Cannabis Grow

Nucci and Turiel explain that, during this period of life, individuals expand their ability to recognize and incorporate multiple, and at times conflicting, aspects of a single issue to form their judgments and conclusions. In order to illustrate this complexity of thought and offer insight into how adolescents conceptualize the issue, this study examined adolescents’ judgments and justifications about marijuana use. This study was based on the proposition that unveiling the factors adolescents use in their thinking and the coordination process involved in this process can provide insight into their judgments about specific issues. Given the instability of public knowledge, perceptions, and attitudes toward the issue of marijuana use and its prevalence among the adolescent population in general , this issue was selected as the topic of research for this project. Specifically, this study was an investigation of adolescents’ judgments and justifications about marijuana use through the lens of social domain theory. Through the use of open-ended questions asking respondents to evaluate the act and their reasons for the evaluations, the study was intended to illuminate how adolescents conceptualize marijuana use. Marijuana use was also compared to other more clear-cut social issues in order to demonstrate its more ambiguous nature. It was intended that the results of this investigation contribute to the social domain theory body of research,how to trim cannabis and provide insight into adolescents’ judgments about a complex social issue that is relevant to this period of development.

The data partially confirmed the hypothesis that adolescents would show inconsistent judgments of marijuana use. Though they did show a mix of evaluations, respondents indicated more favorable views of the act overall. When asked about the act generally, only 8% of the respondents reported negative evaluations of the act . Not surprisingly, positive act evaluations of marijuana were negatively correlated with responses that there should be a law prohibiting use. Significantly more respondents disagreed that there should be a law prohibiting marijuana use than those who agreed with such a law. Likewise, most respondents reported positive evaluations of marijuana use in the case that it was common practice to engage in the act. When stating their reasons for their evaluations to these questions, respondents most frequently referenced conventional, prudential, and personal domain justifications. Specifically, the Custom/Tradition, Social Coordination, Safety, and Personal Choice categories were most frequently referenced. Respondents also frequently referenced the medical use of marijuana. Justifications to item 1 were considered most representative of the considerations that respondents found to be most relevant to the issue. Based on their responses to this item, considerations about the medical use of marijuana, the safety of marijuana, and personal choice to engage in the act were most salient to respondents’ reasoning. The other items in the marijuana use item set asked respondents to reason about specific conditions such as legality and common practices, and justifications to these items often referenced such considerations. For example, justifications for item 2 frequently referenced the Authority category, justifications for item 3 frequently referenced the Authority and Age Contingency, and justifications to item 4 frequently referenced the Custom/Tradition category.

Notably, however, the Safety and Personal Choice categories were consistently the next most frequently referenced justifications for each of these items. This finding as well as findings regarding justifications provided for item 1 suggest that safety and personal choice considerations were paramount to this sample’s reasoning about marijuana use. This proposition is supported by results that likewise suggested that prudential reasons were most frequently referenced; this justification was significantly more likely to be used than personal or moral justifications, and the personal domain was significantly more likely to be referenced than the moral domain. Results confirmed the hypothesis that adolescents reason about marijuana use by adults differently from how they reason about marijuana use by adolescents. Respondents were significantly more likely to provide positive evaluations of marijuana use under the age contingency condition than when generally asked about marijuana use. There was a 23% increase in respondents’ positive evaluations of the act under the age contingency condition than in their general evaluations of the act. Furthermore, respondents who initially had uncertain evaluations or negative evaluations of marijuana use seemed to be influenced by the added age contingency placed on the act: respectively 75% and 77% of respondents who had initially provided uncertain/mixed evaluations and negative evaluations of marijuana use shifted to positive evaluations of the act under the age contingency condition. These results suggest that an age law for marijuana was impactful to their evaluations about the acceptability of use. Justifications to this item supported this assertion, as respondents often stated that individuals 21 and older are “mature” and “more responsible” and thereby better able to make decisions about engagement in these types of activities. Respondents also frequently compared marijuana to alcohol when responding to this item and stated that the two substances are similar and should therefore treated in a similar fashion.

These findings are interesting to consider in the context of timing of data collection for this study: The administration of the study took place nine months prior to the November 2016 election in California , which resulted in the legalization of the recreational use of marijuana for individuals age 21 and over . The timing of data collection may have played an influential role in respondents’ judgments about marijuana use. For example, it is possible that respondents were not only exposed to political advertisements regarding the legalization of recreational marijuana use. Respondents may have even participated in classroom or social discussions about the issue of recreational legalization. It is not possible to know whether and to what extent such factors impacted these respondents’ judgments about marijuana curing use in the present study. However, such potential influences are important factors to bear in mind when considering the present study results . It is noteworthy that, as mentioned, the age contingency condition yielded the most positive evaluations of marijuana use in this item set. These mostly positive evaluations of marijuana use under this condition suggest that the age of the user is indeed an important factor in respondents’ judgments of the act. Moreover, given that this legal age condition has components of both conventional and prudential considerations, these findings have implications for the social domains that the respondents seemed to find most relevant to marijuana use; that respondents were significantly swayed toward positive evaluations of the act under this condition indicates that respondents find the conventional and prudential domains particularly relevant to their evaluations. Domain reference results suggesting that respondents provided significantly more prudential and conventional domain justifications in their responses to the marijuana item set provides further evidence that these considerations were particularly impactful to this sample’s reasoning about marijuana use.Respondents’ conceptualization of marijuana use regarding criterion judgments was determined through an assessment of their general act evaluations of marijuana use and through questions asking about marijuana use given specific conditional factors . Response patterns suggested that criterion judgments associated with the moral domain were not applicable, as the vast majority of respondents did not generally evaluate the act as wrong, nor did their evaluations necessarily indicate that they think of the issue as independent of law/rules/authority or common practice .

These results contrast with results from the studies conducted by Abide et al. , Amonini and Donovan , and Kuther and Higgins-D’Alessandro , which suggested that participants frequently or primarily evaluated marijuana or drug use as a moral issue. However, as was discussed in the review of the literature, these studies did not distinguish prudential considerations from moral, conventional, and otherwise personal ones when asking participants to make their evaluations; participants were asked to classify issues within the moral, personal, and/or conventional domains only. The lack of prudential domain differentiation may have confused their findings, as participants may have been thinking in terms of safety and harm when evaluating substance or marijuana use as “wrong regardless of existing laws” or as “morally wrong” . Separating the prudential domain from the others allowed for more accurate inferences to be made from the findings of the present study than those of such previous research. The response patterns from this study further suggest that conventional criterion judgments were less relevant to marijuana use evaluations than other considerations may have been. Respondents provided similarly mixed responses when asked about the acceptability of use in the presence or in the absence of a law prohibiting use. This suggests that the condition of rules or laws against marijuana were not significantly influential to their evaluations . Context specificity also seemed uninfluential to their judgments. This was evidenced by results showing no significant shifts in respondents’ evaluations of marijuana use under the common practice condition proposed; a statistically significant majority of respondents who were asked to consider this condition maintained that use would be all right even if was not commonly practiced or accepted . Taken together, these results suggest that marijuana use does not seem to meet the criterion judgments found to be associated with the moral and conventional domains. The lack of applicability of the moral and conventional criterion judgments is in turn suggestive that the personal domain is most closely characteristic of the marijuana use issue. Findings suggesting that personal domain criterion judgments were prominent in respondents’ reasoning about marijuana are consistent with previous research likewise suggesting that adolescents primarily evaluated substance use within the personal domain .Informational assumptions are the reasons or evidence that individuals point to when justifying their evaluations of an issue . In other words, individuals’ understandings of an issue are based on the informational assumptions that they have come to associate with the matter, and such understandings are utilized when reasoning about it. It is often the uncertainties of the informational assumptions associated with non-prototypical social issues that give them their ambiguous character, and in turn result in inconsistent judgments of these issues. Results from this study provide evidence suggesting that informational assumptions about the harm involved in marijuana use were related to respondents’ evaluations of the act. Results indicated that the significant majority of respondents held informational assumptions that frequent marijuana use causes physical or psychological harm to the user. The hypothesis that informational assumptions about the harm of using marijuana would be associated with responses to general marijuana act evaluations was supported. Though small in number , all individuals who reported that marijuana use was not all right were more likely to report that use causes harm, implying that the harmfulness of marijuana use contributed their negative initial evaluation of the act. The impact of informational assumptions about marijuana use harm on respondents’ judgments is further supported by the finding that 74% of those who provided uncertain evaluations of marijuana use when generally evaluating the act also reported that frequent marijuana use causes harm. This finding implies that beliefs about the harm involved in marijuana use may have contributed to these respondents’ negative general evaluations about the acceptability of use. The reverse finding likewise suggested that informational assumptions about harm play a role in evaluation judgments about marijuana use: Beliefs about the lack of harm involved in use also had an impact on evaluations, as those who reported positive evaluations of marijuana use were less likely to report that marijuana use causes harm. Specifically, of those who said that marijuana use is all right, only 38% reported thinking that use causes harm. This is in contrast to the 74% and 100% of the respective uncertain and negative evaluators of marijuana use who reported that use causes harm. The impact of beliefs about harm on evaluations about marijuana use was further assessed through the manipulation conditions that followed the general question about marijuana use. It was hypothesized that, when asked about the acceptability of use under the condition that it is not harmful, respondents would be more likely to evaluate the use of marijuana positively. Conversely, it was hypothesized that, when asked about the acceptability of use under the condition that marijuana use is harmful, participants would be expected to provide negative act evaluations. Results partially supported these hypotheses. Respondents who reported that frequent marijuana use harms the user were significantly more likely to evaluate use as all right under the condition that it was conclusively determined to be safe for the user. However, the condition of harmfulness did not seem to have a significant impact on the evaluations of the acceptability of marijuana use by those respondents who originally reported that frequent marijuana use is not harmful.

Additional research evidence for adolescents’ multi-faceted reasoning about ambiguous social issues such as substance use was conducted by Shaw, Amsel and Schillo . They investigated late adolescents’ domain reasoning when presented with hypothetical scenarios involving risk-taking behaviors and by asking respondents to justify engagement or lack thereof in the behavior/activity. It was found that 84% of the respondents’ justifications referred to at least one social domain of reasoning. Moreover, 88% of the justifications respondents provided when evaluating each of the risktaking behaviors made reference to a combination of prudential, conventional, and moral considerations as reasons for not engaging in the behavior/activity. This and other studies have thereby shown the multiple lines of reasoning adolescents employ when reasoning about such ambiguous social issues and behaviors. Such variability in adolescents’ domains of reasoning in the above studies suggests that they are accounting for various contextual factors when judging these issues. As adolescents develop, they are more able to consider multiple facets of an issue rather than thinking about the issue in a unilateral way. Thus, as they become more able to integrate the various features of an issue as well as their informational assumptions,cure cannabis their thinking about these ambiguous issues becomes more complex and their evaluations more multi-dimensional . The above review of the literature indicates that the findings about which social domain of reasoning is most prominent in adolescents’ thinking about an issue like substance use have been inconsistent.

Results also suggest that teens may draw upon a multitude of factors across social domains when reasoning about such issues. Moreover, problems with the methodology and/or analysis of some of these studies suggest that a forced-choice approach to data collection in this line of research limits the clarity and interpretability of results, and therefore the ability to draw conclusions from the findings. As related more specifically to the issue that is the focus of the present research, previous research has suggested that marijuana use is a social matter that involves different and at times conflicting considerations. The array of relevant facets involved in marijuana use make it an ambiguous social issue as opposed to prototypical moral, conventional, or personal issues. Thus far, the following points have been discussed: 1) marijuana use is an important yet vaguely understood social issue that warrants further research, 2) marijuana use is an ambiguous issue that is often comprised of various relevant facets that merit consideration, 3) the salience of these various considerations are associated with the informational assumptions held by an individual, and 4) understanding the various informational assumptions that become salient in adolescents’ reasoning about marijuana use can help elucidate the basis for their judgments and related justifications. In the present investigation, the patterns of adolescents’ judgments and justifications regarding marijuana use were explored through open-ended questions about their evaluations of marijuana use in general and under the consideration of certain hypothetical conditions. These patterns of reasoning were then compared to the patterns of judgments regarding unambiguous issues. In addition to questions about marijuana use, respondents were asked to evaluate a prototypical moral issue and a prototypical personal issue . Adolescents’ judgments and justifications about the prototypical moral or personal issues were expected to be judged within the respective moral or personal domains.

