Full length articleU.S. cannabis legalization and use of vaping and edible products among youth
Introduction
Cannabis legalization is evolving rapidly in the United States. This has prompted a need to study how legal cannabis laws (LCL) such as medical cannabis laws (MCL) or recreational cannabis laws (RCL) may impact cannabis use patterns. Understanding how such laws affect youth is crucial because of this group’s vulnerability to the adverse effects of cannabis. Chronic cannabis use during adolescence has been associated with impaired brain development, educational achievement, and psychosocial functioning (Hall and Degenhardt, 2015, Rigucci et al., 2016, Volkow et al., 2014), and early initiation of cannabis use elevates the risk of developing a cannabis use disorder (DeWit et al., 2000, Swift et al., 2008).
Cannabis legalization promotes the creation and proliferation of alternative cannabis use products such as edibles and vaping devices (Hopfer, 2014, Hunt and Miles, 2015, Subritzky et al., 2015). Access to such products may alter how cannabis is consumed by the close to two million adolescents and seven million young adults currently using cannabis (Center for Behavioral Health Statistics and Quality, 2015), and may impact age of onset of cannabis use. Edible products such as cannabis-infused baked goods, drinks, and candy, have become increasingly popular but are often inaccurately labeled and deliver variable doses of cannabis’ primary psychoactive constituent, tetrahydrocannabinol (THC) (Subritzky et al., 2015, Vandrey et al., 2015). Most of the edible cannabis products currently marketed lack empirically-based safety standards and packaging regulations (Benjamin and Fossler, 2016, Cao et al., 2016, Subritzky et al., 2015), and products continue to be marketed in ways that are attractive to youth (MacCoun and Mello, 2015). Some LCL states have taken measures to limit products’ attractiveness to youth and require child-resistant packaging (Marijuana Enforcement Division, 2017) in response to the sharp increase in edible cannabis overdoses among youth (Wang et al., 2016). Despite these critical issues, few data are available documenting patterns of use of cannabis edibles among youth.
E-cigarettes and other vaping devices are becoming increasingly popular among middle and high school aged youth in the United States (Anand et al., 2015, Krishnan-Sarin et al., 2015, Singh et al., 2016). These devices heat liquid or solid preparations of substances to allow a user to inhale the psychoactive compounds (e.g., nicotine, THC) from these substances in non-combusted forms. Vaping can significantly reduce carcinogenic toxins consumed when inhaling combustible cannabis and tobacco smoke (Polosa, 2015, Van Dam and Earleywine, 2010) and youth do perceive e-cigarettes to be healthier and less risky than traditional combustible cigarettes (Camenga et al., 2015, Kong et al., 2015). Cannabis vaping has received limited study but also appears to be on the rise among adolescents and young adults (Jones et al., 2016, Morean et al., 2015). Among e-cigarette users, cannabis vaping occurs more often in populations of high school aged youth than adults (Morean et al., 2015). Recent data suggest that adolescents who vape cannabis most often use highly potent cannabis oil, wax, or liquid preparations (Morean et al., 2015). How the use of these high-potency products impacts neurodevelopment is unknown, but of pressing concern as it may place youth at risk for psychosis (Di Forti et al., 2014) and cannabis use disorders (Freeman and Winstock, 2015). Moreover, vaping has the potential to contribute to increased rates of cannabis uptake, lower age of cannabis use onset (Budney et al., 2015), and increased public cannabis use (Giroud et al., 2015, Jones et al., 2016, Morean et al., 2015), all of which may prompt more frequent and perhaps larger quantities of cannabis use (Budney et al., 2015, Fischer et al., 2015). To date, however, few data exist on the use of vaping devices for cannabis consumption among youth despite these potential risks.
States have passed unique LCL each with different combinations of legal provisions (Hunt and Miles, 2015) − creating a heterogeneous landscape of cannabis regulatory models across the U.S. (Bestrashniy and Winters, 2015, Pacula et al., 2014a). Some states only allow medicinal cannabis use while other states allow both medicinal and recreational cannabis use. Within these two regulatory frameworks, access and distribution mechanisms vary dramatically. Some states permit for-profit cannabis dispensaries or home cultivation (HC) of cannabis while other states do not. Limits on personal possession amounts range from 1 to 24 ounces or are ambiguously defined as a “30-day” or “60-day” supply. In some states, cannabis can only be vaporized or used in edible form (not smoked). Equivocal results in the literature concerning the effect of cannabis legalization on public health are likely a product of poor accounting for this diversity among LCLs (Pacula et al., 2015, Sevigny et al., 2014). Each LCL provision has the potential to affect patterns and consequences of use, and interaction among LCL provisions may yield additive, synergistic, or counter effects.
In a previous study, we used Facebook sampling methods to demonstrate strong cross-sectional relations between the presence of LCL provisions and increased likelihood of vaping and edible use among adults (Borodovsky et al., 2016). Specifically, we found that adults from states with (1) higher numbers of cannabis dispensaries per person and (2) longer durations of having an MCL in place were significantly more likely to have tried vaping cannabis and cannabis edibles. Age of onset of vaping and edibles use was not related to these LCL provisions. In the present study, we used this same valid and reliable sampling method (Ramo et al., 2012) to examine these same associations in a youth sample and explore the impact of two additional LCL provisions (home cultivation and recreational legalization) on vaping and edible use. We hypothesized that longer durations of having an MCL in place, a greater number of dispensaries per 100,000 people, the presence of a recreational cannabis law, and the presence of a home cultivation provision would be associated with higher likelihood of lifetime use and younger age of onset of cannabis vaping and edibles.
Section snippets
Survey
An anonymous online survey hosted by Qualtrics collected information on demographics (including state residence) and cannabis use. Cannabis use items focused on lifetime use, current use, and age of onset of both cannabis use in general and of different methods of cannabis administration (smoking, vaping, and eating). Qualtrics data quality functions prevented multiple responses from a single individual and ensured that responses came from people and not internet bots. The survey required all
Sample description
Table 2 displays overall characteristics of the sample and characteristic comparisons between Non-LCL vs. LCL states. The mean age of the entire sample was 16.36 years (SD = 1.09), and approximately 46% were male. Minorities were somewhat underrepresented (approx. 3% African-American, and 14% Hispanic). Approximately 84% were between 9th and 12th grade. Participants from LCL and Non-LCL differed significantly across current education level, lifetime days of cannabis use, and age of cannabis use
Discussion
This study examined relations among specific provisions of LCL and cannabis vaping and use of edibles in youth ages 14–18. Consistent with our previous study of adult cannabis users recruited via Facebook, the present analyses indicated that longer LCL duration and higher dispensary density were related to a higher likelihood of lifetime vaping and edible use. The current study extended those findings by showing that provisions for recreational cannabis use and for permitting home cultivation
Contributors
JTB, DCL, BSC, JDS, JLG and AJB designed the survey. DCL and JTB managed online recruitment and data cleaning efforts. JTB conducted the analyses of the data. JTB and AJB wrote the initial draft of the manuscript. All authors contributed to the writing and have approved the final manuscript.
Role of funding source
Funding for this study was provided by NIH-NIDA grants R01-DA032243, P30-DA029926, and T32-DA037202; the NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Conflict of interest
The authors have no conflicts of interest to declare.
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