Additionally, the magnitude of the problem is worse in some neighborhoods than others. Popular brands of flavored cigarillos cost significantly less in Washington DC block groups with a higher proportion of African Americans 14 and in California census tracts with lower median household income. For the first time, this study examines neighborhood variation in the maximum pack size of cigarillos priced at $1 or less and assesses the prevalence of marijuana co-marketing in the retail environment for tobacco. School neighborhoods are the focus of this research because 78% of USA teens attend school within walking distance of a tobacco retailer. In addition, emerging research suggests that adolescents’ exposure to retail marketing is associated with greater curiosity about smoking cigars15 and higher odds of ever smoking blunts. The Table summarizes descriptive statistics for store type and for schools as well as mixed models with these covariates. Nearly half of the LCC retailers near schools were convenience stores with or without gasoline/petrol. Overall, 61.5% of LCC retailers near schools contained at least one type of marijuana co-marketing: 53.2% sold blunt wraps, 27.2% sold cigarillos marketed as blunts and 26.0% sold blunt wraps, blunts or other LCC with a marijuana related “concept” flavor. After adjusting for store type, plant benches marijuana co-marketing was more prevalent in school neighborhoods with lower median household income and with a higher proportion of school-age youth .
Nearly all LCC retailers sold cigarillos for $1 or less. The largest pack size at that price contained 2 cigarillos on average . The largest packs priced at $1 or less were singles in 10.9% of stores, 2-packs in 46.8%, 3-packs in 19.2%, 4-packs in 5.5%, and 5 or 6 cigarillos in 5.5%. After adjusting for store type, a significantly larger pack size of cigarillos was priced at $1 or less in school neighborhoods with lower median household income and near schools with a lower proportion of Hispanic students .In California, 79% of licensed tobacco retailers near public schools sold LCCs and approximately 6 in 10 of these LCC retailers sold cigar products labeled as blunts or blunt wraps or sold cigar products with a marijuana-related flavor descriptor. A greater presence of marijuana co-marketing in neighborhoods with a higher proportion of school-age youth and lower median household income raises concerns about how industry marketing tactics may contribute to disparities in LCC use. The study results also suggest that $1 buys significantly more cigarillos in California school neighborhoods with lower median household income. Policies to establish minimum pack sizes and prices could reduce the widespread availability of cheap cigar products and address disparities in disadvantaged areas. After Boston’s 2012 cigar regulation, the mean price for a grape-flavored cigar was $1.35 higher than in comparison communities. The industry circumvented sales restrictions in some cities by marketing even larger packs of cigarillos at the same low price, 22 and the industry’s tipping point on supersized cigarillo packs for less than $1 is not yet known.
The retail availability of 5- and 6-packs of LCCs for less than $1 observed near California schools underscores policy recommendations to establish minimum prices for multipacks . A novel measure of marijuana co-marketing and a representative sample of retailers near schools are strengths of the current study. A limitation is that the study assessed the presence of marijuana co-marketing, but not the quantity. The protocol likely underestimates the prevalence of marijuana co-marketing near schools because we lacked a comprehensive list of LCC brands and flavor varieties. Indeed, state and local tobacco control policy research and enforcement would be greatly enhanced by access to a comprehensive list of tobacco products from the US Food and Drug Administration, including product name, category, identification number and flavor. Both a routinely updated list and product repository would be useful for tobacco control research, particularly for further identifying how packaging and product design reference marijuana use. This first assessment of marijuana co-marketing focused on brand and flavor names because of their appeal to youth. However, the narrow focus is a limitation that also likely underestimates the prevalence of marijuana co-marketing. Other elements of packaging and product design should be considered in future assessments. Examples are pack imagery that refers to blunt making, such as the zipper on Splitarillos, as well as re-sealable packaging for cigarillos and blunt wraps, which is convenient for tobacco users who want to store marijuana. Coding for brands that are perforated to facilitate blunt making and marketing that refers to “EZ roll” should also be considered.