However, judgments and justifications about marijuana use were expected to reflect a different pattern ; evaluations of marijuana use were expected to be inconsistent and to reference various domains of reasoning depending on the informational assumptions held. This study, which assessed adolescents’ evaluations and judgments about marijuana use is modeled on previous social domain research that has investigated individuals’ reasoning about ambiguous social issues, such as pornography, homosexuality, and abortion . The present study used a similar research methodology as the Turiel et al. studies. Some of the questions that were used in the Turiel et al. studies have likewise been adapted for the aims of the present study. The present study employed a short-answer response format to data collection, which allowed for a larger sample size , while retaining the value that qualitative data collection methodology offers. By allowing respondents to provide justifications for their evaluations rather than only expressions of agreement or disagreement, it was expected that the present study would yield greater depth in understanding how respondents evaluate issues. Data were gathered through the administration of surveys that asked participants whether and why/why not 1) marijuana use is all right or not all right, 2) there should be a law in the U.S. prohibiting the use of marijuana, 3) marijuana use by individuals of certain ages is all right, and 4) marijuana use would be all right if was common practice for people in the U.S. to engage in it. Based on the participant’s responses to these items, he/she was asked follow-up questions about his/her evaluation of the issue in the case of certain hypothetical situations.

The survey items addressed whether and how adolescents use informational assumptions when justifying their judgments of marijuana use. This was accomplished by 1) obtaining the participants’ reasons for their evaluations, followed by 2) specific items asking participants whether they think frequent marijuana use causes physical or psychological harm to the user. The participants were also asked follow-up questions based on their response to the item regarding their thoughts on whether or not marijuana use causes harm to the user. If the participant responded that he/she does not think frequent marijuana use causes harm to the user,curing drying he/she was asked to suppose that scientists conclusively determined that marijuana use was in fact harmful to the user and to judge whether marijuana use would be all right or not all right in this case. If the participant responded that he/she does think frequent marijuana use causes harm to the user, he/she was asked to suppose that scientists conclusively determined that marijuana use was not harmful to the user and to judge whether marijuana use would be all right or not all right in this case. Research aims and intended contributions of the present study. Though there have been some studies aimed at understanding adolescent reasoning about marijuana use through a social domain framework , much of the research in this field has been based on a forced-choice, survey format for data collection. While such methods can be useful for amassing large amounts of data by presenting a number of multiple-choice items to participants, they are limited in the capacity to extract the participants’ thinking; the forced choice format fails to reveal the complexity of thinking and the informational assumptions individuals draw upon to reach their judgments. This study adopts an open-ended written response format of data collection. In this way, the study expanded upon findings from previous research by assessing the ways criterion judgments, justifications, and informational assumptions are brought to bear during adolescents’ evaluations of use of marijuana. Specifically, the questions were designed to assess participants’ evaluations and justifications about the acceptability of marijuana use as related to age, rules/laws/authority contingency, and common practice. These questions, as well as specific questions regarding participants’ beliefs and understandings about the presence and degree of harm associated with use, are designed to assess the informational assumptions adolescents maintain regarding marijuana use. There are three hypotheses for the expected results of this study. The first is that marijuana use is regarded as an ambiguous social issue that elicits multi-domain considerations, resulting in positive and negative evaluations that may be inconsistent across- and even within- individuals depending upon the specific criterion judgments and justifications employed. Variation in response types and patterns are expected between participants, as are inconsistent patterns of criterion judgments within participants’ responses . Likewise, variations within and between participants are expected with regard to the justifications and domains that participants reference in their responses.

The second hypothesis is that individual evaluations will be associated with the informational assumptions held regarding the extent of harm in marijuana use. When asked about the acceptability of use under the condition that it is not harmful, participants are expected to evaluate the use of marijuana positively if prudential concerns were part of the basis for their initially negative evaluation of marijuana use. On the other hand, when asked about the acceptability of use under the condition that marijuana use is harmful, participants are expected to provide negative act evaluations in response to this follow-up question if prudential considerations were part of the basis for their initially positive evaluation of use. The third hypothesis for this study is that, whereas evaluations in criterion judgments of marijuana use will be variable within and between subjects, evaluations of prototypical issues will be consistent . In other words, results from the questions addressing marijuana use issue were expected to contrast with results of prototypical moral and prototypical personal issues in that the prototypical moral issue is expected to be consistently evaluated negatively with justifications referencing the Welfare, Justice and Rights, and Moral Obligation categories and the prototypical personal issue are expected to be consistently evaluated positively with justifications referencing the Personal Choice category. To summarize, results from this portion of the study are expected to show the following: 1) consistently negative judgments regarding the acceptability of stealing, 2) consistently positive judgments about the acceptability of using one’s allowance money to purchase music, and, respectively, 3) morally-based criterion judgments and justifications in response to the stealing issue and 4) personal domain-based criterion judgments and justifications in response to the purchasing music issue. Participants for this study were 100 adolescents aged sixteen to eighteen years of age and in their junior and senior years of high school. Participants were composed of 35 males and 65 females. Seven of the participants were age 16, sixty-three participants were age 17, and thirty were 18 years of age. The majority of the participants were in the 12th grade. Fourteen of the participants were in the 11th grade. The racial/ethnic composition of the participants was primarily White and Hispanic , but there were also a small number of participants who identified as ‘Mixed’ , Asian , or ‘Other’ . Participants were recruited from a high school in a mid-sized rural city in the northern San Francisco Bay Area that is primarily composed of middle class households . Participation in the study was optional and based on students’ interest in participating in the research. The surveys were administered to students in the four class periods of the Psychology course offered at the high school. Study administration took place during typical school day hours. The classroom teacher explained to students that they would have the opportunity to participate in a research study being conducted by a graduate student for the purposes of a doctoral dissertation. Students were asked to review Student Consent/Assent forms as well as Parent Permission Form and to return signed forms if choosing to participate in the study . Completion and submission of the Student Consent/Assent and the Parent Permission Form were mandatory prerequisites for being given the choice to participate in the study on the day of administration. The Graduate Student Investigator reviewed three guidelines for the surveys that would be handed out. The following instructions, which had been written on the front board prior to the students’ arrival, were reviewed and further explained with the participants: 1) State “all right,” “not all right,” or “depends” in response to each question, 2) always make sure to state your reason for your response , and 3) for items that have a part and part , answer either part or –the survey provides directions about whether to answer part or based on the previous response given. After reviewing these guidelines, participants were asked if they had any questions. Participants’ questions were answered and the surveys were distributed. Participants were asked about their judgments of marijuana use in general , whether there should be a law that prohibits marijuana use, and whether marijuana use would be all right if there was not a law prohibiting use , or if there was law prohibiting use . Respondents were then asked to evaluate marijuana in the case that the majority of the people in the United States decided that marijuana use should be allowed for individuals ages 21 and over, and in the case that it was common practice for individuals to engage in marijuana use.

As research continues, it will be important to include underrepresented populations as patterns of use for medical purposes may differ by socioeconomic status, race, and access to medical care. Despite the lack of evidence on the efficacy of marijuana use for health conditions, nearly half of those who disclosed medical marijuana use to their doctors reported they were supportive and only 8% of patients felt their doctors were not supportive. The overall high perception of support in our survey contrasts several prior physician surveys describing low approval rates of medical marijuana. In 2005, a survey of 960 physicians nationwide found that only 36% supported legalization of medical marijuana and 26% were neutral.A 2013 survey of 520 family physicians in Colorado found that, despite medical marijuana being legal, only 19% of physicians believed they should be able to recommend it and most agreed it posed serious mental and physical health risks.We did not query healthcare providers directly but instead asked participants their perception of their healthcare providers’ level of support. As such, participants who reported marijuana use to their doctor may have already known they would be supportive. Our data is also more recent compared to the prior surveys, and physicians’ attitudes may parallel the decreased perception of harm that has been documented in surveys of the general population.Indeed,curing weed a more recent survey of 400 medical oncologists found that 46% would recommend medical marijuana to their patients and 67% viewed it as a helpful adjunct to pain management.We also found that 26% of those who used marijuana for medical purposes did not inform their doctor and that this rate was higher in states where medical marijuana was illegal.

Potential reasons for non-disclosure include mistrust, fear of disapproval or bias, and legal consequences in states where marijuana is illegal. Additionally, it is possible patients did not disclose their use because their doctor did not directly ask them. Given the lack of evidence, training, and guidelines on the use of marijuana for medical purposes, some healthcare providers may feel uncomfortable discussing this with patients. Regardless of the reasons why marijuana use was not disclosed, this demonstrates a concerning lack of communication and missed opportunity for providers to counsel patients about the risks and benefits of marijuana use. Additionally, we found that 21% of participants using medical marijuana did not have a doctor. The majority were between ages 18 and 34 and only 22% had a total household income of more than $75,000. Therefore, while their insurance status is unknown, their young age and lower income may have impacted their decision or ability to see a provider. Despite the limitations of the evidence, several healthcare institutions and societies have created policies and guidelines for their healthcare workers to have these important conversations. For example, while Veterans Health Administration providers are unable to complete forms referring patients to State-approved marijuana programs, 2017 VA guidelines encourage physicians to discuss marijuana use with patients and explore how its use may be affecting their health.Though our study benefits from a nationally representative sample, it has several limitations. First, the ordering of the list was not randomized across participants. Also, our results may be more reflective of individuals who are willing to participate in online surveys. However, demographics of our survey respondents were similar to those from prior national studies and there was no evidence of non-response bias on key demographics.Another limitation is that our survey did not directly address perceived efficacy of marijuana use for medical conditions. It would be helpful to know if patients and their healthcare providers believe marijuana is improving their symptoms. Also, we asked about chronic pain as a general category and not specific sub-types of pain.

Finally, we did not survey providers directly, rather, respondents reported their perception of their doctors’ views on marijuana and we did not ask about disclosure to other types of healthcare providers. Despite these limitations, our results demonstrate that US adults are using marijuana to treat conditions where it has not been convincingly shown to provide benefit and highlight the urgent need for higher quality studies on the effectiveness of medical marijuana. They also underscore the need for clinical guidelines to support more complete and informed discussions between patients and providers about medical marijuana use.Marijuana use is common, particularly in people living with HIV . Prior studies suggest that the prevalence of current marijuana use in PLWH ranges from 20% to 60%. In the general population, this number is 8%8 . Discussions with patients about marijuana have taken on more urgency in HIV primary care over the past several years as over half of states have moved to legalize medical marijuana, which is likely to increase use. Furthermore, at least 27 states have designated HIV seropositivity as a qualifying diagnosis for medical marijuana certification. Although experimental trials that substantiate specific benefits are lacking, commonly reported reasons for marijuana use in PLWH include pain relief, as well as other symptoms such as nausea and anorexia. Additionally, chronic pain is common in PLWH, with prevalence estimates ranging from 25% to 85% depending on the cohort studied, and is the most common reason why people seek treatment with medical marijuana. However, recent systematic reviews have highlighted the limited evidence base for medical marijuana in treating pain and other symptoms in the general population, and specifically in PLWH. Another common perception includes a belief that marijuana may allow patients prescribed long-term opioid therapy for chronic pain to reduce their opioid use. Ecological studies in the general population and one study in PLWH support this possibility. With this background, HIV clinicians need empirically based findings to guide patients regarding marijuana use. Additionally, clinicians are faced with the tension between state laws naming HIV as a qualifying diagnosis for medical marijuana and the limited evidence base.

Recent studies suggest that the lay public has generally positive views of the benefits of medical marijuana and views risks as minimal. Given the limited evidence base, providers may be influenced by the layperson’s view of marijuana. Since clinical trials studying the effects of medical marijuana are hampered by federal classification of marijuana as a schedule I substance,weed curing observational data must be relied on to advance our understanding of the impact of marijuana on health outcomes. We investigated whether recreational marijuana use among PLWH who have chronic pain is associated with two clinically important chronic pain-related outcomes: changes in pain severity and prescribed opioid use . We first asked whether a change in marijuana use over time predicted a change in pain severity, hypothesizing that an increase in marijuana use would be associated with decreased pain and a decrease in marijuana use would be associated with an increase in pain severity. We then asked whether baseline marijuana use would be associated with lower opioid prescribing. We hypothesized that baseline marijuana use would be associated with lower rates of initiation and higher rates of discontinuation of prescribed opioids. This study is an analysis of data from a large, ongoing national prospective cohort study of chronic pain and HIV outcomes embedded within the Centers for AIDS Research Network of Integrated Clinical Systems. CNICS sites are patient-centered medical homes for PLWH, meaning that they provide primary and specialty care for PLWH including mental health treatment and social services. The majority of patients from CNICS sites are enrolled in the cohort. CNICS collects demographic and clinical data at routine clinic visits, including laboratory tests, visit data, and prescribed medications from the electronic medical record. Additionally, as part of routine clinical care appointments, participants complete in-person Patient Reported Outcome measures on a computer or tablet on a variety of social and behavioral domains approximately every 4 to 6 months. The CNICS clinical assessment of PROs includes the Alcohol, Smoking, and Substance Involvement Screening Test , which collects self-report of “non-medical” marijuana use over the past 3 months.

