with several negative consequences. Protective behavioral strategies (PBSs) are a potential mechanism of behavior change for reducing substance use, yet PBS use for cannabis is not well understood. The purpose of this paper is to further define and measure the PBS construct for cannabis.

Design/methodology/approach –

A community sample of cannabis users (n = 54) participated in eight focus groups discussing the use of PBSs. Participants completed surveys regarding demographics, cannabis use habits and cannabis problems. The authors also administered an existing measure of cannabis PBS and asked them to generate new or unique protective strategies that they had used or had heard of others using.

Findings –

Thematic analysis of qualitative focus group data provided information about cannabis users' reasons for regulating cannabis use (e.g. health or legal problems, interpersonal) as well as strategies to moderate cannabis use or attenuate their risk for experiencing adverse consequences (e.g. distraction, existential/spiritual strategies). Analyses of quantitative survey data revealed that use of PBSs was negatively correlated with cannabis outcomes. Perceived helpfulness of strategies was an important predictor of decreased cannabis use and adverse consequences.

Research limitations/implications –

Findings expand the understanding of the definition and measurement of strategies for regulating cannabis use and reducing related risk of experiencing adverse consequences.

Originality/value –

This is the first study to examine cannabis-related PBS using both qualitative and quantitative methods, which provide insights into the definition of PBS and for future refinements of PBS measurement.

Reducing the health risks derived from exposure to addictive substances

PURPOSE OF REVIEW

To discuss the health risks due to exposure to alcohol, illegal drugs and nicotine and how these risks might be reduced.

RECENT FINDINGS

In 2016, worldwide, alcohol, illegal drugs and nicotine were responsible for some 10 million deaths. There is evolutionary and biological evidence that humans are predisposed to consuming alcohol, illegal drugs and nicotine - present-day problems are caused by high levels of potency, exposure and drug delivery systems. The two priority substances for action are alcohol and smoked cigarettes; their exposure can be reduced by price increases, setting minimum prices per product, regulating a shift form smoked cigarettes to electronic nicotine delivery devices and, theoretically, reducing the ethanol content of existing beverages. Legalization of cannabis requires a strict regulatory framework.

SUMMARY

Purposeful policy can reduce the harm done by alcohol, illegal drugs and nicotine. In particular, policy to reduce exposure to alcohol requires considerable strengthening.

Co-use of cannabis, tobacco, and alcohol during adolescence: policy and regulatory implications

Legislative reforms have legalized use of cannabis for medical and recreational purposes. Efforts to evaluate the public health impact of these changes have predominantly focused on determining whether liberalizing cannabis policies has increased cannabis use patterns. Co-use of cannabis and other licit substances, namely tobacco and alcohol, is common during the developmental period of adolescence, which is generally characterized by an increase in risk-taking and novelty-seeking. However, limited research has sought to evaluate the potential implications of reforms to medical and recreational cannabis laws on concurrent and simultaneous use of cannabis, tobacco, and alcohol during adolescence. The current report reviews the extant literature detailing the prevalence and outcomes associated with concurrent and simultaneous cannabis-tobacco and cannabis-alcohol use, including recent work that has examined how concurrent and simultaneous use may be influenced by cannabis reform. This review details how the cannabis landscape and cannabis retail marketplace have evolved and briefly summarizes the corresponding policy and regulatory challenges that have emerged. The report concludes with a focused cannabis co-use research agenda that adopts different strategies including behavioural economic, self-administration, and survey research methods.

Legal cannabis laws, home cultivation, and use of edible cannabis products: A growing relationship?

BACKGROUND

Over half of U.S. states have enacted legal cannabis laws (LCL). In parallel, edible cannabis products (i.e., edibles) have presented new regulatory challenges. LCL provisions that dictate access to cannabis (e.g., home cultivation (HC) or dispensaries (DSP)) may impact edible production and use. This study examined relationships among HC and DSP provisions, cannabis cultivation, and edible use.

METHODS

An online cannabis use survey was distributed using Facebook. Data were collected from 1813 cannabis-using adults. U.S. states were classified as states without LCL (Non-LCL) or LCL states that: (1) only permit DSP (LCL DSP-only), (2) only permit HC (LCL HC-only), or (3) permit HC and DSP (LCL HC+DSP). Analyses tested associations among these classifications, cannabis growing, and edible use and procurement.