Future research could assess marijuana co-marketing across a larger scope of tobacco/nicotine products. The same devices can be used for vaping both nicotine and marijuana. Advertising for vaping products also features compatibility with “herbs” and otherwise associates nicotine with words or images that refer to marijuana . Conducted before California legalized recreational marijuana use, the current study represents a baseline for understanding how retail marketing responds to a policy environment where restrictions on marijuana and tobacco are changing, albeit in opposite directions. The prevalence of marijuana co-marketing near schools makes it imperative to understand how tobacco marketing capitalizes on the appeal of marijuana to youth and other priority populations. How marijuana co-marketing contributes to dual and concurrent use of marijuana and tobacco warrants study, particularly for youth and young adults. In previous research, the prevalence of adult marijuana use in 50 California cities was positively correlated with the retail availability of blunts. Whether this is correlated with blunt use by adolescents is not yet known. Consumer perception studies are necessary to assess whether marijuana co-marketing increases the appeal of cigar smoking or contributes to false beliefs about product ingredients. Research is also needed to understand how the tobacco industry exploits opportunities for marijuana co-marketing in response to policies that restrict sales of flavored tobacco products and to policies that legalize recreational marijuana use. Such assessments are essential to understand young people’s use patterns and to inform current policy concerns about how expanding retail environments for recreational marijuana will impact tobacco marketing and use.Alcohol and other drug use is high among US adolescents and increases with age. In the United States, current use of alcohol, tobacco and marijuana is reported by 32.8%, 16% and 21.7% of high school students, respectively. In the same group, lifetime use of alcohol, tobacco and marijuana is 63.2%, 32.3% and 38.6%, respectively1 . Early initiation of alcohol has also been associated with subsequent misuse of prescription drugs and illicit drugs6 . Furthermore, in recent years, the number of drug overdose deaths has exceeded fatalities from motor vehicle crashes among adults. Given the potential negative consequences of drug use during adolescence, screening for alcohol and other drugs is recommended by numerous medical and federal organizations. A pediatric emergency department visit represents a distinctive opportunity to capture high-risk adolescents missed in other settings. Nearly 1.5 million adolescents use the nation’s emergency departments as their only source of care. These adolescents may be more likely to report drug use, worsening health status, and mental health problems, highlighting a need for PED-based screening . In light of the public health crisis of drug abuse, the PED represents a unique opportunity for identification and intervention of youth at risk for this condition. Drug use screening through interviewing or surveys as part of a comprehensive biopsychosocial screening, rolling bench is recommended when delivering routine or emergency adolescent health care. Studies in busy PEDs have shown that brief screening is feasible and acceptable. The ideal screen should require minimal training and implementation time and should be sensitive enough to detect patients who have alcohol and other drug use and misuse while not over identifying those with non-hazardous use. Many alcohol and drug screening instruments exist; however, one brief instrument that can be incorporated into triage assessments and accurately detect alcohol and drug use issues would be most efficient.
A number of brief screening instruments are appropriate for use in the PED, yet no one instrument is universally utilized. A recent review of pediatric alcohol and other drug screening instruments for the emergency department found evidence supporting the use of a Diagnostic and Statistical Manual of Mental Disorders 2-question instrument to screen for alcohol misuse and a Diagnostic Interview Schedule for Children 1- question instrument to screen for cannabis misuse. Other options for brief drug use screening for adolescents include the Brief Screener for Tobacco, Alcohol and Other Drugs , which asks about past year alcohol, tobacco and cannabis use or the Screening to Brief Intervention tool which identifies frequency of alcohol, tobacco, marijuana and other drug use. The National Institute of Alcohol Abuse and Alcoholism has recommended a brief screen which asks about a teen’s drinking frequency and friends’ drinking, as a potentially effective predictor of current and future alcohol misuse. Recent studies demonstrate the NIAAA two-question screen to be a valid approach for alcohol screening that is briefer than most other comparable screens. If a positive alcohol screen is positively associated with drug use, this may represent a strong screening option for the PED where short implementation time is necessary. The purpose of the present study was to examine whether the NIAAA two-question alcohol screen is also positively associated with an adolescent’s cannabis use disorder , cigarette smoking, or lifetime use of other drugs in a PED setting. A secondary aim was to determine if the association between the NIAAA two-question alcohol screen and other drug use varied by demographic characteristics. The present study is a secondary analysis of baseline data from a prospective cohort design which examined the reliability and validity of the NIAAA two-question screen. Sixteen PED sites from the Pediatric Emergency Care Applied Research Network participated in this study. Youth 12 to 17 years of age who were being treated for a non-life threatening injury, illness or mental health condition were eligible for this study if they were medically, cognitively and behaviorally stable based on the medical team’s recommendation. Exclusion criteria included not being accompanied by an adult qualified to give written permission for the youth’s participation in the study; parents or teens unable to read and speak English or Spanish; or lacking a telephone or an address of residence. A detailed study methodology is described in a previously published paper . After enrollment, an assessment battery that included the NIAAA two-question screen28 and other measures of drug use and risk behavior was self-administered on a tablet computer. The NIAAA two-question alcohol screen28 asks slightly different questions based on whether a teen is in middle or high school. Middle school and high school were determined by age unless participants identified as 14 years which were sorted by grade level . The past year alcohol use question is used to categorize teen risk level based on NIAAA recommendations . Any alcohol use among middle school participants categorizes them at moderate or high risk, while high school users can be categorized as lower, moderate or high risk based on their frequency of use. We have reported on the reliability and validity of this instrument in the PED41; others have reported on its validity in other medical settings. To determine the relationship between the NIAAA two-question screen and CUD, the screen was compared to marijuana diagnoses derived from the substance abuse module of the DISC. For this study, a question about craving marijuana was added so that the CUD diagnosis would be based on DSM-5, rather than the DSM-4, criteria. The tobacco module of the DISC was also administered to assess tobacco use disorders. However, since in the practice setting tobacco use is more commonly examined lifetime tobacco use was coded yes or no. The DISC is the most widely used and studied mental health interview that has been tested in both clinical and community populations. DISC has high sensitivity for psychiatric disorders, including substance use disorders. The Drug Use Questionnaire was used to assess the number of days the teen used cocaine, lysergic acid diethylamide , phencyclidine , inhalants and other drugs in a given time period. Internal consistency of the DUQ is 0.75. The Cochran-Armitage test was used to test the association between the NIAAA two question screen categories and CUD diagnosis, lifetime tobacco use, and lifetime other drug use. A logistic regression was used to test for the association of sex and age group with CUD diagnosis, lifetime tobacco use and lifetime drug use.