The possible categories are no current use, use 1–2 times in the past 3 months, monthly, weekly, or daily. Pain instruments were added to the CNICS clinical assessment between July 2015 and July 2016, providing 12 months of data from which to study chronic pain in this cohort. The following five CNICS sites included the Pain instruments and contributed data to this analysis: Fenway Health in Boston, the University of Alabama at Birmingham , University of California, San Diego , University of North Carolina , and University of Washington . At the time of this study, marijuana was legal recreationally in Washington , medically in Washington and California , and illegal in all other sites. Pain instruments included the Brief Chronic Pain Questionnaire . The BCPQ asks whether participants have pain that has lasted for more than 3 months, and the severity of their pain. Participants who reported at least “moderate” pain for at least 3 months were classified as “chronic pain” and also received the three-item PEG to assess pain severity. This instrument assesses pain intensity , interference with enjoyment of life , and interference with general activity on a scale of 0–10 for each item. Participants with at least moderate chronic pain were also asked to complete the following question: “Check everywhere you have had pain for at least 3 months: numbness or tingling in hands and/or feet; headache; abdominal pain; low back pain; hip pain; shoulder pain; knee pain; pain everywhere in your body.” This study was approved by the Institutional Review Board of the University of Alabama at Birmingham . The date participants completed their first pain PRO instrument was defined as their “index visit.” The study period was defined as the 1-year period following the index visit. Criteria for inclusion in this analysis were age ≥18 years, participation in CNICS for at least one year prior to the index visit to allow for assessment of prescribed opioids during this period and to prevent inclusion of participants new to HIV care, and chronic pain. We also required participants to have two marijuana and two pain PRO measurements during the study period so that changes in these variables could be assessed. Marijuana use—Marijuana use was assessed at the PRO assessments during the study period. Among participants who reported no current use, use monthly, use 1–2 times per month, or use weekly, we defined an increase in marijuana use as any change to a category of more frequent use during the study period. Participants who reported daily use were not able to increase their use and therefore were not included in this analysis. Among participants who reported use 1–2 times in the past 3 months, monthly, weekly, or daily, we defined a decrease in marijuana use as any change to a category of less frequent use during the study period. Participants who reported no current use were not able to decrease their use and therefore were not included in this analysis. For analysis of marijuana use at the index visit, levels were combined to improve interpretations such that three groups were considered; daily/weekly use, monthly/1–2 times in past 3 months, and no current use.The PEG score was calculated as the mean of the 3 items in the questionnaire. We defined long-term opioid therapy as opioid therapy for 90 consecutive days based on medical record data. Prescribed opioid discontinuation was defined as being prescribed LTOT at any point during the year prior to the index visit, and not being prescribed LTOT during the follow-up period. Prescribed opioid initiation was defined as not being prescribed LTOT for one year prior to the index visit and having LTOT initiated during the study period. While it may be of interest to examine longitudinal relationships using all potential visits, only 12% of patients have more than two visits during the follow-up period and it is not clear how having less than the maximum number of observations would be considered statistically significant as this is a clinical cohort without a formal protocol. Change in pain severity outcome: For the relationship between marijuana use and change in pain severity, we considered whether an individual’s marijuana use increased or decreased during the study period.

However, most published studies have focused only on adolescents under the age of 18 years and do not reflect the adult population to which medical marijuana policies apply . Therefore, long-term longitudinal studies are needed to monitor the effects of marijuana legalization, marijuana initiation/ re-initiation, cigarette initiation/ reinitiation, and patterns of co-use across all age categories. Additionally, it is recommended that such studies take into account statewide variables including number of years since the policy went into effect to adequately capture any measurable changes. These data are needed to explore the growing evidence and public health concerns about the potential “gateway” effect of marijuana on cigarette initiation and nicotine dependence in adolescents and young adults in addition to the potential for re-initiation of cigarettes among former tobacco users. As more states pass marijuana policies, potential increases in co-use could have important treatment implications. Cigarette smokers who also reported current marijuana use were more likely to have nicotine dependence,commercial greenhouse benches which is a known predictor of smoking and quitting behavior . The positive link between co-use and nicotine dependence was observed across age categories but these associations differed across measures of dependence . We analyzed both NDSS and TTFC. NDSS scores might have been a better measure of nicotine dependence in our comparison across age groups since the scale addresses five aspects of dependence .

In comparison, the TTFC single-item scores might not have captured dependency, particularly in adolescent and young adult populations, who have yet to become regular and established smokers. Other studies have shown problems in using TTFC as a measure of dependence in young adults . Since our analysis included both adolescents and adults, we report both NDSS and TTFC measures of nicotine dependence. In addition, in the present study, cigarette smokers who reported ever but not current marijuana use were at greater risk of having nicotine dependence compared to never marijuana users. This finding supports that the effect of THC exposure on nicotine receptors may be irreversible . Studies are needed to further examine both short term and possibly even the long-term effects of THC and nicotine exposure on nicotine dependence and tobacco cessation. In this analysis, 12–17 year old adolescent and 50–64 year old cigarette and marijuana cousers had the highest odds of having nicotine dependence. These findings support previous studies linking co-use and nicotine dependence in adolescents and young adults and add to preliminary data that this association was also stable in adults and, surprisingly, particularly robust in 50–64 year old adults. These findings reflect evidence of a U-shaped effect between age and nicotine dependence which peaks at age 50 years due to changes in nicotinic receptors and nicotine-associated metabolism with age , and suggest that this relationship was stable among co-users. Studies are needed to determine the extent to which THC exposure and/or current marijuana use add to this effect . Additionally, 50–64 year olds may represent a unique birth cohort who spent their formative years during the 1960’s and 1970’s with minimal tobacco regulations coupled with a counterculture that promoted marijuana use among a large population . More studies on the Baby Boomer generation, specifically, their perceptions about marijuana, current marijuana use including purpose of use , modality, cigarette co-use, and health outcomes could provide a glimpse into the future as continued legalization will likely influence social norms across the general population .

As more states adopt liberal marijuana policies, more studies are needed to understand co-use including the relationship between THC and nicotine in addition to other individual-level factors such as genetics and personality traits that might influence dependence and cessation . We found higher percentages of non-Hispanic Whites and Blacks/ African-Americans in states where medical marijuana was illegal. In this study, these results may be attenuated since our analysis comparing nicotine dependence depended on exclusion of blunt use. The American Civil Liberties Union report data from the NSDUH and Uniform Crime Reporting Data showing that Black males were no more likely to report marijuana use, but 4-times more likely to be incarcerated for marijuana possession compared to their non-Hispanic White male counterparts . Epidemiologic data have shown a linear increase in cigarette and marijuana co-use in Whites, Blacks/ African-Americans, and Hispanics with the fastest rate of increase among Blacks/ African-Americans . Among Blacks/ African-Americans, it is possible that statewide legalization of medical marijuana could help to reduce marijuana-related incarcerations, and at the same time, influence the rate of couse. We are cognizant of the many layers that add to the complexities around the issue of marijuana legalization that are well beyond the scope of our study. We recommend future research will assess potential and actual benefits/ costs of marijuana legalization to society at large, and in states where marijuana is legal, identify issues that can be addressed with specific regulatory measures .Study limitations include the cross sectional nature of these analyses which limits our ability to infer causality. Interpretation of our findings is limited to cigarette smokers which is distinct from those who reported other tobacco products . We were unable to examine statewide legalization of medical marijuana by the number of years the policy went into effect using the NSDUH to account for time lags from adoption to full implementation. The NSDUH public dataset only provides a binary categorization of states that were legal vs. illegal that lumps states that just passed the law with long-term legalization states limits our ability to detect long-term effects and may have attenuated our findings. Further study is needed to examine the effect of combusted vs. non-combusted marijuana use on nicotine given increasing prevalence of edible and aerosolized delivery of marijuana with vaporizers .

At present, the NSDUH does not ask respondents to indicate whether use was combusted and/ or non-combusted and we recommend that future surveys collect information on marijuana modality to elucidate the relationship between various forms of marijuana intake and nicotine and/ or THC dependence. Data on combusted vs. non-combusted THC intake can also help to identify if there might be differences in health effects across marijuana use modality. In addition, the present study did not examine population density which might be a potential covariate for marijuana use. Strengths of the study were use of a large national dataset representative of the U.S. population and internal validity of nicotine dependence comparisons across age categories using the same dataset,grow bench which eliminates methodological variations from one study to another. Medical marijuana legalization was positively associated with cigarette and marijuana couse and co-users were at greater risk for nicotine dependence. Long-term longitudinal data across age groups are needed to elucidate these results. In the meantime, it is recommended that stakeholders in tobacco control participate in policy discussions involving marijuana legalization including regulatory measures to prevent further co-use and develop novel cessation treatments to help co-users who may have a harder time with quitting. Marijuana use is legal for medical or recreational purposes in 33 states and Washington, DC . Recreational legalization has ushered in rapid commercialization . Both Colorado and Washington—the first 2 states to legalize marijuana for recreational use—have seen retail sales exceed a billion dollars annually . States with recreational marijuana have been inundated with mass marketing promoting marijuana use, and also an increase in novel marijuana products with tetrahydrocannabinol content at concentrations not evaluated for safety in humans . Given the absence of federal regulations in managing the commercial marijuana market, individual states are developing regulations governing marijuana advertising, production, and sale . In US adults, rates of recreational marijuana use and cannabis use disorders have increased considerably over the last several years .Legalization for medical purposes has been accompanied with increased daily use and marijuana use disorders among US adults . Approximately 15% of the US adult population used marijuana in some form in 2017 . Between 2016 and 2017, past-month use of marijuana increased nearly 2% among adults aged 18 to 25 years and 1.2% among adults 26 years and older . Additionally, national surveys suggest the perception of ‘‘great risk’’ from weekly marijuana use dropped from 50.4% in 2002 to 33.3% in 2014 and has dropped further since . Recent national surveys also demonstrate that the public attributes benefits to marijuana that are not supported by existing scientific evidence, such as relief from anxiety, stress, and depression, improved appetite, and improved sleep . It is unknown whether adult residents of states where marijuana has been commercialized for recreational use are more likely to attribute benefits to marijuana use.

Given the growing body of evidence that adverse consequences are associated with regular marijuana use , determining whether residents of recreational states perceive marijuana use differently than residents of states without commercial legalization is an important consideration and may inform the needs for more investment in communications of potential risks to the public. In this study, we examine the differences in beliefs about marijuana use and rates of use across states defined by their marijuana legalization status .Survey questions were developed by identifying gaps in existing federally funded national surveys, including the National Survey on Drug Use and Health and Monitoring the Future , and drafting questions to address those gaps. Questions were refined through interviews with marijuana industry professionals, dispensary staff, marijuana distributors, and mental health and substance use disorder experts. Survey items developed included individual opinions on the risks and benefits of marijuana use, comparisons of risks and benefits of marijuana to other psychoactive substances, and the form, amount, and frequency with which individuals use marijuana. In total, the survey included 29 questions assessing beliefs about the risks and benefits of marijuana and 54 questions assessing marijuana use. Answer options for all opinion questions used Likert scales to allow participants to respond with the answer most closely aligned with their beliefs. All questions were written at an 8th-grade reading level and were tested on a convenience sample of 40 adults to ensure readability and construct validity. Full details on survey development have been previously published . The survey tool is available in the supplementary material .We conducted a survey of a nationally representative sample of 16,280 US adults on risks and benefits of marijuana use. The survey was conducted using Knowledge Panel —a nationally representative panel of civilian, non-institutionalized US adults aged 18 years and older that has been used to survey public opinion since 1999 . The address-based sampling covers 97% of the country and encompasses a statistical representation of the US population. Households without internet access are provided with an Internet connection and a tablet to ensure participation. All participants in the panel are sampled with a known probability of selection. No one can volunteer to participate. Participants are provided with no more than 6 surveys a month and are expected to complete an average of four surveys a month . Sampling was stratified by legalization status of marijuana in the state of residence . California residents and young adults aged 18 to 26 years old were over sampled to facilitate a future investigation into the role of recreational legalization on use patterns among young adults in California. Sampling weights were provided by GfK.The response rate, determined using methods outlined by the American Association for Public Opinion Research, was the ratio of respondents to all potential participants . Characteristics of the survey respondents were weighted using weights provided by GfK to approximate the US population based on age, sex, race, ethnicity, education, household income, home ownership, and metropolitan area. All analyses used weighting commands using the weight variable provided by GfK to generate national estimates. We first compared the sociodemographic characteristics of our respondents to that of the NSDUH—an annual, federally funded epidemiologic survey . We then compared views and forms of marijuana use of residents across recreational, medical, and nonlegal states using chi-square statistics. Finally, we reported the prevalence of different forms of use stratified by legalization status of states and the associated 95% confidence interval . In supplementary analyses, using logistic regression, we examined views of residents of recreational states compared with other states after adjusting for baseline demographic characteristics including age, sex, race, employment status, and household size.