RESULTS

Individuals in LCL HC-only and LCL HC+DSP states were more likely to report currently growing cannabis at home (OR: 3.3, 95% CI: 1.7, 6.2; OR: 3.9, 95% CI: 2.4, 6.3, respectively) and past-month edible use (OR: 2.1, 95% CI: 1.4, 3.4; OR: 2.9, 95% CI: 2.2, 3.9, respectively) than individuals in LCL DSP-only states. Regardless of state, those who had grown cannabis were more likely to have made edibles than those who had never grown cannabis (OR: 2.2, 95% CI: 1.8, 2.6). Individuals in LCL HC-only states were more likely to have made edibles in the past month than individuals from Non-LCL (OR: 2.75, 95% CI: 1.5, 5.3) and DSP-only states (OR: 2.1, 95% CI: 1.0, 4.4). Individuals in LCL HC+DSP states were more likely to have purchased edibles in the past month than individuals from Non-LCL (OR: 3.7, 95% CI: 2.4, 5.6) and DSP-only states (OR: 3.2, 95% CI: 1.8, 5.5).

CONCLUSION

Specific LCL provisions may differentially affect individuals' propensity to grow cannabis and make, buy, and use edible cannabis products. Permitting home cultivation contributes to a greater likelihood of growing cannabis. Those who grow cannabis economize the plant by creating homemade edible cannabis products. Conversely, permitting dispensaries increases the likelihood of purchasing edibles. The psychoactive effects of edibles with unknown and variable cannabinoid content will be unpredictable. Policymakers should carefully consider how specific LCL provisions can affect patterns of cannabis edible product access and quality.

Understanding Rates of Marijuana Use and Consequences Among Adolescents in a Changing Legal Landscape

PURPOSE OF REVIEW

There is not one answer to address whether marijuana use has increased, decreased, or stayed the same given changes in state legalization of medical and non-medical marijuana in the USA.

RECENT FINDINGS

Evidence suggests some health benefits for medical marijuana; however, initiation of marijuana use is a risk factor for developing problem cannabis use. Though use rates have remained stable over recent years, about one in three 10th graders report marijuana use, most adolescents do not view the drug as harmful, and over 650,000 youth aged 12 to 17 struggle with cannabis use disorder.

SUMMARY

Although the health benefits of medical marijuana are becoming better understood, more research is needed. Intervention and prevention programs must better address effects of marijuana, acknowledging that while there may be some benefits medically, marijuana use can affect functioning during adolescence when the brain is still developing.

Correlates of Blunt Smoking Among African American, Hispanic/Latino, and White Adults: Results From the 2014 National Survey on Drug Use and Health

BACKGROUND

Blunt use is highly prevalent in the United States and has been associated with several negative health consequences, such as an increased risk for cardiovascular and pulmonary diseases. Although recent studies have identified characteristics (e.g., gender) that are associated with blunt use, it is unclear if these factors correlate with blunt use equally across racial/ethnic groups.

METHODS

Using cross-sectional data from the 2014 National Survey on Drug Use and Health, this study aimed to determine if demographic, health and substance use correlates of current (i.e., past 30-day) and lifetime blunt use were similar across 37,628 non-Hispanic African American, Hispanic/Latino and non-Hispanic White adults.

RESULTS

Findings revealed 8.3% of African American, 3.3% of Hispanic/Latino and 2.5% of White adults reported current blunt smoking. Across all racial/ethnic groups, age and current and lifetime cigarette and illicit drug use were associated with current and lifetime blunt use. However, gender, educational level, income, current alcohol use and self-reported health status were differentially associated with current and lifetime blunt use across racial/ethnic groups. Employment status and lifetime depression were not associated with blunt use behaviors among any of the racial/ethnic groups.

CONCLUSIONS

The relationship between gender, socioeconomic status, alcohol use and self-reported health status and blunt use differs among African American, Hispanic/Latino and White adults. Researchers and providers should consider the heterogeneity in factors that are associated with blunt use when designing prevention and treatment interventions for African American, Hispanic/Latino and White adult blunt smokers.