To assess volume of activation within posterior parietal and left prefrontal ROIs, we calculated the number voxels showing significantly greater activation during SWM relative to vigilance for each participant within each ROI. We then performed regression analyses to predict volume of activation from age, gender, and their interaction. To determine whether movement during fMRI scanning might affect results, we examined relationships between age and bulk motion in two ways. Both total number of removed repetitions and average movement in each direction throughout the task were examined in relation to age and gender using correlational analyses. The number of repetitions removed for excessive motion during the task declined with age . However, in brain regions demonstrating a relationship between SWM response and age, number of removed repetitions did not significantly relate to brain response , and the relationship between age and brain response in each cluster remained significant after controlling for number of removed repetitions. Mean rotational and translational motion were not significantly related to age. The average rotational movement throughout the task was 0.07, 0.22, and 0.09 degrees for roll, pitch, and yaw, respectively; the average translational movement was 0.16, 0.06, and 0.09 mm for superior, left, and posterior, respectively. There were no significant gender differences for number of repetitions removed for movement or on any directional movement parameter, with the exception of males demonstrating significantly greater rotational motion than females in the pitch direction = -2.08, p < .05.Age positively predicted SWM brain response in bilateral medial portions of superior frontal gyrus ; left superior and middle frontal gyri ;inferior aspects of the left precuneus and angular gyrus ; and a cluster encompassing the right inferior parietal lobule, postcentral gyrus, and insula .

A negative relationship between age and SWM response was observed in the left superior frontal gyrus ; left precuneus and superior parietal lobule ; superior portions of the right inferior parietal lobule ; and the right lingual gyrus . Exploratory follow-up analyses revealed that in the medial superior frontal cluster, teens evidenced less response during SWM than during vigilance,commercial drying racks with younger youths showing greater vigilance response than older teens. Further, in the right lingual gyrus, youths demonstrated less response during SWM than during rest , with older teens showing a greater decrease in SWM response relative to fixation than younger teens . In the left superior frontal gyrus , most participants showed no significant response to SWM relative to vigA significant age × gender interaction was observed in the right fronto polar superior frontal gyrus , in the same location as the gender difference described above . In this cluster, males showed a negative relationship between age and SWM response, but females showed a positive relationship.To understand whether age and gender related differences in BOLD response could be accounted for by task performance , we examined mediational models using a series of regressions . As vigilance reaction time was the only task performance index related to age or gender, regression analyses examined whether it mediated the relationship between age or gender and BOLD response in any of the clusters listed in Table 2. Vigilance reaction time was not significantly related to brain response in any region that was related to age or gender, and therefore did not mediate the relationship between age or gender and BOLD response. The posterior parietal ROI encompassing areas demonstrating significant activation to SWM relative to vigilance in young and old youths was 96,876 microliters, and spanned bilateral portions of the precuneus and superior and inferior parietal lobules. Within that cluster, ROI analyses demonstrated that activation for young adolescents was mostly in superior regions of parietal cortex, while response for old teens was mostly in inferior parietal areas .

Although age and the age × gender interaction did not predict volume of parietal activation within the combined parietal ROI, males demonstrated larger volumes of activations than females =5.62, p<.025. Further, males showed a significant negative relationship between age and volume of activation , while females showed no relationship between age and volume of response. Within the left prefrontal ROI , age significantly predicted the volume of activation, with larger volumes of activation demonstrated by older teens =4.95, p=.03. There was no significant effect of gender or the age × gender interaction on the volume of left prefrontal activation. This cross-sectional study examined the effects of age and gender on brain response during a SWM task among 12- to 17-year-olds. In general, we observed comparable task performance across the age range and between genders, and all teens showed typical response patterns for SWM, with activation in bilateral prefrontal and posterior parietal cortices. This pattern parallels adult activation during spatial working memory tasks and supports occipitoparietal, or “dorsal stream,” processing of spatial locations , suggesting that, in general, teens use similar working memory and spatial processing strategies as adults. However, specific localization and intensity of response varied across the adolescent age range, and males and females showed slightly different activations. These differential patterns emerged despite similar task performance across the age range and between genders, suggesting that developmental changes in SWM brain response are driven by factors other than task performance.In contrast to the literature suggesting that SWM abilities on n-back tasks improve across the adolescent age range , we did not observe age related improvements in performance on our SWM task. While this was likely due to the low difficulty level of the task used which approached ceiling effects, it is a benefit to the neuroimaging component of this study as it prevented confounding performance effects on the neural activation patterns observed across this age range.

Although task performance was not related to age, teens performed more accurately on vigilance than SWM, yet reaction times were faster on SWM. Our previous studies using this task demonstrated similar findings, with slightly faster performance on SWM than vigilance . While the reason for this difference is unclear, it could be that the small visual discrimination necessary for dot detection during vigilance blocks is more time consuming than the broader location detection required during SWM blocks. Future studies should attempt to eliminate this difference in reaction times between experimental and control conditions, perhaps by designing a task with easier visual discrimination .As hypothesized, age positively predicted SWM activation within the prefrontal cortex. Specifically,rolling grow table age was positively associated with both the intensity and extent of brain response in the left middle and superior frontal gyri . This cluster spanned frontopolar cortex but also encompassed parts of dorsolateral prefrontal cortex. Frontopolar prefrontal cortex activation has been associated with subgoal processing and evaluation of internally generated information . Thus, older teens may invoke more self-generated strategies, including rule induction or more efficient retrieval processes. This cluster also included portions of dorsolateral prefrontal cortex, which has been consistently implicated in working memory tasks. Adult studies have suggested that prefrontal activation is often left-lateralized during verbal working memory tasks ; thus the greater left prefrontal response among older teens may suggest that older teens employ more verbal rehearsal strategies during the task than younger adolescents. While the task was designed to minimize verbal encoding, older teens may have imagined the eight possible stimulus locations as positions on a clock face, facilitating verbal labeling and resulting in greater left prefrontal activity. Also consistent with our hypotheses, we observed a positive relationship between age and SWM response in posterior parietal regions. However, while we detected a positive relationship between age and SWM activation in bilateral inferior parietal regions, including inferior aspects of the right precuneus and left inferior parietal lobule, our data also revealed a negative relationship between age and brain response in bilateral superior parietal cortex, comprising superior portions of the right inferior parietal lobule, left precuneus and left superior parietal lobule. Exploratory ROI analyses confirmed these findings, demonstrating that while both young and old teens evidenced overlapping posterior parietal activation, younger youths showed activation mostly in superior regions, but older teens showed activation mostly in inferior regions. Together, these results indicate a shift from superior to inferior parietal areas utilized during SWM across adolescence. Previous fMRI studies of SWM have suggested that parietal activation intensity increases across adolescence , yet small sample sizes and different task designs may have prevented the observation of additional negative relationships identified in the current study. While functional parcellation of parietal involvement in sub-components of spatial working memory is largely unknown, some researchers of adult populations have suggested that superior parietal regions may be important for spatial rehearsal during working memory , while inferior parietal regions may be implicated in short-term storage during working memory .

Therefore, the superior to inferior shift in parietal activation across adolescence could represent a change in spatial working memory strategies. Younger adolescents may rely more on spatial rehearsal, which could become more automated throughout adolescence, requiring less superiorparietal activation. Along those lines, older adolescents may be better able to engage inferior parietal regions involved with spatial storage, and rely less on spatial rehearsal. Moreover, if older adolescents are employing greater verbal rehearsal strategies as discussed above, then spatial rehearsal may be less efficient, and therefore utilized to a lesser degree. In addition, stage of pubertal development was negatively associated with response in the superior right inferior parietal lobule cluster, above and beyond the effects of chronological age. Previous literature has demonstrated the impact of sex hormones on the development of cerebral lateralization , and pubertal timing has been related to functional asymmetry . Similarly, in this study, right parietal maturation appears linked to pubertal stage while left parietal development is not, suggesting asymmetrical cortical development that may be hormonally influenced. This finding points to the importance of individual variation in biological maturation that may not be accounted for by chronological age, and suggests that indices of pubertal development may further characterize neural maturation and help explain changes in SWM brain response patterns and cognitive strategies across adolescence. As well as showing changing fMRI response patterns to SWM tasks across adolescence , previous adolescent research has also demonstrated age-related increases in the spatial extent of frontal and parietal SWM activation . We found a greater number of significantly activated voxels in left prefrontal cortex with increasing adolescent age, suggesting that in some regions, both the magnitude of response and the volume of significant activation increase across adolescence. However, the results of our spatial extent analysis in posterior parietal cortex showed no significant relationship between age and volume of significant SWM response. Taken together with our results demonstrating age-related regional changes in the intensity of activation, these findings suggest that in late developing frontal brain regions, intense and more widespread activation emerges, while in slightly earlier developing posterior parietal networks, there is a focal shift in localization of activity. When examined in light of the adult working memory literature, adolescent age-related changes in frontal and parietal networks involved in SWM support the evolution of more efficient cognitive strategies. In the lingual gyrus, we observed deactivation that increased with age. Increasing occipital deactivation across adolescence could represent enhanced priming, and therefore greater recognition and reprocessing of repeated spatial locations among older youths. Teens in this study also demonstrated less response during SWM than during the vigilance condition in medial superior frontal cortex, yet this discrepancy dissipated across adolescence, such that this area was no longer “under active” in older teens. Medial frontal cortex is highly active at rest, during which it is involved in attentional monitoring of various internal and external stimuli . Medial frontal cortex underactivation during a cognitive task may represent reallocation of limited attentional resources to areas directly involved in task performance . Thus, SWM task demands may be more difficult for younger youths, who require greater attentional allocation to maintain performance, and therefore greater under-activation of medial frontal cortex. fMRI Response and Gender This is the first known fMRI study to attempt to examine the role of gender in relation to the neural substrates involved in SWM across adolescent development. While our findings do not entirely support the hypothesis that females would evidence more mature SWM response patterns than males, several interesting gender specific findings suggest that males and females utilize slightly different brain regions to perform well on a SWM task. Specifically, females demonstrated more right anterior cingulate response during the vigilance condition than did males.

After further review, involving the Planning Commission and additional public hearings, the county voted to permit marijuana production and processing establishments if they complied with notice provisions and strict zoning restrictions. On the eastern side of Washington state, the Spokane County Commission imposed a moratorium on outdoor marijuana farms in November 2016, because of residential complaints about odors from marijuana agriculture and processing; at the time of the moratorium, over 160 marijuana growers and processors were operating in the county.By the end date of our data collection , some counties still had moratoriums in place and stated in policy documents they were awaiting additional information to make a permanent decision. A few counties permitted marijuana facilities but integrated policy mechanisms to address residential concerns about matters such as odors, bright lighting, and increased traffic and perceived risk of crime associated with these establishments. For example, Chelan County, Washington, required marijuana producers and processors to register and pay a fee for an enforcement fund to ensure regulatory compliance.Although policy communication and advocacy strategies varied by county and state, we found patterns during our qualitative review of ordinance and newspaper article data related to primary county-level policy stakeholders, and arguments in support of or opposition to local marijuana policy. Primary stakeholders and advocates involved in county-level marijuana policy debates were similar in both states and included elected county officials tasked with decision making , law enforcement ,greenhouse rolling benches individual marijuana growers/farmers, marijuana business license applicants, parents, and other residents.

Several ordinances also named county voters as stakeholders who would be impacted by policy decisions. Some ordinances named specific county government departments , zoning authorities/commissions, or public entities as local stakeholders. We did not identify any specific advocacy groups or advocates external to the county involved in county-level policy debates.Our analysis of arguments in support of or opposition to specific policies revealed that many counties pointed to local public opinion as a basis for decision making, as well as local election results from the statewide 2012 marijuana legalization referendum, as evidence of either support of or opposition to legalizing marijuana facilities. For example, in 2012, The Wall Street Journal quoted the chair of the Douglas County, Colorado, Board of Commissioners as saying the local election results supported a prohibition: “Our county has never passed or supported anything regarding the legalization of marijuana…we tend to be very conservative,” he said.35 Alternatively, in Jefferson County, Washington, the ordinance included the quote, “Whereas, some 65% of voters in Jefferson County voted yes on Initiative 502,”to support allowing marijuana facilities. Similarly, a local newspaper article about a 2015 proposal to extend a moratorium in Huerfano County, Colorado, quoted a resident as saying, “Legalization of marijuana passed by 60 percent of the vote here in Huerfano, and we need to respect the will of the people.”Table 2 presents the main policy arguments, including public opinion, to support or oppose county-level marijuana policy positions in Colorado and Washington. Frequent arguments in Colorado and Washington in favor of allowing some or all commercial marijuana facilities focused on economic gain, reduced criminality, and potential health benefits. Economic arguments from proponents of legalized marijuana varied and included mention of local revenue increases for the municipality, increased employment opportunities , expanded tourism, and personal financial gain for local residents involved in marijuana cultivation, processing, or retail. In Whitman County, Colorado, opponents of a moratorium said it “would prohibit people from getting jobs and cause the county to lose out on revenue from the industry.”

During a community forum in Wahkiakum County, Washington, a resident pointed to local revenue for a nearby county in support of allowing marijuana retail facilities, “I am merely speaking from a financial perspective…The county is in financial difficulty, and this is a legal revenue source available to the county.”Criminality arguments—less commonly mentioned by marijuana legalization proponents than economic arguments—pointed to the potential reduction of illegal marijuana markets and activity as a benefit.We identified a wider variety of arguments used in support of prohibitions, including economic loss arguments to counter economic gain arguments from proponents of legalized marijuana. Economic loss arguments pointed to the possible loss of tax revenues , increased lawsuits, and increased cost of law enforcement to enforce regulations. Concerns about public health, safety, and welfare were among the most frequently mentioned arguments against permitting local marijuana establishments. Residents noted concerns about environmental hazards , increased addiction, increased traffic issues around retailers, and the risk of accidental poisoning or overdose among minors. Additionally, elected local officials and residents pointed to federal law, namely the illegality of the cultivation, possession, sale, and use of marijuana under federal criminal statutes, as a deterrent for allowing marijuana facilities.The article noted residents’ concerns about illegal growing of marijuana in Colorado, which was described as a substantial challenge for local and federal law enforcement. Three minor arguments included land use concerns, proximity to states where marijuana was illegal, and possible harm to the county’s reputation or local identity. For the latter, proponents of bans/moratoriums pointed to potential harm or loss of neighborhood character/identity, suggesting that allowing a marijuana facility would be detrimental to the status quo. In the following sections, we provide illustrative examples of four counties to describe in more detail the various county policy environments and highlight policy changes within the counties.

These counties are classified using a brief version of the rural-urban categories from the USDA Economic Research Service’s Rural-Urban Continuum Codes: metropolitan; non-metropolitan, urban; and rural.40On November 12, 2013, Mason County, a non-metropolitan, urban county located in western Washington , initially adopted an ordinance allowing licensed marijuana producers, processors, and retailers.Meeting minutes from a county commissioner meeting on June 24, 2014, highlighted resident concerns about marijuana producers and processors during a public comment period when a majority of marijuana opponents,greenhouse bench top self-identified as county residents who lived near a licensed marijuana production or manufacturing facility,expressed NIMBY sentiments about these facilities. Noted concerns included possible criminal activity, safety issues, odor problems, environmental risks , decreased property value, and law enforcement implementation issues.On July 1, 2014, the board of commissioners enacted a six-month moratorium prohibiting building or land use related to the production and processing of marijuana, allowing these activities solely in agricultural and industrial zones .On July 22, 2014, opponents of the moratorium said they felt specifically targeted and residents should “be concerned about meth, heroin and other drugs, not legal marijuana,” in addition to expressing concerns about financial losses. Proponents reiterated arguments about the potential crime impact, loss of property value, and marijuana being “against federal law.” Some residents asked for more time for public input and recommended revising the ordinance to address residential concerns but allow legal cultivation, processing, and sales.On October 21, 2014, the board of commissioners voted to repeal the moratorium and simultaneously issued code amendments to address certain residential concerns .Costilla County is a rural county located along the southern Colorado border with New Mexico. It presents a unique local jurisdiction that enacted policies to allow cultivation and retail facilities.Permitting these facilities contrasted with other rural counties that opted to prohibit all marijuana facilities. Costilla County spans 1,227 square miles with a large swath of high desert land lacking in building or residential infrastructure. The low cost of land, coupled with state legalization of recreational marijuana, led to an influx of outsiders interested in purchasing property for commercial marijuana cultivation and production.Marijuana facility licensing and license renewal fees were sources of revenue in addition to the distribution of the retail marijuana state sales tax. Local governments could also implement their own local sales or excise taxes. Concerns included the increased use of educational and social service resources for new families from out of state and lack of local licensing and enforcement personnel. The Denver Post quoted a county commissioner as saying there was a shift in the jail population from local residents to a majority “from outside,” but also said there was not a spike in crime in these early years.A local disagreement between a proposed marijuana cultivation facility and a museum in early 2015 highlighted the conflict between marijuana business license owners and other establishments in the county. Supporters of the museum opposed issuing a license for the proposed facility, mentioning the facility’s potential impact on minors and other museum visitors.Ultimately, the business owner decided to change the location of the marijuana cultivation facility to “be a good neighbor” and ameliorate possible odor and lighting concerns. The owner, however, continued to pursue a license for a retail facility and medical marijuana dispensary next to the museum.Chaffee County, located in the central part of Colorado, is an example of a non-metropolitan, urban county with a restrictive marijuana policy environment.

In September 2013, the county unanimously approved ordinance 2013-02, which temporarily banned new recreational marijuana establishments in the county through December 31, 2014.However, the county permitted recreational marijuana cultivation licenses in industrial zones, and some facilities that cultivated medical marijuana or manufactured medical marijuana–infused products were exempt from the ban—if such facilities were in good standing in the county and met the state and county licensing standards, they were allowed to convert to recreational facilities.Grandfathered facilities could apply for recreational facility licenses .Ordinance 2014-02,unanimously adopted in 2014, amended the prior ban through December 31, 2015, to include all marijuana facilities and limit the number of facilities in the county to six. An exception was again made for cultivation or manufacturing facilities in good standing with the county and state; these facilities were grandfathered and could renew their licenses or expand their operations and the number of plants within their existing parcel allotted. The moratorium banning any type of recreational marijuana establishment, with the exception of certain grandfathered facilities, was reissued multiple times .Benton County, Washington, is a metropolitan county bordering Oregon. This county was a unique case: it transitioned from permitting marijuana businesses to enacting moratoriums, ordinances, and zoning limitations, and eventually banning new recreational marijuana facilities while grandfathering in existing operations in response to local concerns and complaints. Benton County did not start out with a ban. In 2015, recreational marijuana retail facilities opened in the county.Later that year, multiple residents expressed concern over a marijuana grow site, which led to an emergency moratorium and public hearing process.The controversy continued, and, in late 2017, a local newspaper article featured alternate perspectives from two longtime county residents expressed during the county’s public hearing: one had concerns about the odor associated with marijuana facilities and the effect on children, whereas the other, a landowner who rented property to a marijuana producer, opposed a ban.Opponents of a ban mentioned economic empowerment and access to medicinal marijuana, whereas supporters mentioned odor and enforcement issues. The county opted to ban new marijuana retail facilities and enact a moratorium on new producers and processors. In April 2018, the board of county commissioners voted two to one to permanently ban all new marijuana production and processing operations in all unincorporated zoning districts, although over 50 licensed operators in these areas were allowed to continue operating.The commission also expanded the sheriff’s authority to enforce nuisance and odor rules in response to residential complaints.Our county-level recreational marijuana policy surveillance study reveals a patchwork of local policies in place by 2019 in the two earliest states to legalize recreational marijuana. Our findings add to existing literature that suggests state marijuana legalization policies are nuanced and complex, varying at the local level.Our policy change results highlight the importance of ongoing policy surveillance research to examine changes to local marijuana policy over time. We found 40 counties across both states prohibited all marijuana facilities by early 2019, either through temporary or permanent bans. Prior research in Washington similarly found 10 counties had moratoriums or permanent bans in effect on retail recreational cannabis outlets as of mid- 20147 and mid-2016,3 compared to 9 counties at the end of our study period . To our knowledge, this is the first study to report county-level recreational marijuana policies in Colorado. We found that nearly half of Colorado counties had prohibited all types of marijuana facilities by the end of our study period. This is a high percentage compared to Washington. Of note, the lower percentage in Washington may be partially explained by Washington’s merger of recreational and medical marijuana markets in 2015.

Although we report complete data for all analyses, meta analyses of cross-sectional studies examining cough, sputum production, and wheezing were limited by heterogeneity. Heterogeneity was likely related to the lack of uniform assessment of marijuana use and outcome ascertainment . Our current understanding of the long-term health effects of marijuana could be improved by standardized assessment tools for marijuana use and studies with larger samples of marijuana-only users and longer follow-up times. Low-strength evidence indicates that smoking marijuana is associated with cough, sputum production, and wheezing. Current understanding of marijuana’s effect on pulmonary function tests and development of obstructive lung disease is insufficient and is limited by low exposure and young study populations. Given rapidly expanding use, we need large scale longitudinal studies examining the long-term pulmonary effects of daily marijuana use.Marijuana is one of the most widely used illicit substances world-wide. Although it has been reported that marijuana use rate has stabilized or even decreased in recent years in most high-income countries, the continuing high prevalence of use among adolescents and young adults is a cause for concern. Such emerging trends have heightened interest in the link between mental health problems and adolescent marijuana use to inform policy and prevention efforts. Understanding the comorbidity between psychopathology and marijuana use is complicated. Marijuana use is associated with numerous different psychiatric disorders, cannabis drying racks commercial each of which tend to co-occur with one another. Additionally complicating matters is the potential bidirectional nature of this association, with evidence that marijuana use may both predict and result from poor zmental health.

A parsimonious explanation of this comorbidity may be that a small set of transdiagnostic psychopathological vulnerabilities that give rise to numerous mental health conditions may also contribute to and result from marijuana use. Such transdiagnostic vulnerabilities may account for the pervasive patterns of psychiatric comorbidity with use of marijuana and other substances. One such transdiagnostic vulnerability is anhedonia— diminished capacity to experience pleasure in response to rewards. As a subjective manifestation of deficient reward processing capabilities, anhedonia is believed to result from hypoactive brain reward circuitry. While anhedonia is a core feature in a DSM-defined major depressive episode, it has also been linked to other psychopathologies comorbid with drug use, including psychosis, borderline personality disorder , social anxiety, attention deficit hyperactivity disorder and post-traumatic stress disorder and has therefore been proposed to be a transdiagnostic process. Departing from its consideration as a ‘symptom’ of a disease state as in DSM-defined major depression, anhedonia has also been conceptualized as a continuous dimension, upon which there are substantial inter individual differences. Individuals at the lower end of the anhedonic spectrum experience high levels of pleasure and experience robust affective responses to pleasurable events, whereas those at the upper end of this spectrum exhibit more prominent deficits in their pleasure experience.Anhedonia operates as a ‘trait like’ dimension that is stable yet malleable, which is empirically and conceptually distinct from other emotional constructs, such as reward sensitivity , alexithymia and emotional numbing , sadness and negative affect. Recent literature documents a consistent association between anhedonia and substance use in adults.

To the best of our knowledge, there has been only prior study of the association between anhedonia and marijuana use in youth, which found higher anhedonia levels among treatment-seeking marijuana users than healthy controls in a cross-sectional analysis of 62 French adolescents and young adults. Given the absence of longitudinal data, it is unclear whether anhedonia is a risk factor for or consequence of adolescent marijuana use. Because youth with higher anhedonia levels experience little pleasure from routine rewards they may seek out drugs of abuse, such as marijuana, which stimulate neural circuitry that underlie pleasure pharmacologically. Alternatively, repeated tetrahydrocannabinol exposure during adolescence produces enduring deficits in brain reward system function and anhedonia-like behavior in rodent models. In observational studies of adults, heavy or problematic marijuana use is associated with subsequent anhedonia and diminished brain reward region activity during reward anticipation. Consequently, it is plausible that anhedonia may both increase risk of marijuana use and result from marijuana use. Because early adolescence is a period in which risk of marijuana use uptake is high and the developing brain may be vulnerable to cannabinoid-induced neuroadaptations, this study estimated the strength of bidirectional longitudinal associations between anhedonia and marijuana use among adolescents during the first 2 years of high school. The primary aim was to test the following hypotheses: greater baseline anhedonia would be associated with a faster rate of escalation in marijuana use across follow-up periods; and more frequent use of marijuana at baseline would be associated with increases in anhedonia across follow-ups. A secondary aim was to test whether these putative risk pathways were amplified or suppressed among pertinent sub-populations and contexts.

Associations of affective disturbance and other risk factors with adolescent substance use escalation have been reported to be amplified among girls, early- onset substance users and those with substance-using peers.We therefore tested whether associations between anhedonia and marijuana use were moderated by gender, history of marijuana use prior to the study surveillance period at baseline and peer marijuana use at baseline.To characterize trajectories of anhedonia and marijuana use across time, latent growth curve modeling was applied to estimate a baseline level and linear slope for both anhedonia and marijuana use. Univariate latent growth curve models were first fitted for marijuana use and anhedonia separately to determine the shape and variance of trajectories. A two-process parallel latent growth curve model was then fitted, which simultaneously included growth factors for anhedonia and marijuana use after adjusting for covariates listed above and including within-construct level-to-slope associations. The parallel process model was constructed to test: bidirectional longitudinal associations by including directional paths from baseline anhedonia level to marijuana use slope as well as baseline marijuana use level to anhedonia slope; and non-directional correlations between baseline levels of anhedonia and marijuana use and between anhedonia slope and marijuana use slope. Significant directional longitudinal paths between anhedonia and marijuana use in the overall sample were tested subsequently in moderation analyses of differences in the strength of paths across subsamples stratified by moderator status using a multi-group analysis. Analyses were performed using Mplus with the complex analysis function to adjust parameter standard errors due to clustering of the data by school. To address item- and wave-level missing data, full information maximum likelihood estimation with robust standard errors was applied. Continuous and categorical ordinal scaled outcomes were applied for anhedonia and marijuana use, vertical grow racks cost respectively. The Akaike information criterion and the Bayesian information criterion were used to gauge model fit in which lower values represent better-fitting models. For moderator analyses, χ2 differences were calculated using log-likelihood values and the number of free parameters contrasting the model fit with equality constraints on the anhedonia–marijuana use path of interest across groups stratified by the moderator variable. Standardized parameter estimates and 95% confidence intervals are reported. Significance was set at α = 0.05 .Youth with higher levels of anhedonia at baseline were at increased risk of marijuana use escalation during early adolescence in this study. In addition, levels of anhedonia and marijuana use reported at the beginning of high school were associated cross-sectionally with each other.

To the best of our knowledge, the only prior study on this topic found higher levels of anhedonia in 32 treatment-seeking marijuana users than 30 healthy controls in a cross-sectional analysis of French 14–20-year-olds who did not adjust for confounders. The current data provide new evidence elucidating the nature and direction of this association in a large community-based sample, which advances a literature that has addressed the role of anhedonia predominately in adult samples. The association of baseline anhedonia with marijuana use escalation was observed after adjustment of numerous possible confounders, including demographic variables, symptom levels of three psychiatric syndromes linked previously with anhedonia and alcohol and tobacco use. Consequently, it is unlikely that anhedonia is merely a marker of these other psychopathological sources of marijuana use risk or a non-specific proclivity to any type of substance use. The temporal ordering of anhedonia relative to marijuana was addressed by the overarching bidirectional modeling strategy, which showed evidence of one direction of association and not the other direction . Ordering was confirmed further in moderator tests showing that the association of anhedonia with subsequent marijuana use did not differ by baseline history of marijuana use. Thus, differences in risk of marijuana use between adolescents with higher anhedonia may be observed in cases when anhedonia precedes the onset of marijuana use. Why might anhedonia be associated uniquely with subsequent risk of marijuana use escalation in early adolescence? Anhedonic individuals require a higher threshold of reward stimulation to generate an affective response and therefore may be particularly motivated to seek out pharmacological rewards to satisfy the basic drive to experience pleasure, as evidenced by prior work linking anhedonia to subsequent tobacco smoking escalation. Among the three most commonly used drugs of abuse in youth , marijuana may possess the most robust mood-altering psychoactive effects in young adolescents. Consequently, marijuana may have unique appeal for anhedonic youth driven to experience pleasure that they may otherwise be unable to derive easily via typical non-drug rewards. The study results may open new opportunities for marijuana use prevention. Brief measures of anhedonia that have been validated in youth, such as the SHAPS scale used here, may be useful for identifying teens at risk who may benefit from interventions. If anhedonia is ultimately deemed a causal risk factor, targeting anhedonia may prove useful in marijuana use prevention. Interventions promoting youth engagement in healthy alternative rewarding behaviors without resorting to drug use have shown promise in prevention, and could be useful for offsetting anhedonia-related risk of marijuana use update. Moderator results raise several potential scientific and practical implications. The association was stronger among adolescents with friends who used marijuana, suggesting that expression of a proclivity to marijuana use may be amplified among teens in environments in which marijuana is easily accessible and socially normative. The association of anhedonia with marijuana use escalation did not differ by gender or baseline history of marijuana use. Thus, preventive interventions that address anhedonia may: benefit both boys and girls , aid in disrupting risk of onset as well as progression of marijuana use following initiation and be particularly valuable for teens in high-risk social environments. While anhedonia increased linearly over the first 2 years of high school on average, the rate of change in anhedonia was not associated with baseline marijuana use or changes in marijuana use across time. Given that anhedonia is a manifestation of deficient reward activity, this finding is discordant with pre-clinical evidence of THCinduced dampening of brain reward activity and prior adult observational data, showing that heavy or problematic marijuana use is associated with subsequent anhedonia and diminished brain reward region activity during reward anticipation. Perhaps the typical level and chronicity of exposure to marijuana use in this general sample of high school students was insufficient for detecting cannabinoid-induced manifestations of reward deficiency. Longer periods of follow-up may be needed to determine the extent of marijuana exposure at which cannabinoid-induced reward functioning impairment and resultant psychopathological sequelae may arise. Strengths of this study include the large and demographically diverse sample, repeated-measures follow-up over a key developmental period, modeling of multi-directional associations, rigorous adjustment of potential confounders, high participation and retention rates and moderator tests to elucidate generalizability of the associations. Future work in which inclusion of biomarkers and objective measures is feasible may prove useful. Prevalence of heavy marijuana use was low in this sample, which precluded examination of clinical outcomes, such as marijuana use disorder. Students who did complete the final follow-up had lower baseline marijuana use and anhedonia, which might impact representativeness. Further evaluation of the impact of family history of mental health or substance use problems as well as use of other illicit substances, which was not addressed here, is warranted.Medical marijuana has moderate-to-high-quality evidence to treat conditions including chronic pain, neuropathic pain, spasticity due to multiple sclerosis, and chemotherapy associated nausea and vomiting .

It appears that the gaps in hospitalizations involving marijuana dependence and abuse were continuously widened between the states adopting and non-adopting medical marijuana policies with states adopting medical marijuana policies increased more sharply. Throughout the study period, the states with medical marijuana policies continuously had higher rates of hospitalizations related to opioid dependence or abuse. Hospitalization rates related to OPR overdose were originally higher in the states with medical marijuana policies, but increased less rapidly compared to the states without medical marijuana policies. Table 1 reports the associations of hospitalizations to the indicator of medical marijuana policy implementation, controlling for time-varying marijuana-related policies, state-level socioeconomic factors, and state and year fixed effects. The implementation of medical marijuana policies did not have any significant associations with hospitalizations related to marijuana dependence or abuse. However, it was associated with a 23% reduction in hospitalizations related to opioid dependence or abuse and a 13% reduction in hospitalizations related to OPR overdose . In Table 2, the first column for each outcome variable evaluates the indicator of medical marijuana dispensaries. Relative to generic implementation of medical marijuana legalization,plant growing rack the operation of medical marijuana dispensaries had comparable associations with hospitalizations related to opioid dependence or abuse and OPR overdose .

The second column for each outcome variable reports results including both the indicator of medical marijuana policy and the indicator of medical marijuana dispensaries. Medical marijuana dispensaries alone did not have any independent associations with any hospitalization outcomes after indicators for medical marijuana policy implementation were also included in the regressions. In Table 3, we explored if any policy effects could be detected in the periods prior to the implementation year of medical marijuana policies. We found no evidence that hospitalization rates of any category differed between states adopting and non-adopting medical marijuana policies in the pre-policy periods. Table 3 also assesses the presence of dynamic policy effects after the implementation year. We found that the reduction in hospitalizations related to opioid dependence or abuse was most salient after 1 year of policy implementation , whereas the reduction in hospitalizations related to OPR overdose was observed in the third year after policy implementation . With respect to other policy and socioeconomic covariates, uninsured rate was associated with increased OPR overdose hospitalizations. Other covariates including marijuana decriminalization, prescription drug monitoring program, and pain management clinic regulations were generally not associated with any hospitalization outcomes. Using state-level administrative hospitalization data during 1997–2014, we found no convincing evidence that the implementation of medical marijuana policies was associated with a subsequent increase in marijuana-related hospitalizations. This result was robust to the key policy dates defined in different ways. In conjunction with the studies that demonstrated negative or null associations of medical marijuana policies to substance abuse treatment admissions , suicide rates , and crime rates , our study counters the arguments about the severe health consequences that legalizing medical marijuana may bring to the public health.

It should be noted that this study does not necessarily contradict some prior research that reported an increase in marijuana use prevalence in association with medical marijuana policies . It just appears that, even if legalization resulted in an increase in the prevalence, it did not contribute to the severe health consequences that concern the public the most. Whether such findings hold in the long term needs further monitoring and investigations. This study demonstrated significant reductions in OPR-related hospitalizations associated with the implementation of medical marijuana policies. These findings were supported by the recent studies that reported reduced prescription medications , OPR overdose mortality , opioid positivity among young and middle aged fatally injured drivers , and substance abuse treatment admissions in association with medical marijuana legalization. As mentioned earlier, using marijuana can lead to either an increase or a reduction in OPR use depending on the use purposes and the underlying assumptions. This study appears to support the hypothesis that patients prescribed with OPR substitute OPR with marijuana, but it is not directly testable in our data. An alternative explanation for the results reported in this study is that states with medical marijuana legalization may also have tough OPR prescription regulations. However, this hypothesis was not supported by the null associations of OPR prescription regulations estimated in this study. Future empirical evaluations are warranted to explore the use pattern of OPR and marijuana and substantiate the substituting and gateway effects of the two drugs. Consistent with prior research , policy effects reported in this study were not static. We found reductions in OPR-related hospitalizations immediately after the year of policy implementation as well as delayed reductions in the third post-policy year. Nonetheless, the availability of medical marijuana dispensaries was not independently associated with hospitalizations as suggested by other studies .

A possible interpretation is that only 1 state in our data legalized medical marijuana but did not have operating medical marijuana dispensaries; a few other states opened medical marijuana dispensaries within only 1–2 years after the legalization of medical marijuana. The lack of variations in policy adoption and timing limited our ability to detect independent effects of detailed policy provisions of medical marijuana legalization. The 300% increase in hospitalization rates related to marijuana is striking. In contrast, the past-month prevalence of marijuana use increased at a much slower rate from 6% in 2002 to 7.5% in 2013 . It is unclear what factors have been driving the huge discrepancies between the trends of use prevalence and the trends of hospitalization rates. Although quite a few states legalized medical marijuana or decriminalized marijuana, this study suggested that they did not contribute to the rise of marijuana-related hospitalizations. One alternative hypothesis is the escalation in marijuana potency , which has tripled from 4% in 1995 to 12% in 2014 in the U.S. . Nonetheless, empirical evidence again did not find any associations between the potency increase and the legalization of medical marijuana . Studies to understand the growing market share of high-potency marijuana and its associations with marijuana-related hospitalizations are urgently needed. The unprecedented increase in OPR-related hospitalization rates and other related health outcomes has become a major public health crisis. Compared to the limited research on marijuana, OPR abuse and overdose epidemic has been relatively well studied. It is largely driven by the liberalization of OPR prescription for the treatment of chronic non-cancer pain . Despite lack of evidence in this study,indoor vertical garden system prescription drug monitoring programs and pain management clinic regulations have shown promises to tackle the OPR crisis in some other studies . If the causal relationship indicated in this study can be substantiated in future research, medical marijuana legalization and regulationmay be considered as an alternative strategy to reduce OPR-related hospitalizations without aggravating the adverse consequences related to marijuana.

Our study was subject to several limitations, most of which were related to the data used. First, some states included hospitalization records in the SID from non-community hospitals such as psychiatric facilities and Veterans Affairs hospitals, but some states did not . States may also vary on ICD-9-CM coding practice particularly for drug dependence, abuse, and overdose cases. The coding of opioid dependence or abuse may include heroin cases. The inclusion of state fixed effects should to some extent alleviate these biases in the reporting. Second, the aggregate SID data represented the total number of discharges but not the total number of patients because a patient may be admitted to hospital more than once in a year. The public-use SID were not available before 1997 and not all states participated in the SID during the study period. The findings may not be generalizable to the states that were excluded from this study. Particularly, the results may be inapplicable to California, which has the longest history of medical marijuana legalization as well as the largest population of registered medical marijuana patients and the largest number of medical marijuana dispensaries. Third, although no statistical differences in hospitalization rates between states adopting and non-adopting medical marijuana policies were revealed before policy implementation, we cannot rule out policy endogeneity issues that may be caused by time-varying unobserved factors and were not captured by the two-way fixed effects models. In addition, we were not able to examine detailed policy provisions of medical marijuana legalization such as home cultivation and requirement of patient registry because of small sample size and lack of variations. We were not able to assess OPR-related policies that were adopted by a few states most recently, such as requirements of following OPR prescribing guidelines and mandatory checking prescription drug monitoring program data by providers. This limitation, however, is unlikely to influence the study findings significantly because these policies were not adopted until the very end of the study period or after the study period. Finally, the study findings do not apply to recreational marijuana legalization. In fact, the findings are likely to alter if marijuana for recreational purpose is indeed a gateway drug to OPR. Examinations on the most recent regulations of recreational marijuana are warranted. Laws and social norms around marijuana use are changing rapidly in the United States. Twenty-four states and Washington D.C. have legalized some form of medical marijuana, four additional states have decriminalized marijuana possession, and four states with medical marijuana policies recently voted to legalize retail marijuana.To inform policy efforts around marijuana, it is important to monitor the sociodemographic and psychosocial correlates of marijuana use. Nationally, young adults have the highest rates of past 30 day marijuana use, with 18.9% of 18–25 year olds using in 2013, compared to 7.1% of 12–17 year olds and 5.5% of adults 26 years old and older.In California marijuana use rates are even higher among young adults , and about 7% higher than cigarette use.However, rates of use may differ across race/ethnicity, sex, sexual orientation, socioeconomic status and region. National data show past 30 day marijuana use is highest among non-Hispanic Native Hawaiian/Pacific Islander young adults ages 18–25, followed by non-Hispanic American Indians , blacks , whites and Latinos .Men in this age range are also estimated to use marijuana at slightly higher rates , as are young adults with less than a high school education .However in longitudinal studies of adolescents, including those accounting for cannabis use disorders, non-Hispanic black adolescents and young adults and those identifying with two or more racial categories appear to be at greater risk.Furthermore, as local data may differ significantly from findings in national data sets, closer examination of sociodemographic associations with marijuana use in a diverse population of young adults may suggest unique targets for intervention. Young adulthood is a time of transition, in which people are navigating new roles and identities; it can also be a time of great stress.Past research has found that adolescents and young adults identify stress as a motive for using marijuana as they perceive it to be an effective coping method.Young adults who report using marijuana as a coping mechanism demonstrate poorer mental health outcomes and greater risk for marijuana dependence and other substance use, such as alcohol and tobacco,and some studies report Black and multiracial young people co-use marijuana with tobacco and alcohol more frequently.Psychological distress has also been shown to be related to use of marijuana in adults,but there is limited research on the relationship between psychological distress and marijuana use in young adults.At a population level distress is an especially useful measure as it quantifies sub-clinical incidence of mental illness and may provide additional insight as to how and why young adults use marijuana.Young adults’ who are transitioning in social roles may experience heightened feelings of loneliness, or a perceived deficit in the quality or quantity of their social relationships.Loneliness has been found to be positively related to alcohol and marijuana use, but not consistently.Conversely, perceived social support, or the idea that there are people in someone’s life who can provide emotional support and help with problems,might be associated with a lower probability of using marijuana. However at least one study among adolescents found social support to predict an increase in substance use while others have found inverse associations.

Participants were invited to participate in 9 in-person clinic examinations over the study period . We used data from the first seven visits, up to year 20, as ECG measures were available at baseline, visit Year 7, and 20. Each participant who attended the examination received non-monetary gifts and monetary reimbursement to cover expenses. All study protocols were approved by the institutional review boards at each site. Multiple marijuana use variables are available for all visits . Current marijuana use was assessed by the following survey question: ‘During the last 30 days, on how many days did you use marijuana?’. We defined daily use as 30 days of use in the last 30 days. Direct self-reported lifetime exposure was assessed by the question: ‘About how many times in your lifetime have you used marijuana?’ We used current use and baseline lifetime use to compute marijuana-years, with 1 year of exposure equivalent to 365 days of marijuana use. We assumed that current use at each visit reflected the average number of days of use during the months before and after each visit. We estimated the cumulative lifetime use by adding the total number of days using marijuana during followup. We adjusted our estimate upwards whenever participants self-reported higher lifetime use than we compute for each visit. Marijuana use was not legal in the cities at this time. Standard 12-lead electrocardiogram was recorded at baseline, Year 7 and Year 20 visits,weed growing systems as described extensively elsewhere. All abnormalities were coded according to Minnesota Code Manual of Electrocardiographic Findings . The MC is used for population research and clinical trials and standardizes coding of ECG abnormalities.

We classified abnormalities according to MC . We also built composite categories of major and minor abnormalities: If an individual’s ECG contained any abnormality on the major list , the ECG was classed as composite major. If it contained only abnormalities on the minor list , we classed the ECG as composite minor. This allowed us to study both composite major and minor abnormalities and specific ECG abnormalities.Tobacco cigarette smoking behavior was evaluated at each in-person CARDIA examination and at yearly phone follow-up between CARDIA examinations. We used these data to estimate cumulative lifetime exposure to tobacco cigarettes in terms of pack-years. We estimated alcohol consumption as drink-years . Education was the highest educational grade reached by the participant by examination Year 20. We measured physical activity at every visit with the CARDIA physical activity history questionnaire. Our cardiovascular risk factor measurements included blood pressure, blood cholesterol, body mass index , binge drinking and diagnosis of diabetes mellitus, which were collected at each CARDIA examination . We observed prevalent abnormalities at visit 0, 7, and 20, but focused on Year 20 since major ECG abnormalities are expectedly more prevalent later in life and since cumulative marijuana exposure rises with time. Based on the number of computed cumulative marijuana-years and data on current use, we divided participants into four categories: never used marijuana; past use and moderate cumulative lifetime marijuana use, up to or 0.5 marijuana-years; past use and higher cumulative lifetime marijuana use, above 0.5 marijuana-years; and, current users , no matter the level of their cumulative use. We first analyzed the association between marijuana use and ECG abnormalities in unadjusted logistic regression models, separately at visit 0, 7, and 20. We then adjusted for demographic variables and then further adjusted for potential confounders such as tobacco cigarette smoking, alcohol consumption, and physical activity and BMI .. We decided to restrict main multi-variable adjusted models to the previously mentioned variables because of low event number in specific ECG abnormalities, but still performed exploratory analyses with fully adjusted models including cardiovascular health variables , presented in the online supplement.

To account for deaths and informative censoring in later examinations , we used inverse probability of attrition weights . We separately fit a model for loss to follow-up caused by the death, and a separate model for censoring due to reasons other than death, computed in one score. We used last-value-carried-forward and backward imputation for missing covariables and verified results using multiple imputation. The first considered only cumulative use and not current use; the second compared daily marijuana use to less frequent, past use, and never use. Finally, we stratified our results to see if they varied by sex and race because prevalence of ECG abnormalities, and distribution of exposure and covariables differs between Black and white, and male and female participants. We restricted regression analyses to ECG abnormalities that occurred in at least 50 of each race-sex stratum. We also fitted models with marijuana-years modelled as a restricted cubic spline as covariable for state of marijuana use . We further modelled incident abnormalities between Year 0 and Year 20. We included specific major and minor abnormalities at Year 20 that were not already identified in these categories in Year 0. For example, a specific minor abnormality detected at Year 0 that evolved into a major abnormality detected at Year 20 was coded as an incident major abnormality at Year 20. We applied a series of unadjusted and multi-variable adjusted models to analyze the association between current and lifetime cumulative marijuana use on incident ECG abnormalities. Tests of statistical significance were two-tailed; alpha level was 0.05. All statistical analyses were performed on Stata version 14.2 . We hypothesized that cumulative marijuana use was not associated with ECG abnormalities, but that current use might be associated with unspecific changes in ECG.

Various small experimental studies suggested immediate effects after using marijuana, with measured parameters returning to pre-exposure levels after ceasing marijuana use. The primary research question and analysis plan were submitted to the CARDIA Presentation & Publication Committee, before obtaining and analysing the data. However, they were not pre-registered on a publicly available platform and the results should thus be considered exploratory. Table 2 shows that at the Year 20 examination, 173 participants had composite major abnormalities and 944 had composite minor abnormalities . Composite and specific major abnormalities at Year 20 did not vary with status of marijuana use, but showed a tendency towards fewer events in current marijuana users: when we compared current marijuana use to never use,indoor farming systems the unadjusted OR for composite major ECG abnormalities was 0.77 . After multi-variable adjustment, the OR was 0.55 . Tables 2 and 3 show that in the unadjusted model, composite minor abnormalities and some specific minor abnormalities were more common among current marijuana users . These differences were attenuated after adjustment for demographic variables . The odds ratios stayed similar between categories of marijuana use after multi-variable adjustment and use of IPAW . Figure 1 illustrates that after multi-variable adjustment, no specific ECG abnormality or composite major or minor abnormalities was significantly associated with marijuana use. Current marijuana users had a multi-variable adjusted OR of 0.34 for major ST-T abnormalities, with a p-value across categories of 0.17. Past users with a cumulative use of over 0.5 marijuana-years had a multi-variable adjusted OR of 2.06 for minor ST-T abnormalities, with a pvalues across categories of 0.044. At Year 0 and Year 7, no ECG abnormality was significantly associated with marijuana use . Further adjusting for cardiovascular risk factors did not change results . We found no association between alternative categorizations of marijuana use and prevalent major or minor ECG abnormality after multi-variable adjustment. When we compared >2 marijuana-years of cumulative use to never use, the multi-variable adjusted OR for composite major ECG abnormalities was 0.70 and the multi-variable adjusted OR for composite minor ECG abnormalities was 1.03 . When we compared daily marijuana use to never use, the proportion of composite major abnormalities was no higher . Because few daily users had major abnormalities , we did not fit logistic regression models. For composite minor ECG abnormalities, the multi-variable adjusted OR was 1.72 . We found no association between current marijuana use and ECG abnormalities after adjusting for cumulative marijuana use . In stratified analyses by sex and race, black women with 0.5 to 2 marijuana-years of cumulative exposure had a multi-variable adjusted OR of minor ST-T abnormalities of 2.40 , with a p-value across categories of 0.10 . We found no abnormality associated with cumulative marijuana use in stratified analyses by sex and race at baseline or Year 7 . Current use at Year 20 was not associated with prevalent or incident ECG abnormalities in stratified analyses . Whether we applied IPAW or not, and used LVCBF or multiple imputation, results were virtually unchanged.

We found no evidence that current or lifetime cumulative use of marijuana was associated with a higher prevalence or incidence of major or minor ECG abnormalities in this cohort including black and white participants, although major ECG abnormalities seemed to be less frequent in current marijuana users. In this population, we also observed the tendency towards more minor ECG abnormalities compared to never marijuana users. Whether participants used marijuana daily, in the last 30 days or intermittently over a lifetime, marijuana use was not associated with an increase in prevalent or incident specific ECG abnormalities by middle-age. Applying different classifications of marijuana use did not change our results. Our findings did not vary by sex and race. Unlike some small experimental studies from the USA in the late 1970’s that, in samples of around 10 people, suggested marijuana was associated with some specific ECG abnormalities, we found these were just as frequent in current or cumulative marijuana users as in never users. The small sample size, brief exposure of participants to THC, short follow-up, and inclusion only of young, healthy men makes it difficult to draw useful conclusions on the population level from these experimental studies. We found multiple case-reports from the early 2010’s about ECG abnormalities following marijuana use. In our large biracial 20-year cohort of women and men participants who reported a broad variety of marijuana use habits, from never users to daily users, we found no evidence to support an association between marijuana and any ECG abnormality, incident abnormalities in new marijuana users, or abnormalities that would indicate past, ongoing, or future myocardial infarction. Our findings align with earlier epidemiological research on thousands of participants from Europe and the USA, including participants of the same cohort, that found no association between marijuana and CVD, mortality or other measure of sub-clinical atherosclerosis. When we stratified results by sex and race, we noticed that black participants presented with a higher proportion of ECG abnormalities than white participants, regardless of their marijuana use habits, but black marijuana users had no more ECG abnormalities than black never users; likewise, white marijuana users had no more ECG abnormalities than white never users. The assessment of exposure to marijuana was not validated by biological markers, so we rely on participant self-reports. Marijuana use was illegal during the whole course of the study and we cannot exclude social desirability bias, but because participants were queried about marijuana and other illegal drug use at each clinical visit, we could track past exposures. With this method, 84% percent of participants reported any past marijuana, suggesting that possible social desirability bias was mitigated by the trust participants had in the study personnel to report their true exposure. The low number of daily marijuana users at Year 20 in CARDIA limited our ability to fit multi-variable adjusted models, and our results should be carefully interpreted in this population. Future studies with higher sample size will be better equipped to assess the association between daily marijuana use and ECG abnormalities. Also, immediate effects of marijuana might not be reflected on resting ECGs performed hours or days after its use. We rely on marijuana use information provided by participants every 2 to 5 years, and participants only reported on how many days they had used marijuana within the last 30 days. Our analyses cannot inform on the acute effects of marijuana use on ECG. Previous experiments suggested acute effects of marijuana use on ECGs, with conflicting results . Further experimental studies, especially among people with underlying risk of CVD, are needed to test the effects of acute marijuana use on ECG abnormalities. Though the cohort we studied was racially diverse and spanned 20 years, our analysis was limited mainly to a middle-aged population, where CVD is not yet common.

Current research indicates that secondhand marijuana smoke contains many of the same chemicals as secondhand tobacco smoke and some in greater concentrations with recent studies demonstrating that secondhand marijuana smoke has negative cardiovascular effects similar to tobacco smoke.Non-smokers exposed to secondhand marijuana smoke had detectable levels of THC and metabolites, with levels increasing when higher potency marijuana was used.Non-smokers exposed to cannabis smoke for 60 min in an unventilated room had detectable levels of THC in blood following the exposure, increased heart rate, mild to moderate self-reported sedative drug effects and performed worse on a cognitive test.As normalisation of marijuana use continues, it is important to monitor the effects of normalisation on tobacco use, perceptions and smoke-free spaces. Smoke-free policies should cover all products, including combustible marijuana and electronic vaporisers for tobacco and marijuana. Signs and information signalling smoke-free policies should be adapted to clearly include marijuana smoke where applicable. Information about harmful effects of secondhand tobacco smoke was found to be a deterrent to smoking initiation and a motivator for cessation for youth.Studies should explore messaging around the negative effects of secondhand marijuana smoke. As a qualitative study,hydroponic rack system our relatively small sample provides insight into how some young adults in Colorado integrate tobacco, marijuana and vaporiser use.

While these experiences may not be representative, this work begins to shed light on how these products are used and made sense of alongside one another. Further in-depth qualitative work is needed to document the complexities of perceptions of tobacco and marijuana in distinct legal contexts , and examine differences between perceptions of medical and retail marijuana in relationship to tobacco. More work is also needed to understand those who primarily vaporise nicotine, those who vaporise marijuana and those who use both. The SCTC research initiative addresses high-priority gaps in tobacco control research through collaboration between academic researchers and local tobacco control agencies and community organisations. Legalisation of marijuana is one area that is highly salient for many state and community tobacco programmes because of its potential to affect use and perceptions of tobacco. Moreover, tobacco control experts within agencies are frequently tasked with recommending marijuana policies or educating citizens about rules of use and potential health effects. Tobacco, marijuana and vaporisers are most effectively studied together and future research should address perceptions of comparative harm of these products; social, political and health effects of their use; and adequate measurement of use patterns, especially when products are combined. Finally, tobacco programmes and policies should take into account emerging research on the complexities of this triangulum, particularly in the context of marijuana legalisation.Following recreational marijuana legalization and commercialization in the US, marijuana dispensaries have served as a major venue for marijuana retail sales in neighborhoods.

Nonetheless, research on the impacts of marijuana dispensaries on public health remains limited . Availability, accessibility, and point-of-sale marketing of retail outlets have been associated with attitudes, perceptions, and health behaviors in tobacco and alcohol literature . Marijuana dispensaries may impact marijuana-related outcomes in a similar manner. They may increase availability and accessibility of marijuana , promote greater awareness and consumption through marketing activities , increase product appeal such as through increased quality and potency , diversify product variation such as vaping devices and edibles , reduce prices through mass production and introduction of competition , and shape social norms favorable of marijuana use . A major challenge in understanding the availability and retail environments of marijuana dispensaries is identifying a complete and accurate list of marijuana dispensaries in neighborhoods. In a state operating a statewide licensing system, one can obtain the official licensing directories from government databases. Nonetheless, most of these directories are updated infrequently. More importantly, they do not reflect the operation status of dispensaries in reality or capture unlicensed dispensaries that are common in areas with weak law enforcement. Business directories provided by commercial providers are commonly used to identify tobacco, alcohol, and food retail outlets when state licensing directories are unavailable or unsatisfactory . Unfortunately, these commercial databases had not systematically gathered information on marijuana dispensaries by the time of this study. One can also conduct a field census with direct search and observation to enumerate a certain type of business in a geographic area. It is considered to be the best practice in outlet identification and often used to validate the business lists obtained from commercial databases . The limitation of field census is obvious: the required efforts and resources increase exponentially as the geographic area of interest expands.

Due to practical and budget concerns, most tobacco, alcohol, and food outlet studies that adopted this method searched retail outlets in smaller regions such as a county . State-level field censuses, especially in a large state like California, are nearly nonexistent. In light of the challenges of using conventional approaches to identify marijuana dispensaries, existing studies have primarily relied upon a single or a few online crowd sourcing platforms, such as Weedmaps, Leafly, and Yelp, to obtain dispensary information voluntarily submitted by dispensary owners and marijuana users . Because these platforms serve as online communities to promote dispensaries, products, and share experiences, they are perceived to be more up-to-date and comprehensive than official licensing directories. Particularly, these platforms provide data on both licensed and unlicensed dispensaries. Despite the increasingly common use of online crowd sourcing platforms in marijuana research, the validity of this approach has not been comprehensively assessed at statewide level. To date, only two studies have conducted validation in a single county , one before recreational marijuana commercialization and one after the commercialization in California. In this study, we examined the validity of using secondary data sources, including the state licensing directory and commonly used online crowd sourcing platforms, in enumerating brick-and-mortar marijuana dispensaries across the entire state of California. California is the most populous state with the longest history of medical marijuana legalization in the US. In November 2016 California legalized recreational marijuana and in January 2018 California initiated retail sale of recreational marijuana in dispensaries. California now has the largest legal marijuana market in the world,rolling tables grow with sales rising from $2.5 billion in 2018 to $3.1 billion in 2019 . Although California allows delivery services, in this study, we concentrated only on brick-and-mortar marijuana dispensaries because delivery-only providers do not have storefronts to showcase and promote products. In addition, the wide geographic coverage of delivery services contributes little variation in marijuana availability at neighborhood level. We offered a protocol for identifying dispensaries that can be replicated in other large geographic regions with marijuana retail sales. We aimed to answer two research questions. The first question was to what extent online crowd sourcing platforms are valid in enumerating licensed brick-and-mortar dispensaries. The motivation was that many dispensaries in California operated without a license. Even for licensed dispensaries, how they operate in practice may not agree with what was approved in the license. Findings from the first question will provide quantifiable evidence on the level of agreement between state licensing directory and online crowd sourcing platforms, add surveillance data point on the operation of unlicensed dispensaries, and inform policymakers regarding the validity of using online crowd sourcing platforms as alternatives when state licensing directory is not publicly accessible or licensing information is inadequate . The second question was to what extent state licensing directory and online crowd sourcing platforms are valid in enumerating the universe of active brick-and-mortar dispensaries. The motivation was that a single data source may not capture all active dispensaries in California and the information in a data source may not agree with how dispensaries operate in practice. Findings from the second question will provide quantifiable evidence on the strengths and weaknesses of each data source, inform surveillance and research regarding how to best strategize data use when resources are limited, and demonstrate the need for combining multiple data sources and verifying information to obtain the universe of dispensaries in a large geographic area. Because recreational-only, medical-only, and recreational & medical dispensaries co-existed in California, we also assessed validity measures by dispensary category.

Dispensaries may tend to promote themselves on online crowd sourcing platforms in larger counties with keen competition, we hence further assessed validity measures by county population size. From May to July 2019, eight trained research associates aged 21 or older called the 2,121 unique businesses to verify their street address, operation status, category of business, and presence of storefronts . Each call took fewer than 5 minutes on average. As commonly done in compliance check inspections of tobacco product retailers, the research associates did not reveal the research purpose of the calls. Instead, they identified themselves as interested customers who were considering a visit in near future. To determine dispensary category, researchers asked if a doctor’s recommendation or a patient registration card was required to enter the dispensary and make purchase. An affirmative response indicated the dispensary category to be medical only. If the response was negative yet customers with a doctor’s recommendation or a patient registration card were eligible for reduced tax rates, the dispensary was categorized as recreational & medical. The remaining dispensaries were considered to be recreational only. Up to five calls were made to each business in different business hours and/or on different business days to determine operation status. If a dispensary could not be reached after five call attempts, researchers checked its recent online activities on Weedmaps, Leafly, Yelp, and Google Map Reviews. If the dispensary had any online activity within the past month , it would be considered active1 . After removing inactive businesses, businesses not selling marijuana, and businesses without storefronts during the verification procedure, the 2,121 unique records were reduced to 826 businesses . These 826 dispensaries constituted the call-verified, combined database of active brick-and-mortar dispensaries in California. Validity statistics, including sensitivity, specificity, positive predictive value , and negative predictive value were computed for each of the four secondary data sources when applicable. Definitions and calculations were described in Technical Note S1. To compute validity statistics, a gold standard must be defined that can identify the “true positive” and the “true negative”. However, it is infeasible in this study due to budget and time constraints for a statewide census. Two gold standards were adopted alternatively to answer the two research questions. To answer the first question regarding the validity of online crowd sourcing platforms in enumerating licensed brick-and-mortar marijuana dispensaries, the first gold standard was whether a record was listed in the BCC state licensing directory . To answer the second question regarding the validity of state licensing directory and online crowd sourcing platforms in enumerating active brick-and-mortar marijuana dispensaries, the second gold standard was whether a record was included in the call-verified, combined database of active dispensaries . We must also define a test that can identify the “positive test” and the “negative test” in validity statistics calculations. Two tests were conducted. The first test was whether a record was present in a given data source after online data cleaning . We used this test to examine the validity of using a single data source with simple online data cleaning for dispensary identification, an approach requiring moderate resources. The second test was whether a record passed call verification; in other words, whether the record was verified to be an active brick-and-mortar dispensary . We used this test to examine the validity of using a single data source with simple online data cleaning plus call verification for dispensary identification, an approach requiring much more resources. To illustrate these validity statistics in the context of this study, we provide an example below . In this example, the data source of interest is Weedmaps, the gold standard is whether a record on Weedmaps was present in the BCC state licensing directory, and the test is whether a record was present on Weedmaps after online data cleaning. Sensitivity measures the probability of a record present on Weedmaps conditional on the record being included in the BCC directory, calculated as the number of records that were present on both Weedmaps and the BCC directory divided by the number of records present on the BCC directory. Specificity measures the probability of a record absent on Weedmaps conditional on the record being excluded from the BCC directory, calculated as the number of records that were neither present on Weedmaps nor present on the BCC directory divided by the number of records excluded from the BCC directory.